I'm searching for treatment options for a difficult patient of mine, who is post op week 5 after a revision of his L TKA. HPI: 60 yr old male, operated on 5 weeks ago, elective surgery revision of L TKA, previously operated upon 1 year ago. Complication free revision. Hx: originally injured L knee as a 19 year old soccer player, 'ACL rupture and MCL tear' as per pt. ACL and MCL repair as a 21 year old. 3x arthroscopic surgeries between 80's and 90's d/t decreased ROM and reduced function. Activity Hx: pt remained very active between 21 and his early 50's. His reduced knee ROM limited the intensity of his activioty but not the frequency. PMHx: unremarkable
Treatments thus far: mainly focussed on joint protection, AAROM and AROM during these first 4.5 weeks, pushing closed and open chain home exercise program. Scar tissue massage and soft tissue mobs to compliment program.
Problems: pt seems to be stuck at 65 degrees of AROM. Overpressure after an active warm up and manual joint mobs gets him to 75 degrees, but it does not remain once overpressure released. His limitations seem to be purely soft tissue based as he has heavy scar tissue formation.
Questions: I am hitting a bit of a roadblock regarding treatment options for the assisted breaking up of his scar tissue to fascilitate increased AROM + AAROM. Any ideas??
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if his perceived restriction at end range flexion is posterior he may be lacking posterior tibial glide. If you get him at end range, have him mentally record how strong the barrier feels, then do essentially a posterior drawer test/mobilization on him, if the barrier eases some, he needs more accessory motion there.
Arthrofibrosis is tough to treat and outcomes aren't great in PT considering the cost and number of visits. Usually patients end up with manipulation or open lysis of adhesions either way. In some cases I think it serves the patient and healthcare system more value to have these done sooner rather than later in some cases. I'm actually building an EMR that can recognize these trends and provide the PT with insights. It's an artificial intelligence called Jonni. Catchy, right? lol
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