This course is for anyone involved in the early rehabilitation after knee injury or surgery. It would also be of value to trainee physiotherapists.
Because internal joint scarring, if it is going to occur, is likely to trigger early in the rehabilitation process, then it is the patient and the physiotherapist who need to be looking out for the danger signs. If they understand the issues and what to watch for, then management can be optimised before there is a progression to the tragic outcome of intractable scarring (arthrofibrosis) with irreversible stiffness of the knee.
The course explains the issues, anatomy and terminology - with loads of easy to follow illustrations and videos - so that your rehabilitation programme will really start to make proper sense. You will learn what the physiotherapist is trying to do, and why. You will learn about those surgical procedures that may be helpful in the process of freeing up movement again.The course should take four hours to complete, but there is no need for any pre-knowledge as it is fully comprehensive.
Meet your hosts - Sheila Strover and Sebastiano Nutarelli, and find out what makes them both passionate about the topic of knee stiffness.
Sheila Strover BSC(Hons) MBBCh MBA
Medical doctor based in the UK. Founder of the KNEEguru website, which is dedicated to helping people with knee problems find the information they seek and the help that they need.
Physiotherapist in training. Based in Italy but studying in Switzerland.
Find out what it means in practical terms for both men and women going about their daily lives with a knee that they cannot fully bend or fully straighten, and how this impacts not only their work and leisure, but also their relationships.
Click through the icons at the top of the 'Resources' section, to check the list of resources, write your own notes, engage in or follow discussions, or return to the menu.
This section gives the basic terminology related to describing range-of-motion problems of the knee. At the end of the course there is also a Glossary of terms.
Learn how men and women differ in how flexible their knees are. Gain a clear idea of your own range of motion goals, and whether you should focus on your extension or your flexion - so that you can work with the physical therapist and understand what is going on.
Learn about the anatomy of the capsule, so you can understand how it plays a role in knee stiffness. Also learn how the capsule allows fluid to be retained in the knee.
Look into the knee like a keyhole surgeon! See the internal ligaments and shock absorbers of the knee - the cruciate ligaments and menisci - and locate the boundaries of the capsule from the inside. This will help you to understand the later sections on the kinds of knee surgery for the stiff knee.
Find out why the patella bone and its position within the tendon of the quads muscle is central to understanding many problem both of extension and of flexion.
Get to grips with the subtle anatomical details that help you to both really understand modern 'manual' techniques of physiotherapy and also to understand some of the procedures of 'salvage' when scar tissue demands such surgery.
Learn how the knee muscles can both power movement by contracting, and also allow the opposite movement by paying out slack, so that opposing muscle groups act in concert with one another to ensure that movement is controlled and smooth.
The patellar bone - is it special?
See if your own knee problem fits into one of the high risk categories, so that you can be on full alert about the potential for knee stiffness problems during rehabilitation.
Learn about additional high risk situations that may trigger adhesions and scarring, so that if you see yourself in this list you can be extra careful with your rehab.
Learn why you need to be alert in the important first two months so that the propensity for stiffness is minimised and any progression towards stiffness is met with an informed and urgent response - once the knee is already stiff then the journey to rehabilitation will be much harder.
Run through the principles of the exercises, stretches and manual techniques that are of particular value in the early stages of knee rehabilitation, during the 'window of opportunity' that we referred to earlier.
Learn the fundamentals of early pain control.
Learn about the P.R.I.C.E. routine and other ways to reduce inflammation in the early stages.
Get to know the main stretches and exercises for mobilising the important tissues around the knee.
See the various patellar mobilisation exercises, as performed by the physical therapist.
Learn this key principle - there is a fine line between the right therapy and too much.
Learn what exercises to do once things are starting to settle down.
Be the first to spot potential trouble with your knee rehabilitation, and you will be in good time to make an appointment for the therapist to check things out.
Life can be a challenge when you have a stiff knee. It is not just the discomfort of activities of daily living, but there is also the social impact when your knee affects others - whether strangers on a bus or your closest partner. You may be encouraged to accept a less than perfect result, but remember that the person who is proposing this does not have to live with it for the rest of their life.
Physiotherapists will fall into two camps - those who know all this stuff we are teaching at this course, and those who do not. The former group are likely to be able to explain clearly what is happening to your knee, and will be pro-active in referring you back when necessary to the surgeon. The latter group are likely to be frustrated and confused by the lack of progress, and embarrassed to ask the surgeon for help. This is where your new knowledge will be invaluable.
Training to be a knee surgeon can take well over a decade, but very little time is devoted to formal teaching about rehabilitation. Of course, it can be argued that rehabilitation is clearly the domain of the physical therapist, but to our mind each needs to be fully cognisant of the principles of the other's work, so that the surgeon can understand the issues the therapist faces and vice versa.
Families need to trust their family member who may slip gradually into severe depression as they become torn between their own real rehabilitation anxieties and what they feel may be unreasonable reassurances by their doctor.
The surgeon does not have many options at his disposal to deal with adhesions once the physical therapist has declared that rehabilitation progress has stalled. These options include 'lysis of adhesions', 'manipulation under anaesthesia', 'anterior interval release' and 'joint insufflation'.
Because we are talking about essentially an inflammatory process, many patients feel there is benefit in exploring those chemical pathways that can affect inflammation.
One of the problems with communication about joint scarring is that terms are used without a precise definition of what the clinician is dealing with. Such terms may include 'fibroarthrosis', 'flexion contracture', 'arthrofibrosis', 'arthrofibrosis syndrome', 'chronic extensor lag', 'chronic flexion deficit'. At the end of this course, you should have a very clear idea of the best descriptors.
Check whether it is loss of extension or loss of flexion which is the main problem. Understanding the anatomy helps to explain where the main scar tissue resides.
Scarring in the region of the patellar tendon can close up the anterior interval and as the scar matures it shrinks and tugs the tendon down until it is virtually stuck to the tibia.
It is twenty years since Dr Shelbourne drew attention to the importance of extension loss and a low-lying patella in his classification system, which became the benchmark for many years.
Once there is established arthrofibrosis, surgery to improve knee motion is challenging, and focuses largely on rescuing what is possible of function. Some compromises may have to be accepted.
Learn the key principles of rehabilitation after surgery for arthrofibrosis, and then download the pdf documents where you will find more details.
Keep this as a handy memory aide.
Dr Sheila Strover (BScHons MBBCh MBA) is Director of ftmg Associates Ltd in the UK and responsible for key strategy and the development of the clinical content on the KNEEguru website. She is a medical practitioner (ex anaesthetist), with many years' experience working in a medical managerial capacity with the knee surgeons and physiotherapists at the Droitwich Knee Clinic and The Knee Foundation in the UK, although she left those two organisations in 2003, and no longer has any commercial involvement with them.
Sebastiano Nutarelli is a former 'complex problem knee' patient who travelled to some of the best orthopaedic clinics around the world for several years to find the right help for his problem, undergoing multiples surgeries and rehabilitation. This life-changing experience drove him, once back on his feet, to switch his life, from being both a web accessibility engineer and a career athlete, to enrol in a four year Physical Therapy Bachelor Degree Program at the university in Switzerland, where he's currently living during the weekdays. In the meanwhile he's working in an athletic and rehabilitation center in Italy with an organisational role. The long experience as a patient highly raised his personal bar of the level of service he'd like to provide to his future patients and orthopaedic rehabilitation is his main field of interest.