Stiffness After Knee Surgery (Arthrofibrosis)

What arthrofibrosis is

After any knee operation, the body heals by laying down scar tissue. In most knees this is soft and allows movement to return. In some, the body produces too much scar, or it forms in the wrong places, such as the front of the knee, behind the kneecap or in the notch where the ACL sits. The result is a knee that will not straighten fully, will not bend fully, or both. This is called arthrofibrosis.

It can follow ACL reconstruction, knee replacement, fracture surgery, multi-ligament surgery and, less often, arthroscopy. Loss of full straightening is usually the more disabling problem, because it causes limping, front knee pain and tiredness of the thigh.

How it feels, in patients' words

• I cannot get my knee flat on the bed, and my heel does not lift when I push the knee down
• It feels tight and stuck, as if something is blocking it
• It bends so far and then stops with a hard end
• My kneecap does not move much and the front of the knee aches
• I limp because I walk with the knee slightly bent
• Progress in physiotherapy has stalled or gone backwards

After ACL surgery, a clunk with a block to straightening can be a cyclops lesion, a small ball of scar tissue in front of the new graft.

Why some knees get stiff

There is usually more than one reason. Pain and swelling that are not controlled make it hard to move the knee in the early weeks. Long periods with the knee resting bent on a pillow allow it to stiffen in that position. Some people have a stronger scarring response, and a few have a graft position or implant size that limits movement. Surgery done while the knee is still swollen and stiff after an injury carries a higher risk, which is why many surgeons wait for movement to return before ACL reconstruction. Infection, although uncommon, must always be considered when a knee becomes stiff, hot and painful.

What helps in the first weeks

Prevention is far easier than treatment. Before surgery, aim for a quiet knee with good straightening. After surgery, the priorities are usually full straightening first, then steady progress in bending, with control of pain and swelling so that exercises are possible.

• Do your straightening exercises several times a day, including resting with the heel on a rolled towel and the knee unsupported
• Avoid a pillow under the knee when lying down
• Take pain relief as advised so you can exercise
• Use ice and elevation to control swelling
• Tell your surgeon or physiotherapist early if you are not reaching the agreed milestones

In Doha, many patients combine sessions at the hospital with a daily home programme. If you plan to fly home or travel in the first weeks, discuss it first so your rehabilitation is not interrupted.

When physiotherapy is not enough

Dr. Gelber examines the knee, measures the range of movement, checks the kneecap's mobility and looks for warmth or swelling. X-rays check the position of implants or fixation, and MRI can show a cyclops lesion or scar tissue. Blood tests or a fluid sample are used if infection is a possibility.

If progress has stalled despite good rehabilitation, options include:

• Manipulation under anaesthesia: while you are asleep, the surgeon gently bends the knee to break early, soft adhesions, most useful in the first weeks to few months after knee replacement
• Arthroscopic release: removing scar tissue, a cyclops lesion or tight bands through small incisions, often combined with manipulation
• Open release or revision surgery: for long-standing or severe stiffness, or when a component or graft position is the cause

Any procedure is followed straight away by intensive physiotherapy, because the gain made in theatre must be kept by daily work in the weeks that follow.

Recovery and when to book

Movement often continues to improve for months, so stiffness at six weeks is not the final result. Bending needed for daily life in Qatar, such as getting into a car, climbing stairs, sitting on a low majlis seat or kneeling, is discussed openly when goals are set, and some patients pray seated on a chair while recovering; the ruling can be discussed with a scholar.

Book a review at Aman Hospital if you cannot fully straighten your knee, if bending has stopped improving, or if you are unsure whether your progress is normal. If the stiff knee is also hot, red or very painful, or you have a fever, seek urgent care the same day. A second opinion is also welcome if your surgery was done elsewhere.