how do you get rid of scar tissue without surgery?

[alexmac]

Hello

I'm looking for some advise on knee stiffness and scar tissue problems as well as ROM following acl surgery.

I had an aclr surgery done about 5 months ago. My ROM is actually pretty good so I sympathise with anyone who has got a more severe scar tissue problems than me. My problem is that whilat I can get my full ROM, this is only possible when I am warmed up. This is ok during the day because I can just keep it warmed up by flexing and extending it every 15 mins. The problem is that at night scar tissue reforms, it stiffens up and I'm back to square one at the start of each day. I should say my extension is ok, it's flexion that's the problem. I start each day with about 130 flexion. Every morning I warm it up and then do some flexion exercises and pretty quickly I get my full range of about 155 flexion. I can feel the clunk clunk and crunch crunch of the scar tissue breaking up when I warm it up. I try to keep my full ROM all day but as I have to sleep I lose it during the night. I wake up the next day and the scar tissue has reformed and I have gained nothing. I repeat the same process. And so on. No change since 3 weeks post surgery. Very frustrating.

My OS does not want to do anything, got 2nd opinion said same thing. Not a serious enough lack of ROM for further surgery I'm told. Problem is I don't know any physios who have a clue how to deal with scar tissue and ROM. I'm doing all the correct exercises (I've checked the arthrofibrosis section on this site for those). I've read some other people's posts and it seems that following scar tissue surgery people have had to do things like use a CPM non stop etc. Thanks for some great information and tips on other posts regarding which exercises work etc. I think I'm doing the right things, my problem is how to keep it going because as soon as I stop it takes just 15 mins for my knee to start stiffening up again.

I guess my questions are these:-
1. Is it possible to get rid of scar tissue and prevent it reforming by keeping the knee moving constantly throughout its full range non stop - by doing full extension and full flexion exercises on a non stop basis?
2. If this is possible, then how do you do this at night without a CPM machine (which doesn't go to full ROM anyway)?
3. Is this the correct non surgical approach to scar tissue?

thanks in advance for any answers and thanks also for info I have already got from other posts

alex mac

[jathib]

There's really no way to prevent scar tissue or get rid of it without surgery. Surgery, of course, causes more scar tissue. Once it forms and prevents ROM it's usually there to stay. It's very hard to break at that point without some kind of manipulation or surgery. So I'm not entirely convinced that your problem in the morning is really even due to scar tissue. Injured joints often stiffen up at night or when we've been sitting for a while. Once the blood gets flowing and warms them up they move a lot better.  That is a problem that could well last a lifetime. If you're getting 155 degrees then you really have nothing to worry about.

[celinenj03]

I had nearly the EXACT type of reaction all the way through the first 6 months. I felt like I always had to warm up to get full flexion. This WILL pass. Want to know what really seems to help if you can handle it is stationary bike with no weights. Just keep the knee loose also try some of the glucosamine chondroiten supplements. I feel this keeps my joint pretty flexible as I've had no flexion problems (outside of occasionaly swelling bouts throughout my recovery). You might also have an IT band that is tightening up on you. Try to roll it out with a foam roller in the morning when you wake up and then again in the afternoon if you can. It's too soon to say if you have a scar tissue problem

I am 13 months out now and at 11 months, I had a major scar tissue break up on my lateral side of my leg. I have heard of people having scar tissue break up at a year out, so it is still early for you. I know it's scary when you're going through it, but looking back I would never have stressed over the flexion, it mostly always comes back within the year, just give it time.

You have 2 opinions, both say no operation, so just give it time. i'd wait out the year and then see how you feel! I bet you are going to be just fine. All the BEST and try not to worry.

[alexmac]

thanks for the replies. I would still really appreciate it if anyone is able to answer my 3 questions which are as follows. Thanks:-

1. Is it possible to get rid of scar tissue and prevent it reforming by keeping the knee moving constantly throughout its full range non stop - by doing full extension and full flexion exercises on a non stop basis? ex/ every 15 mins, 24/7
2. If this is possible, then how do you do this at night without a CPM machine (which doesn't go to full ROM anyway)?
3. Is this the correct non surgical approach to scar tissue?

