Physical Therapy and Sports Medicine for Birmingham, AL
Arthrofibrosis (AF) is abnormal internal scarring inside the knee joint and surrounding structures. It may begin with sticky adhesions that can gum up the surfaces that are close to one another, such as the suprapatellar pouch above the patella, the anterior interval behind the patellar tendon, the area around the cruciate ligaments and the capsular ‘gutters’ at the side of the joint.
The abnormal ‘gumminess’ of these normally mobile tissues leads to painful knee stiffness. Attempts to bend the knee result in sickening pain above the knee in the region of the suprapatellar pouch. Aggressive physiotherapy tends to make the knee hot, swollen, red and painful, and instead of mobility improving it tends to worsen. Lack of understanding about the arthrofibrotic process may lead to doctor and physiotherapist berating the patient for not trying hard enough, and the patient may feel demoralized and angry.
The objective of manipulation under anesthesia (MUA) for the knee is to break sticky adhesions gumming surfaces together before these adhesions turn into proper scar tissue. To this end, the procedure should be done early once it is appreciated that physiotherapy is no longer improving range of motion (ROM) or that ROM is getting worse. During the procedure the patient needs to be fully anaesthetized and under the influence of true muscle relaxants. The hip should be bent to 90 degrees and the surgeon hold the thigh near the knee and apply a gentle rocking motion of the lower limb through flexion and extension while observing improvement.
Not every practitioner will perform the manipulation in exactly the same way. By having the patient under anesthetic or deep sedation, the clinician is able to gently but firmly take the knee through as much of a range of motion as possible in order to free any adhesions. A danger of course is that the inexperienced practitioner may be too rough and cause damage to the tissues.