Knee Surg Sports Traumatol Arthrosc (2010) 18:194–199

DOI 10.1007/s00167-009-0947-1

KNEE

Static progressive stretch improves range of motion

in arthrofibrosis following total knee arthroplasty
Peter M. Bonutti • German A. Marulanda •

Mike S. McGrath • Michael A. Mont •

Michael G. Zywiel

Received: 27 April 2009 / Accepted: 21 September 2009 / Published online: 14 October 2009
Ó Springer-Verlag 2009

Abstract Arthrofibrosis is a relatively common compli-
cation after total knee arthroplasty that negatively affects
function and quality of life. Static progressive stretching is
a technique that has shown promising results in the treat-
ment of contractures of the elbow, ankle, wrist and knee.
This study evaluated a static progressive stretching device
as a treatment method for patients who had refractory knee
stiffness after total knee arthroplasty. Twenty-five patients
who had knee stiffness and no improvement with con-
ventional physical therapy modalities were treated with the
device. After a median of 7 weeks (range, 3–16 weeks),
the median increase in range of motion was 25° (range,
8–82°). The median gain in knee active flexion was 19°
(range, 5–80°). Ninety-two percent of patients were satis-
fied with the results. The authors believe static progressive
stretching devices may be an effective method for
increasing the ranges of motion and satisfaction levels of
Each author certifies that his or her institution has approved
the reporting of these cases, that all investigations were conducted
in conformity with ethical principles of research, and that informed
consent for participating in the study was obtained.
Level of Evidence: Therapeutic Level IV.
P. M. Bonutti
Bonutti Clinic, 1303 W Evergreen Ave, Effingham,
IL 62401, USA
G. A. Marulanda
Department of Orthopaedics and Sports Medicine,
University of South Florida, 12901 Bruce B. Downs Blvd,
Tampa, FL 33612, USA
M. S. McGrath
M. A. Mont (&)
M. G. Zywiel
Rubin Institute for Advanced Orthopedics, Center for Joint
Preservation and Replacement, Sinai Hospital of Baltimore,
2401 W Belvedere Ave, Baltimore, MD 21215, USA
e-mail: mmont@lifebridgehealth.org; rhondamont@aol.com
patients who develop arthrofibrosis after total knee
arthroplasty.
Keywords Total knee replacement
Knee extension

Knee flexion
Knee orthosis
Introduction
Arthrofibrosis is a common complication after total knee
arthroplasty (TKA), with the reported incidence ranging
between 1 and 15% depending on the authors’ diagnostic
criteria [8, 10, 18, 19, 25]. The disorder has been defined as
painful stiffness with scarring and soft tissue proliferation
[1, 20], and synovial membrane thickening and neovascu-
larity are characteristic sonographic findings of the disease
[1]. Several treatments for this condition have been
described, including manipulation under anesthesia,
strengthening exercises, and structured surgical and phys-
ical therapy algorithms [11, 20]. However, the effective-
ness of these interventions is still controversial, particularly
non-surgical interventions, with varying reported outcomes
[20, 22, 23].
Knee stiffness may occasionally occur in the setting of
well-fixed and aligned components in the absence of
infection. In these cases, the main objective is to improve
function while ideally avoiding invasive surgical proce-
dures such as arthroscopic debridements, external fixators
and revision arthroplasty, which can be costly and carry a
risk of complications. Non-invasive alternatives have been
extensively used in an attempt to improve symptoms,
including various orthoses, casting techniques [6, 17, 24],
and intensive rehabilitation protocols with and without the
use of assistive devices [6, 11, 20]. If effective in
improving range of motion, the use of non-invasive

123
Knee Surg Sports Traumatol Arthrosc (2010) 18:194–199
modalities for the treatment of knee arthrofibrosis reduces
costs and complications and improves patient satisfaction
[2, 20].
Many non-invasive assistive devices used to treat post-
operative knee arthrofibrosis apply either creep or stress
relaxation principles to restore the mobility of the affected
joint. Creep loading utilizes low-load prolonged force,
often provided by springs or elastic bands, to gradually
stretch soft tissue. In contrast, stress relaxation maintains
the joint in a fixed position near the end range of motion.
