Arthrofibrosis, scar tissue in the knee

Arthrofibrosis is a condition in which a lot of scar tissue (connective tissue) has developed in a joint. How and why, and what can be done about it?

Athrofibrosis is caused by an inflammatory process. It is the most common of complications after knee surgery and occurs, for example, after a total knee replacement or after a frontal cruciate ligament reconstruction. It can also occur after a severe trauma to the knee accompanied with blood in the joint. Too much scar tissue can also occur in other joints but the knee is the most common site.

You want to know everything: what is arthrofibrosis, how does it develop, what is the best therapy, what can the physiotherapist do and what can I do myself? It is important to know that much can still be achieved at an early stage. Once the scar tissue has been fully formed, recovery is only possible by surgery, and even then success is not assured. So: prevent it! Here you will learn how.

What is normal, what is not?

If a knee has been injured (surgery and / or accident), the body will start to heal the wound. (Yes, surgery is regarded by the  body as an injury)

First an inflammatory reaction occurs. That is normal. How does an inflammatory reaction manifest itself?

  • Pain (dolor)
  • Redness (rubor)
  • Swelling (tumor)
  • Heat, warm (calor)
  • Restriction of movement (functio laesa)

Now the body is going to repair the damage. This happens with the formation of scar tissue. Repairing structures by making scar tissue is good, we have no perfect regenerating possibilities,  but scars do not belong in a joint! Scar tissue in the knee prevents bending and stretching to the full extend. The limitations will also cause a lot of pain. Because it hurts so much, many people stop trying to move, allowing the scars to develop even more and now the problem gets huge.

What are the problems in arthrofibrosis?

The knee is often painful after surgery and it has limitated movement. No matter how hard you practice, after a while the knee becomes more limited and painfull rather than more agile. After a knee replacement you normally can bend 110 degrees, which is enough to be able to cycle. But due to arthrofibrosis, the ability to bend decreases to much less than that, for example to 70 degrees or even less. Cycling is not possible, climbing stairs becomes a problem, and the knee gets more painfull. In addition, the knee is often thick, red and warm. You feel you are getting worse in stead of better.
Stretching is often not complete anymore. If a knee can not stretch the last 5 or 10 degrees, you will immediately notice this in the way you walk. You are limping more and more, needing walking aides.

In which joints arthrofibrosis occurs?

Arthrofibrosis can develop, usually after surgery, but sometimes also after a trauma. It can occur in the knee,  in the shoulder, the hip, in the ankle and in the wrist. Most of the time it affects the knee, so we discuss it here. But everything that is said here also applies to the other joints.

How often does arthrofibrosis occurs in the knee?

A good question: during my research I encountered a large number of figures, which differ greatly. Some surgeons report that this complication occurs in less than 1% of all cases. Others, who specialize in combating arthrofibrosis, talk about 45% of the cases. 10% was also mentioned.
I can not, being a physiotherapist, tell who is right. But 1% seems to me on the low side, given the number of cases that I myself have encountered and the stories people tell on my Dutch site. And 45% seems to be too high. The real occurrence could be somewhere in the middle.

The term arthrofibrosis

In the Netherlands you rarely hear the people talk about ¨arthrofibrosis¨, but some people do need a repair operation or a mobilisation under anaesthesia because of scar tissue. In Germany the word arthrofibrosis is much more used, as it is in the USA. The following names are used in Dutch literature: Arthrofibrosis, artrofibrosis, scar tissue.

My joint movements are limited. Am I developing arthrofibrosis?

First of all, this site does not lead to a diagnosis, it leads to knowledge. If you suspect you are developing arthrofibrosis, please consult your physician! But it never hurts to add to your understanding.

Besides scar tissue in a joint there are a number of other causes of bending limitations:

  • Too short muscles
  • Too much fluid in the joint (the joint is still irritated)
  • Mechanical factors, such as a broken meniscus or a cyclops (see below)
  • If the bones are no longer in line, for whatever reason
  • When tendons are torn,
  • If the operation is not successful, and structures in the knee are not in place
  • If there is nerve damage.

Therefore in case of problematic recouvery a thorough physical examination  is adamant. Unfortunately, scar tissue can’t (very well) be seen on a photo or an mri.

Who gets arthrofibrosis and why?