Unfortuneately, I'm told by my OS that I do have a scar tissue problem. It's only because I have a good ROM overall that he does not consider it serious. The problem for me is that I have had absolutely zero change in 4 months. I would be less concerned if there was any progress at all. I break up the scar tissue on a DAILY basis only for it to reform every single night. I'm looking for a way to get out of this cycle. I can achieve my full ROM but that is of little use if I can't maintain it. Once I have warmed up to full ROM I can feel the scar tissue clunking, grinding in the joint. My OS has confirmed that this is what is occuring. This is preventing me from doing the rest of the rehab. My OS agrees in this respect. He says I need to get rid of this problem before I can work on the rest of the recovery. He simply said I need to work with my physio on this. The problem is I can't find a physio who has any good ideas on this. I've read some excellent posts on this site regarding what exercises work best for ROM and scar tissue. My theory is that I may need to do these exercises 24/7 and I want to know if anyone thinks that approach is likely to be succesful or otherwise. Thanks a lot for any answers.

alex mac

[jathib]

1. Is it possible to get rid of scar tissue and prevent it reforming by keeping the knee moving constantly throughout its full range non stop - by doing full extension and full flexion exercises on a non stop basis? ex/ every 15 mins, 24/7
2. If this is possible, then how do you do this at night without a CPM machine (which doesn't go to full ROM anyway)?
3. Is this the correct non surgical approach to scar tissue?

1) Scar tissue is going to form regardless of what you do. Some people are more prone to it than others. I make lots of it. I had a CPM after my ACLr and PKR. I still got lots of scar tissue. My therapist broke it up after my PKR. He spent an hour at a time working my scar to keep it from attaching to my  kneecap. It's still in there, it's just not stuck to anything. You might be able to prevent it from attaching to things but you won't be able to prevent it from forming.

[Jaci]

Hello Alex.

First off, I highly recommend that you do some research and learn everything you can about scar tissue. This is a situation where what you don't know can truly hurt you. You may get a lot of well meaning advice, but in many cases it can be just plain inaccurate. KNEEguru has made it easy to get accurate information from credible sources in the medical community by offering tutorials, literature review, and clinical case book on the main website. Here are some links to get you there:

Dr. Noyes’ arthrofibrosis tutorial and Dirk Kokmeyer’s rehab tutorial

http://www.kneeguru.co.uk/KNEEnotes/node/633
http://www.kneeguru.co.uk/KNEEnotes/guest-contributors/mr-dirk-kokmeyer/arthrofibrosis-rehab-tutorials-dirk-kokmeyer


Dr. Millett’s articles

http://www.kneeguru.co.uk/KNEEnotes/node/2277

KneeGuru’s arthrofibrosis 'tag'

http://www.kneeguru.co.uk/KNEEnotes/keyword-tags/arthrofibrosis

thanks for the replies. I would still really appreciate it if anyone is able to answer my 3 questions which are as follows. Thanks:-

1. Is it possible to get rid of scar tissue and prevent it reforming by keeping the knee moving constantly throughout its full range non stop - by doing full extension and full flexion exercises on a non stop basis? ex/ every 15 mins, 24/7
2. If this is possible, then how do you do this at night without a CPM machine (which doesn't go to full ROM anyway)?
3. Is this the correct non surgical approach to scar tissue?

Unfortuneately, I'm told by my OS that I do have a scar tissue problem. It's only because I have a good ROM overall that he does not consider it serious. The problem for me is that I have had absolutely zero change in 4 months. I would be less concerned if there was any progress at all. I break up the scar tissue on a DAILY basis only for it to reform every single night. I'm looking for a way to get out of this cycle. I can achieve my full ROM but that is of little use if I can't maintain it. Once I have warmed up to full ROM I can feel the scar tissue clunking, grinding in the joint. My OS has confirmed that this is what is occuring. This is preventing me from doing the rest of the rehab. My OS agrees in this respect. He says I need to get rid of this problem before I can work on the rest of the recovery. He simply said I need to work with my physio on this. The problem is I can't find a physio who has any good ideas on this. I've read some excellent posts on this site regarding what exercises work best for ROM and scar tissue. My theory is that I may need to do these exercises 24/7 and I want to know if anyone thinks that approach is likely to be succesful or otherwise. Thanks a lot for any answers.

alex mac

To address some of your concerns:

Chances are you are not breaking scar tissue during the day by exercising only to have it reform at night. It's more likely that the scar tissue is still in a pliable flexible state and stretches out with daily exercise and movement, then tightens up again when your knee isn't moving. Scar tissue goes through various stages (you'll read about this in Dr. Noyes tutorial). In general, early on post injury or surgery the scar tissue is wispy and can often be broken with appropriate physical therapy. I say 'in general' because an extremely small number of people can have a very exaggerated healing response and form masses of scar tissue in a very short time; such cases may require specialized intervention beyond PT. The further you get from the initiating injury/ procedure the stiffer and more fibrous the scar tissue adhesions become. As the scar tissue tightens it can lead to permanent damage to articular cartilage surfaces and shrinkage of the joint capsule and ultimately to shrinkage of the patellar tendon (conditions called infrapatellar contracture syndrome and patella infera).