As the soft tissue fibers accommodate to this fixed position,
their resistance to stretch gradually decreases. Static pro-
gressive stretch is a technique in which stress relaxation is
applied to a joint, but the displacement is increased at
timed intervals as the tissue remodels and the resistance to
stretch decreases [2]. Successful results using an adjustable
orthosis to provide static progressive stretch have been
reported for the treatment of joint stiffness of the elbow,
ankle, wrist, forearm and knee [2, 3, 6, 14, 15, 24]. The first
author (P.M.B.) previously described the results of this
device in a large patient population with knee arthrofibrosis
after multiple knee surgical procedures such as anterior
cruciate ligament reconstruction, open reduction and
internal fixation of fractures about the knee, and unicom-
partmental knee replacements [2].
The objective of this study was to assess the use of a
static progressive stretching device for the treatment of
arthrofibrosis after TKA and evaluate the knee range of
motion, the duration of treatment, patient satisfaction with
the device, as well as the development of any complica-
tions related to treatment. It was hypothesized that home-
based therapy using a static progressive stretch orthosis
would successfully increase the range of motion of stiff
total knee arthroplasties, with few complications and high
patient satisfaction. Additionally, we sought to investigate
whether patient factors such as gender, age and length of
time between total knee arthroplasty and start of treatment
were associated with range of motion.
Materials and methods
All 25 patients seen between 2006 and 2007 who had knee
stiffness after TKA and who had failed standard postop-
erative physical therapy interventions were treated with a
patient-directed, bidirectional orthotic device that provided
static progressive stretch. Knee stiffness was defined as
active flexion of less than 90° and/or a flexion contracture
that negatively impacted function as reported by the
patient. All patients were evaluated radiographically to
ensure that there were no bony deformities, malaligned
components or component-related failures that could be
responsible for difficulties with motion. We excluded any
195
patients who had malalignment, impingement, joint infec-
tion, heterotopic ossification or other osseous deformities
that could explain the limited range of motion in this study.
The study protocol was reviewed and approved by our
Institutional Review Board, and written consent for par-
ticipation was obtained before initiation of treatment for
each patient.
The study group included 18 men and seven women
who had a median age of 53 years (range, 31–79 years).
All of the patients had previously undergone manipula-
tion under anesthesia to treat the arthrofibrosis but con-
tinued to have knee stiffness after the procedure. Each
patient had previously received standard physical ther-
apy, which included stretching, range-of-motion therapy,
strengthening exercises, gait training and ultrasound. In
each case, the physical therapist determined that the knee
stiffness would not improve using conventional available
techniques and, at that time, the device was
recommended.
The orthosis used in this study was the JAS Knee device
(Joint Active Systems, Effingham, Illinois; Fig. 1). The
device consists of a hinged metal brace with padded cuffs
at either end. One proximal cuff wraps around the thigh
while a distal cuff encircles the lower leg. Using a
racheting lever incorporated into the central tower of the
device, the working angle of the orthosis can be adjusted
and locked to various angles between 20° of hyperexten-
sion and 160° of flexion. To apply the orthosis, the brace is
adjusted to a position matching the existing angle of
maximal flexion. The orthosis is then positioned over the
knee with the center of the brace placed over the patella,
with the patient sitting on at the edge of a chair. Neoprene
wraps are placed between the cuffs and the skin to ensure
maximal contact between the device and the skin, and the
cuffs are securely fastened using the incorporated straps.
Printed instructions on applying the device and its use were
provided to all patients. Additionally, patients were shown
in clinic how to place the orthosis on the extremity and to
adjust the angle until they felt a gentle stretch. The process
was reversed for the treatment of flexion contracture, with
the brace adjusted to the patient’s maximal extension fol-
lowed by decrease in the brace angle until a gentle stretch
was felt in extension.