Connective tissue strings (scar tissue) should not develop in joints, but sometimes they do. There is no sufficient scientific explanation yet that explains whom it affects and why. Surgery or a trauma can be a trigger, recovery goes seriously wrong. Yet there are known risk factors:

  • If there is too little time between an inflammatory reaction of the knee and surgery. For example when  torn off cruciate ligaments are operated too quickly. The knee has not been able to rest and reacts too violently to the operation. Many surgeons wait at least 3 weeks after the ligaments are torn before the start surgery. During those 3 weeks the soft tissue can heal and the mobility can increase. In people who have had surgery within 1 week, arthrofibrosis is much more common!
  • Excessive pain just before or after the operation seems to be a trigger. Therefore strong pain medication is often prescribed. Without these painkillers you can and will not exercise sufficiently and problems will naturally arise …
  • A physiotherapeutic treatment that causes too much pain. During physical exercises please tell us when it hurst! Of course, the physical therapist must pay attention and inquire regularly about pain, please be honest, don´t be tough. Exercises should barely hurt extra, and pain should be at your normal level within 10 minutes. (After surgery it is normal to experience pain, exercises should not add too much.)
  • If a joint is moved too little or too late after surgery.  After a frontal cruciate ligament operation, the patient receives a splint. In the past, that splint had to be used rather a long time, but research has proven that shorter use of a splint and faster start of exercises leads to better results and less arthrofibrosis.
  • Some people are afraid of pain and of damaging the just operated joint so they dare not exercise.  Precisely by not exercising they harm the joint rather than help it heal.
  • Too fast and too intense exercises after the operation can also lead to a problematic healing.
  • Infections or bleeding within the joint may cause  the development of scar tissue.  Also, due to the associated pain, one tends to move and exercise less.
  • Damage within the joint that occurred during surgery (sometimes unavoidable).
  • Imperfect operating techniques.
  • Reaction of the joint to implanted material within the knee.
  • Long-term joint irritation.
  • Diabetes and other systemic diseases make the joints extra vulnerable.
  • Some people tend to make more and larger scars than others, on the skin and in the joints. Genetic factors.

Our dilemma is clear: exercising too little too late is just as bad as exercising too soon or too rigorous.

Exercising should not hurt too much. But no pain after exercising or no reaction in the knee at all is not well either.

It seems that sometimes the body (parts of the nervous system) reacts too vehemently to pain and mechanical stress, thus causing an intense inflammatory reaction. It tries too hard to repair the damage by forming a lot of scar tissue. That is why it is so important that you take the pain medication as prescribed after surgery.  If the pain and the inflammation decrease, the danger of dysregulation of the nervous system also decreases.

After damage caused by surgery, by a fall or accident the body always starts to react in order to repair the dammage. Only sometimes our body reacts too violently!

Cyclops syndrome after anterior cruciate ligament reconstruction

Sometimes, after a front cruciate ligament reconstruction, a ball-shaped growth of the bone develops at the attachment of the new ligament. This is called a cyclops (one eye). Probably this is a reaction to irritation and a consequence of immobility, not fully stretching, too long after the operation, . The knee can bend, but stretching is limited and painful. This can only be remedied with an operation. Clearly this disorder is not an arthrofibrosis.

Therapy, preventing or curing arthrofibrosis

  • Prevention of movement restrictions is very important. It is important to move and exercise as soon as possible after the operation. The surgeon of course has to give permission to mobilize, to exercise, to bear weight. Sometimes the nature of the laesion prevents or forbids to do so. Passive and increasing active exercises to improve the mobility (ROM, Range Of Motion) of the knee are very important. Not moving for a certain period of time after an operation is not desirable, but sometimes unavoidable. The physical therapist is often the first to see that recovery does not follow  schedule: too much pain, the mobility of the knee does not increase sufficiently or even decreases.
  • After a front cruciate ligament reconstruction, many people still get a brace. The brace must ensure that the extension (stretching of the knee) is guaranteed. The use of a brace is admittedly widespread but not fully proven effective. Almost always the brace may be taken off for exercising or taking a shower. After an arthrofibrosis operation, an extension brace is probably useful.
  • If massive scars have been formed, a surgeon can decide to mobilize the knee under anesthetics (you really don’t want to do so without anesthetics). Due to the strength of the manipulation and the damage (bleeding in the joint, torn tissues, a lot of pain) that is reintroduced into the joint (mechanical stress), an inflammatory reaction with extra scarring can occur again. Both violent manipulation (moving) and late manipulation are considerated (in the Neterlands) wrong. In fact, not all surgeons are willing to do this and this therapy may be considered not preferred in the future.
  • Manipulation under anesthesia in combination with the removal of scar tissue via a viewing operation is certainly a possibility. If the scar tissue has been around for a little longer (longer than 6 weeks) then this combination is very effective.
  • The last option is open knee surgery, in which the excessive scar tissue and the connective tissue strands are cut away and,  if necessary also an incorrectly applied cruciate ligaments is repaired. Preferably however is preventing a necessary operation by preventing scar tissue to form in the first place.
  • After a recovery operation due to arthrofibrosis, a CPM machine could be used. Sometimes after a first operation a CPM machine is used, if the damage in the knee is so great that the surgeon expects the risk of forming arthrofibrosis. CPM = Continuous Passive Motion. A CPM is a machine put in bed and designed to move the knee passively to a certain and presice degree of extension and flexion during a certain time. This device can be used in the hospital, the nursing home or at home. It can be used for hours continuously, or a number of times per day for instance for an hour. The results with a CPM are good.

