Adhesions

Adhesions tend to form in the suprapatellar pouch above the kneecap, in the envelope-like bursae below the kneecap and in the soft-tissue gutters around the sides and back of the joint.

How do adhesions limit range of motion?

The sticky strands Of adhesions pull adjacent soft tissues together, binding the surfaces and limiting movement.

Initially they are easily broken with therapeutic knee movement - such as patellar mobilisations and manipulation under anaesthesia - but later the adhesion tissue matures into scar-bands and these thicken and make the knee stiff. When the knee is stiffened by adhesions the condition is called arthrofibrosis.

• Quote from peer-reviewed paper:

  "A full range of motion is required for a normal gait and function of the knee, and hence the knee stiffness due to any cause could lead to pain and functional disability"

  Citation: Vaish A, Vaishya R, Bhasin VB. Etiopathology and Management of Stiff Knees: A Current Concept Review. Indian J Orthop. 2020 Oct 20;55(2):276-284. doi: 10.1007/s43465-020-00287-0. PMID: 33927806; PMCID: PMC8046887.

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What is the difference between adhesions and arthrofibrosis?

Adhesions can be broken with exercise or physiotherapy, and may eventually resolve.

If they do not resolve, they may transform into proper scar tissue, which is arthrofibrosis.

• Quote from peer-reviewed paper:

  "Arthrofibrosis (AF) is an exaggerated immune response....Prevention through early physiotherapeutic interventions and anti-inflammatory medications remain fundamental to avoiding motion loss."

  Citation: Lee DR, Therrien E, Song BM, Camp CL, Krych AJ, Stuart MJ, Abdel MP, Levy BA. Arthrofibrosis Nightmares: Prevention and Management Strategies. Sports Med Arthrosc Rev. 2022 Mar 1;30(1):29-41. doi: 10.1097/JSA.0000000000000324. PMID: 35113841; PMCID: PMC8830598.

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How do you limit adhesions?

There are three areas where adhesions need to be foremost in the mind of both the patient and medical team -4>

• after injury, a knee usually requires a period of rest to try and limit inflammation. Operating or exercising too early may trigger the formation of adhesions.

• physiotherapy requires careful judgement as to how much exercise is enough. The range of motion through which exercise is allowed should be carefully judged by the therapist. The knee may need to be iced down after rehab session. Patellar mobilisations need to be firm but not aggressive.

• manipulation under anaesthesia needs skillful hands, and careful management afterwards to prevent more inflammation being triggered.

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Forum discussions

• Anyone out there unable to bend leg at all when walking

  Patients discussing why they are struggling with stiff knees.

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