Patients followed the provided protocol at home by first
applying the brace and adjusting it to provide gentle stretch
and maintaining it for 5 min. At that time, the intensity of
the stretch was subjectively assessed, and if it had
decreased, the angle of the device was adjusted until the
gentle stretch was attained again. This assessment and
readjustment was repeated every 5 min for a 30 min
treatment session. If the patient required increases in both
flexion and extension, then he or she allocated 30 min for
each movement for a total of 60 min per session. Patients
123
196
Fig. 1 Static progressive stretch orthosis applied in flexion to a
patient with knee stiffness following total knee arthroplasty
underwent one treatment session per day for the first 5 days
and then increased the frequency as tolerated to a maxi-
mum of 3 sessions per day. Treatments were continued
until no further improvements were being achieved for at
least 1 week. All of the patients completed the treatment
protocol in a median of 7 weeks (range, 3–16 weeks).
None of the patients received any additional therapy or
operative treatment for knee stiffness between the start of
the study and the final follow-up.
Patients were followed for a median of 22 months
(range, 10–24 months), including weekly clinic visits
during the period of static progressive stretch device use.
We recorded the duration of treatment, range of motion,
patient satisfaction and complications for each patient.
At each visit, the range of motion was measured with a
long-arm goniometer by a single physical therapist. The
lower extremity was examined for any injuries or skin
complications associated with use of the device, specifi-
cally skin redness in the area of contact of the device cuffs,
skin compromise, or new onset paresthesia or palsy of the
lower extremity. At last follow-up, each patient was asked
to rate their satisfaction with the device using an 11 point
Likert scale with 0 indicating complete dissatisfaction and
10 indicating total satisfaction.
123
Knee Surg Sports Traumatol Arthrosc (2010) 18:194–199
Statistical analysis
Pre-treatment and final ranges of motion were compared
using a paired t-test. The Pearson product moment was
used to test correlation between increase in range of motion
and patient gender, age and length of time from total knee
arthroplasty to start of treatment. Finally, multiple linear
regression was used to investigate the association among
all three factors (age, gender and time from surgery to start
of treatment) to determine whether any of these factors
were associated with the range of motion. All statistical
analyses were performed with the SigmaStat software
package (Systat Corporation, San Jose, California).
Results
All patients experienced an increase in active flexion,
active extension and total active arc of motion with the use
of the device. The median increase in range of motion from
the start of treatment to final follow-up was 25° (range,
8–82°), for a total median range of motion of 105° (range,
61–137°). The median gain in knee active flexion was 19°
(range, 5–80°), and the median gain in active extension was
7° (4–18°). An overview of pre-treatment and post-treat-
ment ranges of motion can be found in Table 1.
Twenty-three of 25 patients (92%) were satisfied with
the results of treatment with the device, reporting a satis-
faction score of 6 or more. The median satisfaction score
was 9 points (range, 1–10 points). Two patients reported
dissatisfaction with the device. One patient was a 53-year-
old man who had been diagnosed with complex regional
pain syndrome. He used the device for 4 weeks, and at final
follow-up gained 8° in his total arc of motion. This patient
continues to have knee pain despite multiple non-operative
interventions and reported a satisfaction rating of 1 point.
A second patient had a satisfaction score of 2 points. This
patient was a 47-year-old man who used the device for
5 weeks and had an overall gain in range of motion of 17°
(2° in active extension and 15° in active flexion) after the
use of the device but retained a 13° flexion contracture at
the end of treatment and at latest follow-up.
No independent correlation was identified between the
magnitude of increase in range of motion and patient
gender (P = 0.93), age (P = 0.43) and length of time
before treatment (P = 0.25). Similarly, multiple linear
regression analysis did not reveal an ability to predict the
final gain in range of motion from patient gender
(P = 0.85), age (P = 0.68) or time before treatment
(P = 0.34).
No injuries, skin compromise, nerve palsies or other
complications associated with the use of the device were
reported.