What should a physiotherapist do to prevent arthrofibrosis?

Physiotherapy is aimed at gaining normal mobility, strength, and proper use of the knee, ie walking, climbing stairs, standing up and sitting down. A physiotherapist accompanies  you to achieve that goals . He or she knows what normally to expect and sees quickly if recovery deviates. The physiotherapist answers your questions and thogether you look for solutions in all day living or work. You also are instructed to do exercises at the right time and in the right way.

The old lady had a total knee replacement at the age of 84. She had been walking with a rollator walker because of balance disorders. After the operation, she went to a rehabilitation facility. Then she returned to her room in the nursing home. She had a letter from her physiotherapist in the rehabilitation facility: Flexion was limited: not yet 110 degrees but only 90 degrees. Furthermore, no problems. The Dutch protocol prescribes 110 degrees. The letter suggested to improve mobility up to 110 degrees, intensive exercise therapy was needed. First an anamnesis: how are you doing and what do you need. She spontaneously burst into tears: bending further caused such enormous pain … Were we going to hurt her? We watched as she walked. She walked pain-free with a rollator, could easily get in and out of the chair, and had no further problems. Pain free, except for the physiotherapy exercises. She did not do cycling anymore. The lack of flection could indicate an arthrofibrosis, so we had to be very careful. We agreed that she would be paying close attention: if her mobility would get less and she would get pain, she would call us immediately. We visited her a few times at greater intervals, but she stayed well.  Toghether we decided to accepted the 90 degrees flection. No more tears and a pain-free knee. Not everything has to be done according to the directive, and not everything goes wrong!

What can I do myself to prevent arthrofibrosis?

    • Take the anti-inflammatory drugs and painkillers following prescription. Do not be tough, just swallow!
    • Cryotherapy or cold application. A cold compress is applied on the knee, preventing direct contact by a piece of cloth between skin and coldpack in order to prevent freeze (fire) blisters. It helps against pain and swelling and feels good when the knee is warm and thick.
    • Start immediately with physiotherapy. The sooner the better.
    • Avoid excesses of pain during and after exercising. To much pain is a warning.
    • Take good care to stretch the knee. Do not sleep for 8 hours of sleep with a pillow below the knee unless that is absolutely necessary because of the pain.
    • Put a rolled up towel under the ankle regularly and let the knee hang for a while. Push it down actively.
    • Practice every hour of the day. But avoid too much pain.
    • Do not only exercise when with the physiotherapist. You should exercise several times a day.
    • Bend your knee regylarly sitting in a chair: the knee should move slowly up to and beyond the 90 degrees.
    • My favorite: see this movie!  As soon as possible, put an exercise bike in the room and use it several times a day. More preferably 5 times or more 3 minutes rather than one time 15 minutes. The saddle is set so high that you can only just reach the pedals with your feet. (if that is safe in relation to your age.) Now you will to rock: you move the pedals forward and back so that the operated knee bends and stretches again. If you do not get the pedals around at first, that is not a problem. After a certain time the knee becomes more flexible and often you can turn the pedals around. Amazingly enough it is easier to move the pedals backwards in the beginning. Then turn the pedals quietly and reasonably pain free for some time. If this goes well, lower the saddle a little bit and you start again with rocking cradles, and then turn around again. And then put the saddle a little bit lower again. Do not forget that when you’re done, you will have to put the saddle high again, because the knee will be stiff again in one hour. If the knee reacts too violently, becomes thick and gives a lot of pain, consult the physiotherapist. In my opinion, everyone should put an exercise bike in the room after a knee operation!

  • During the first six weeks after the operation, you should be intensively busy with maintaining and improving the knee’s ability to move. Spend a lot of time and attention on this!

A CPM machine at home to move the knee passively

The surgeon can decide that you will have to use a CPM machine at home. These are expensive machines and not very well available (in the Netherlands). But there is a good and cheap alternative (do you know the Dutch love “Cheap”?) They are called an exercise bike. See instructions above of watch the instruction movie.

More information about the knee after operations:

Problems after knee surgery like pain, swelling and stiffness

Taking up sports after knee surgery

Keeping a pain diary if pain does not seem to diminish

I am very curious about what happened to you.  Some people can learn from your story, others will recognize themselves in your story.

If my translation is wanting, please report so?

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