If you've had little change in the past four months it seems unlikely that you will have a sudden increase in ROM. I know my OS uses one's ROM when cold as a data point, after all most people cannot sit and work on their ROM all day long, so how is your 'warmed up' ROM a valid measure of functionality? Also, loss of ROM is not the only indicator of excess scar tissue. People can actually have full ROM but significant pain during normal activities or feelings of blockage or mechanical changes and an inability to resume normal activities. Any or all of these symptoms can be present with arthrofibrosis.

At this point post-op it may be unlikely that your PT will be able to ‘break up’ much internal scar tissue. This is not to say that adhesions outside the joint space can’t be broken up as Celine mentioned. I had a therapist who does myofascial release break a pencil thickness adhesion in the suprapatellar pouch area of my knee. It helped with some ROM, but generally the adhesions that have to potential to cause long-term damage are deep within the knee joint and are protected by bones and other structures (Dr. Noyes talks about anatomy in one of the sections of the tutorial).

About your questions from above:

1.  At this point you may need surgical intervention and appropriate follow-up and rehab to resolve the issues you’re experiencing. However, only an OS who has significant experience treating arthrofibrosis can tell give you a proper diagnosis and treatment plan. The unfortunate reality is that most OS have limited knowledge and experience with arthrofibrosis, thus they are not qualified to give you recommendations on it. (Again—you’ll understand this better after reading through the links above.)

There is some truth in the statement that scar tissue is going to form if you have another surgery as scar tissue is a necessary part of normal healing. Arthrofibrosis is not normal healing. Most cases of excess scar tissue formation are due to secondary causes such as the traumatic nature of the injury, post-op joint bleeding, post-op mobilization, insufficient or delayed PT, and so on as mentioned in the tutorial and literature reviews. Very few people have primary arthrofibrosis which is believed to be an immune disorder, the numbers are somewhere around 1% of people who have knee surgery.

If you have surgery performed by a knowledgeable OS, it is possible to reduce scar tissue formation and somewhat control the manner in which it grows with the proper post-op protocol. (There are many medical journal articles on the subject, so I won’t go into all of it here. I can email articles to you if you are interested in more info).

2.  The general idea behind CPM usage is that it helps to normalize the joint fluids in the knee and promote ‘organized’ healing. It really doesn’t help gain ROM if full ROM was not reached in surgery. I go to an OS who is well-known as a pioneer in treatment of arthrofibrosis. He has his patients use CPM in a very small range of motion—usually 0-90 when awake and 30-70 when asleep. He bases the range on what he finds during surgery. For instance my knee has cartilage degeneration due to altered mechanics from scar tissue. The patella contacts the trochlea (femoral groove) at just over 30 degrees, so my OS had me use the CPM between 30-70 degrees. The point being ‘move it to lube it.’ (there’s a great article on CPM by Driscoll. Let me know if you want it)

PT including ROM exercises and patellar mobilizations are used to maintain/ increase ROM.

3. Unfortunately, no one here is qualified to tell you if what you are doing will correct the problems you are encountering. Nor does anyone here have the qualifications to state whether or not what you are experiencing is normal or not. No matter how emphatically people insist that what you are experiencing is exactly what they went through, it is impossible for anyone to really know that. Sure the ‘symptoms’ may sound similar but how can a person with no medical training and without actually seeing your knee make such a statement? Besides, if you happen to find yourself still having problems many months down the road, their emphatic statements will be of little value if you have missed the limited window of opportunity in which to obtain proper treatment and avoid permanent damage to YOUR knee.

Only a qualified OS can properly diagnose your condition and recommend the appropriate treatment. By qualified I mean an OS who has taken the time to learn about the condition, who has been trained by someone who has this specialized knowledge, and who has treated significant numbers of patients.  Here’s a link to a list of specialists that posters on this board have identified as having the specialized skill and knowledge to successfully treat arthrofibrosis:

http://www.kneeguru.co.uk/KNEEtalk/index.php?topic=16156.0

I have been visiting and posting on this board for some time now (I happen to be one of the unfortunate 1% of people who have recalcitrant arthrofibrosis). The best advice I received early on was to learn everything I could about arthrofibrosis from credible sources; that is the only way one can actively and fully advocate for proper care. It is the best way to increase your chances of full recovery. Reading the board and posting here are a good way to start. I highly recommend that you educate yourself by using the links posted above. Then seek treatment from the most qualified OS available to you.