Knee Surg Sports Traumatol Arthrosc (2010) 18:194–199
Table 1 Range of motion before and after treatment with static progressive stretch
Pre-treatment
Median total range of motion (°) 76 (23–112)
Median active flexion (°) 90 (38–120)
Median active extension (°) -13 (-21 to -7)
Discussion
The most important finding of the present study was that
the use of a static progressive stretch using a patient-
directed bidirectional orthotic device for the treatment of
joint stiffness following total knee arthroplasty effectively
increases total range of motion, including both flexion and
extension. Most patients were satisfied with the results of
this treatment and were compliant with the instructions for
its use. No complications were found in this study related
to the use of this device, and the results of its use did not
appear to be dependent on patient factors such as gender,
age or length of time between surgery and start of
treatment.
We acknowledge several limitations to our study. The
use of a long-arm goniometer for the measurement of range
of motion may limit the accuracy of the collected data.
However, two of the present authors have previously
reported inter- and intra-observer variability with this
technique of 3° or less in 100% of cases for knee extension,
and 95% of cases for knee flexion [13]. Because of this, we
do not believe that the conclusions of the present study
would be altered with the use of more advanced instru-
ments. Additionally, the relatively small patient population
limits the power of the statistical analyses performed, and
the lack of a matched control group precludes direct
comparison of the results of the use of the reported device
to other operative or non-operative interventions for the
treatment of knee stiffness following total knee arthro-
plasty. However, all patients experienced improvement in
range of motion, and 92% reported positive satisfaction
with the device. The authors believe that these consistent
benefits observed after a relatively short time of use, and
the avoidance of anesthesia and/or surgical intervention
through the use of this non-invasive modality, support the
use of a static progressive stretch device as an effective
treatment to improve motion in patients with stiff total
knee arthroplasties. No contraindications for the use of the
static progressive stretch orthosis evaluated in the present
study were identified.
Dynamic splinting devices, which use the principle of
creep loading, have been previously evaluated for the
treatment of arthrofibrosis of the knee. These devices
provide a continuous, low-load stretching force on the
joint, with a spring-like mechanism maintaining the force
197
Post-treatment Change
105 (61–137) 25 (8–82)
110 (64–137) 19 (5–80)
-5 (-14 to 0) 7 (2–15)
as the tissue stretches and the joint flexes or extends. Finger
and Willis reported a case of a patient with a 20° knee
flexion contracture following total knee arthroplasty that
did not resolve following 28 physical therapy sessions, but
who was able to achieve full extension with an additional
8 weeks of treatment with a creep loading device [7]. The
authors did not report any further follow-up past the end of
treatment. Steffen and Molliger [21] investigated the
treatment of nursing home patients with bilateral knee
contractures with passive range of motion and manual
stretching therapy in both limbs, with the additional use of
a creep loading splint in one limb. The authors found no
difference in the range of motion between the two treat-
ment groups after 24 months of treatment. Additionally,
they reported that range of motion increased in 12 of 18
limbs treated with creep loading and decreased in 5 limbs.
In contrast, favorable results were obtained in the present
study after a median treatment time of 7 weeks, with a gain
in range of motion in all knees, and with a 92% patient
satisfaction rate.
Stress relaxation is an alternative technique to increase
range of motion, and it is based on stretching the joint past
the end of the active arc of motion and bracing it in posi-
tion for a prolonged period of time. As the tissues stretch,
the force applied by the brace gradually decreases.
A common application of these principles is serial casting
for deformity correction. Fernandez-Palazzi and Battistella
[6] treated 58 hemophiliac patients with knee flexion
contractures using 4–6 weeks of serial casting and wedg-
ing, increasing the angle of bracing every 2–3 days. The
authors found an improvement in mean flexion deformity
from 43° (range, 15–90°) to 9° (range 0–30) at completion
of treatment. The static progressive stretch orthosis eval-
uated in the present report incorporates the principles of
stress relaxation but increases the displacement at consid-
erably more frequent intervals (every 5 min in the protocol
used, when compared to a typical frequency of once every
few days for serial casting) as the end point of the joint
motion arc shifts.
Several additional reports have described the use of
static progressive stretching for joint motion problems.
