**5. Lysis of adhesions**

### **5.1 History and physical examination**

Arthrofibrosis is the development of intra-articular scarring and adhesions due to trauma, previous surgery, prolonged immobilization and infection. In general, arthrofibrosis of the anterior structures of the knee cause of loss of flexion, while scarring of the posterior structures can cause loss of extension. Scarring and adhesions lead to loss of capsular compliance and pain. 29

Physical examination of the patella typically exhibits decreased excursion in all directions. Tenderness in the region of the supra-patellar pouch and/or infrapatellar fat pad is common, along with loss of range of motion.

If arthrofibrosis is recognized early, non-operative measures such as physical therapy modalities, range of motion exercises and anti-inflammatory medications may successfully improve motion. Manipulation under anesthesia has been a commonly performed procedure, however it is falling out of favor due to complications such hemarthrosis, which can predispose to further scar tissue formation, distal femur fractures and patellar tendon rupture. Arthroscopic lysis of adhesions avoids these complications and allows for controlled, focused treatment.