Best wishes,

Jaci

[celinenj03]

You are only 5 months post op. Sorry, but I don't find your OS to be very credible in telling you that you have a scar tissue "problem". What is he basing that on? It is very, very common for ACLR patients to have the exact symptoms you are having the first 6 months. I really doubt you are reforming scar tissue on a daily basis. You're knee is going to feel stiff for probably the first 6 even 9 months after waking up in the morning. I think you are obsessing on the scar tissue issue. Give it more time is what I recommend, 5 months is WAY TOO EARLY to do anything crazy other than your prescirbed PT. You probably still have pockets of swelling there. It takes almost a year for a knee to settle after this kind of surgery. Good luck,

[awb]

Hey, alexmac, you might look into a dynamic flexion splint.  You can wear it overnight.  It's supposed to keep your knee flexed to its max extent.  It's spring-loaded, so you can consciously extend your knee every so often and let it spring back.  I can't vouch for its effectiveness, because I'm having a helluva time overall, but this is how my doctor explained the equipment.  Hope this helps.

[Thornbird]

Hi,

This is my first time posting. I have a problem with knee extension due to scar tissue. I have a terrible time walking and I've been off work for a year. I had many procedures until I had a total knee done in May of 05. Then I was in a bad car accident and broke my fibula and tibia just below the knee repalcement. I had an instant manipulation in the process. I had surgery to remove all the scar tissue 5 months ago and I felt it coming back immediatley. Oh and I've done mass PT in the process. 

I'm wondering if there are any braces out there that can take pressure off the quad muscles when walking. Also, MY OS wants to try and relax my hamstrings by injecting botox in them followed by manipulating and casting my leg straight. Has anyone gone through this procedure.

My main objective right now is to learn how to live with arthrofibrosis. It's has stopped me dead cold in my tracks. Thanks

[celinenj03]

This would be a good post under the arthrofibrosis section. You might be able to get some help with your situation over there. Hope this helps and hope you get better soon.

[Janet]

Thornbird:

I haven't heard of botox injections for this purpose. My reservation would be casting following any procedure. That seems like it would just be asking for more scar tissue to form. I would also ask how manipulation could help with scar tissue that is prohibiting extension. I thought MUA was used for flexion, but to gain extension you need to have the scar tissue removed. That may be different following a TKR, but it is a question I would ask.

Janet

[missmyknee]

How long will you be casted ? I know some OS's use cylinder casting for extension problems but usually for no longer than 24-48 hrs.

Pam

[Molls]

my mother has problems w/ her back.. and i know this is about knees.. but she has had many surgerys on her back and lots of scar tissue... she went to a doctor in Dallas,TX and he has given her a shot of some type of salt water.. i dont know that much about it but it will make it go away and get rid of the pain for about a month or so... i guess depending on how much!! again i dont knwo much about this but this is just a sugestion!!

[ermintham]

I had nearly the EXACT type of reaction all the way through the first 6 months. I felt like I always had to warm up to get full flexion. This WILL pass. Want to know what really seems to help if you can handle it is stationary bike with no weights. Just keep the knee loose also try some of the glucosamine chondroiten supplements. I feel this keeps my joint pretty flexible as I've had no flexion problems (outside of occasionaly swelling bouts throughout my recovery). You might also have an IT band that is tightening up on you. Try to roll it out with a foam roller in the morning when you wake up and then again in the afternoon if you can. It's too soon to say if you have a scar tissue problem

I am 13 months out now and at 11 months, I had a major scar tissue break up on my lateral side of my leg. I have heard of people having scar tissue break up at a year out, so it is still early for you. I know it's scary when you're going through it, but looking back I would never have stressed over the flexion, it mostly always comes back within the year, just give it time.

You have 2 opinions, both say no operation, so just give it time. i'd wait out the year and then see how you feel! I bet you are going to be just fine. All the BEST and try not to worry.

can anyone explain to me wat those words in bold means? wats the IT band? wat foam roller?


thanks a million

[contraaclr]

can anyone explain to me wat those words in bold means? wats the IT band? wat foam roller?


thanks a million

Here is a picture of the IT band. When you look at it you can understand how important it is to stretch it, as it has the potential to pull the patella laterally (to the outside of the knee).
http://www.ithaca.edu/faculty/lahr/LE2000/knee%20pics/knee%20pics/3Alateral-TFLsup.jpg
Here is another picture, along with some stretching exercises for ITBS:
http://www.aafp.org/afp/20050415/1545.html

Rolling your thigh on a foam roller is one of the best ways to stretch/massage the IT band. There is a great demo on how to use a foam roller on the youtube web site:
http://www.youtube.com/watch?v=t32xJspx50o&NR=1