Jansen et al. reported the treatment of a single patient with
knee stiffness following total knee arthroplasty with a
brace that applied static progressive stretch to the affected
limb. Following 29 days of treatment, the patient was able
123
198
to achieve a 17° increase in arc of motion, which was
maintained at 6 month follow-up [9]. Seyler and coinves-
tigators reported that 29 patients gained a mean of 22° in
total range of motion of the knee after a mean of 14 weeks
using a similar device [20]. Additional reports have dem-
onstrated successful results for the use of a similar static
progressive stretch orthosis for the treatment of wrist
stiffness, deficiencies in forearm rotational motion and
knee contractures [2, 14, 15]. Those results are similar to
the findings reported in the present study, where patients
experienced a median increase in total active arc of motion
of 25° with a median of 7 weeks with the use of a static
progressive stretching device.
Manipulation under anesthesia is recommended by
many authors as a first-line treatment for stiffness follow-
ing knee arthroplasty in patients who fail physical therapy
interventions and whose motion deficits are not attributed
to surgical error [4, 12, 25]. Yercan et al. [25] reviewed 46
knees that underwent manipulation under anesthesia fol-
lowed by treatment with continuous passive motion and
outpatient physical therapy, finding a mean improvement in
range of motion of 47° (range not reported) at a mean
follow-up of 31 months (range not reported). Mohammed
et al. [16] recently reviewed the results of manipulation
under anesthesia in 21 patients, finding a mean improve-
ment in range of motion of 30° at 3 month follow-up. Esler
et al. [5] prospectively studied the results of manipulation
under anesthesia in 47 stiff knees following total knee
arthroplasty, finding a mean improvement in range of
motion of 33° at 1 year follow-up. The median improve-
ment in range of motion of 25° observed in the present
study is similar to these results but was achieved without
requiring the patient to undergo in-hospital treatment or
anesthesia, limiting the costs involved with bringing
patients to the operating suite.
Conclusion
Static progressive stretch using a bi-directional adjustable
orthosis and a home-based, patient-directed treatment
protocol appears to effectively increase range of motion in
patients who have stiff total knee arthroplasties, with
minimal complications and high levels of patient satisfac-
tion. The results obtained seem to be independent of patient
factors such as gender, age, and length of time since total
knee arthroplasty at least up to 12 weeks following index
surgery. The use of this device may be an excellent first
choice of treatment modality in patients with persistent
knee stiffness following total knee arthroplasty, prior to
manipulation under anesthesia or lysis of adhesions. We
await additional data to confirm that these results are
maintained at longer term follow-up, and when compared
123
Knee Surg Sports Traumatol Arthrosc (2010) 18:194–199
to a control group that underwent other operative or non-
operative interventions.
Acknowledgments We would like to thank Gina Zerrusen for her
help in the preparation of this manuscript.
References
1. Boldt JG, Munzinger UK, Zanetti M, Hodler J (2004) Arthrofi-
brosis associated with total knee arthroplasty: gray-scale and
power Doppler sonographic findings. AJR Am J Roentgenol
182:337–340
2. Bonutti PM, McGrath MS, Ulrich SD, McKenzie SA, Seyler TM,
Mont MA (2008) Static progressive stretch for the treatment of
knee stiffness. Knee 15:272–276
3. Bonutti PM, Windau JE, Ables BA, Miller BG (1994) Static
progressive stretch to reestablish elbow range of motion. Clin
Orthop Relat Res 303:128–134
4. Brassard MF, Insall JN, Scuderi GR (2001) Complications of
total knee arthroplasty. In: Complications of total knee arthro-
plasty. Insall JN, Scott WN (eds) Surgery of the knee. Churchill
Livingstone, Philadelphia, pp 1801–1844
5. Esler CN, Lock K, Harper WM, Gregg PJ (1999) Manipulation of
total knee replacements. Is the flexion gained retained? J Bone
Joint Surg Br 81:27–29
6. Fernandez-Palazzi F, Battistella LR (1999) Non-operative treat-
ment of flexion contracture of the knee in haemophilia. Haemo-
philia 5(Suppl 1):20–24
7. Finger E, Willis FB (2008) Dynamic splinting for knee flexion
contracture following total knee arthroplasty: a case report. Cases
J 1:421
8. Gollwitzer H, Burgkart R, Diehl P, Gradinger R, Buhren V
(2006) Therapy of arthrofibrosis after total knee arthroplasty.
