Overzealous Physiotherapy: A Cautionary Tale

The development of knee arthrofibrosis is a serious complication of knee surgery, and in particular of knee ligament reconstruction and total knee replacement, and especially if complicated by post-operative bleeding into the joint cavity.

How the physiotherapist guides the all important rehabilitation process can have disastrous or excellent recovery potential for the patient. It is not just surgical factors at play in the patient outcome, but the physiotherapist has a critical role, too.

We know fibrosis (scarring) occurs when inflammatory mediators are set into motion and this is a normal healing response. But an abnormal quantity or quality of the body’s “healing response” may result in collagen deposition, which causes adhesions to be laid down inappropriately in the soft tissue structures of the knee joint. 

Adhesions formed in the capsular structures of the knee may cause at times an irreversible loss of range of motion.

This loss of range of motion may take the form of a “stiff knee” which may include:​

• extensor lag - unable to fully straighten the knee
• flexion lag - unable to fully bend the knee
• patellar motion restriction - painful restriction of all movement

A seasoned physiotherapist should always guide the pace and intensity of the rehabilitation process. Gone are the days when “more was better”.

Thanks to our understanding of molecular biology and the inflammatory cascade, we know that inciting inflammatory modulators is not helpful to healing wounds. We know that aggressive physiotherapy, too, can be an inciting event in the hands of an overzealous physiotherapist, inciting adhesion formation and potentially leading to arthrofibrosis.

Orthopaedic Surgeons becoming more aware

...aggressive physiotherapy can be an inciting event...

Orthopaedic surgeons, though not many enough, are also becoming aware of this phenomenon, and where they once adhered to aggressive rehabilitation protocols they are becoming advocates of minimally aggressive protocols, informing patients of the perils of misinformation warning them of “not being able to achieve full range of motion without aggressive PT” ( see https:/sbfphc,wordpress.cpm/2013/08/21/ceasing-aggressive-physical-therapy-after-knee-replacement/ ). These surgeons are speaking out about the role of the inflammatory response in “thickening of the soft tissues surrounding the total knee replacement and causing a decrease in range of motion”.

Patellar Mobilisations

Central to early mobilisation of the tissues are exercises known as patellar mobilisations. Gentle but skilled hands are needed. The patient should be relaxed with the knee extended, which is the position in which the patella disengages from the underlying groove of the femur bone.

While certainly after ligamentous reconstruction or surgery, protocols ought to be adhered to, it is the physiotherapist's job to gauge when limits are being pushed. Perhaps the most combustible formulation is found in the overzealous, perhaps recently minted, physiotherapist with the eager-to-please athlete on the mend. This combination can prove to be a dangerous combination, as one - often the patient - somehow wields the axis of power from the other, and the rehabilitation can go awry.

Or conversely, as was the case in my personal encounter with a new graduate physiotherapist, who it seems had only seen video or read text on patellar mobilization, began what can only be described as “patellar grinding” with at least 20 pounds of body weight while standing over me (I was only four days from surgery!) in a hand over fist, CPR stance, with force towards my backbone as she performed the inferior/superior mobilizations….she never made it to medial/lateral or oblique mobilization as I stopped the session right there!