Diagnosis and Management of Knee Arthrofibrosis and Associated Pain-Related Fear Using Multidimensional Clinical Reasoning and Exposure In Vivo Concept: A Case Report

BACKGROUND: A plethora of treatment approaches are used to manage persistent pain, disability, and fear associated with restricted knee range of motion following knee surgery. We used the pain and disability driver model (PDDM) and exposure in vivo (EIV) concepts to manage pain-related fear and disability. CASE PRESENTATION: A 68-year-old male who underwent arthroscopic partial meniscectomy presented to physical therapy with a medical diagnosis of Complex Regional Pain Syndrome Type I (CRPS-I) and knee range of motion restriction. Despite extensive medical care and physical therapy for three years (202 visits) he continued to experience debilitating knee pain and demonstrated a high level of fear. To ambulate, he wore a knee brace and used a trekking pole. OUTCOME AND FOLLOW UP: Interventions to address the knee stiffness included combined tibiofemoral joint mobilization and high velocity low amplitude thrust manipulation (HVLAT) targeting tibial internal rotation and low load long duration sustained capsular stretching using total end range time (TERT) principle for extension. His fear was managed using techniques inspired by in vivo exposure concepts. Total knee range of motion improved 110 degrees and the patient was able to ambulate for 30 minutes (0.5 mile) without an assistive device with <2/10 pain intensity. DISCUSSION: Outside-the-box clinical reasoning suggested poor outcomes with previous interventions were likely due to hypervigilance and pain-related fear. This case delineates the value of non-reductionist clinical reasoning in diagnosis and management of musculoskeletal conditions. It also outlines how the exposure in vivo approach helped the patient overcome his long-established avoidance behaviors.