Orthopade 35:143–152
9. Jansen CM, Windau JE, Bonutti PM, Brillhart MV (1996)
Treatment of a knee contracture using a knee orthosis incorpo-
rating stress-relaxation techniques. Phys Ther 76:182–186
10. Kim J, Nelson CL, Lotke PA (2004) Stiffness after total knee
arthroplasty. Prevalence of the complication and outcomes of
revision. J Bone Joint Surg Am 86:1479–1484
11. Magit D, Wolff A, Sutton K, Medvecky MJ (2007) Arthrofibrosis
of the knee. J Am Acad Orthop Surg 15:682–694
12. Maloney WJ (2002) The stiff total knee arthroplasty: evaluation
and management. J Arthroplasty 17:71–73
13. McGrath MS, Mont MA, Siddiqui JA, Baker E, Bhave A (2009)
Evaluation of a custom device for the treatment of flexion con-
tractures after total knee arthroplasty. Clin Orthop Relat Res
467:1485–1492
14. McGrath MS, Ulrich SD, Bonutti PM, Marker DR, Johanssen
HR, Mont MA (2009) Static progressive splinting for restoration
of rotational motion of the forearm. J Hand Ther 22:3–8
15. McGrath MS, Ulrich SD, Bonutti PM, Smith JM, Seyler TM,
Mont MA (2008) Evaluation of static progressive stretch for the
treatment of wrist stiffness. J Hand Surg Am 33:1498–1504
16. Mohammed R, Syed S, Ahmed N (2009) Manipulation under
anaesthesia for stiffness following knee arthroplasty. Ann R Coll
Surg Engl 91:220–223
17. Phillips WE, Audet M (1990) Use of serial casting in the man-
agement of knee joint contractures in an adolescent with cerebral
palsy. Phys Ther 70:521–523
18. Ranawat CS, Ranawat AS, Mehta A (2003) Total knee arthro-
plasty rehabilitation protocol: what makes the difference?
J Arthroplasty 18:27–30
Knee Surg Sports Traumatol Arthrosc (2010) 18:194–199
19. Scranton PE Jr (2001) Management of knee pain and stiffness
after total knee arthroplasty. J Arthroplasty 16:428–435
20. Seyler TM, Marker DR, Bhave A, Plate JF, Marulanda GA,
Bonutti PM, Delanois RE, Mont MA (2007) Functional problems
and arthrofibrosis following total knee arthroplasty. J Bone Joint
Surg Am 89(Suppl 3):59–69
21. Steffen TM, Mollinger LA (1995) Low-load, prolonged stretch in
the treatment of knee flexion contractures in nursing home
residents. Phys Ther 75:886–895
22. Wang JH, Zhao JZ, He YH (2006) A new treatment strategy for
severe arthrofibrosis of the knee. A review of twenty-two cases.
J Bone Joint Surg Am 88:1245–1250
199
23. Wang JH, Zhao JZ, He YH (2007) A new treatment strategy for
severe arthrofibrosis of the knee. Surgical technique. J Bone Joint
Surg Am 89(Suppl 2 Pt.1):93–102
24. Westberry DE, Davids JR, Jacobs JM, Pugh LI, Tanner SL (2006)
Effectiveness of serial stretch casting for resistant or recurrent
knee flexion contractures following hamstring lengthening in
children with cerebral palsy. J Pediatr Orthop 26:109–114
25. Yercan HS, Sugun TS, Bussiere C, Ait Si Selmi T, Davies A,
Neyret P (2006) Stiffness after total knee arthroplasty: preva-
lence, management and outcomes. Knee 13:111–117
123