Episode 260 | Arthrofibrosis After ACLR: Trusting Your Gut When Rehab Isn’t Adding Up

What is up team? Welcome back to another episode of the ACL Athlete Podcast. Today, I want to talk about something that does not get enough attention in ACL rehab, and that is listening to your gut when your knee just does not feel right. A lot of athletes know something is off, but they are told to work through it anyway. This is a common experience, and it often creates confusion between what the body is signaling and what guidance is being given. That disconnect can be frustrating and, at times, harmful. The key point here is that your intuition about your own body matters.

I see this scenario all the time. You are working hard, staying consistent, and checking all the boxes. You are doing the work day in and day out, yet the knee still feels stiff no matter what. It may not fully straighten or bend, and it gets irritated very quickly. It can feel blocked, tight, jammed, or like there is a wall you cannot get past. This often shows up with extension, though it can also happen with flexion, and it simply does not progress the way it should.

When this happens, the usual response is that scar tissue is normal, you just need more time, or you should push through it. Sometimes that advice is appropriate, but sometimes it is not. I have worked with many ACL athletes who are months into rehab, have been seeing their physical therapist and surgeon consistently, and are still dealing with these issues. Early challenges with extension can be normal, and certain graft types can make this more difficult. However, when someone is doing everything right, and the progress still does not add up, that is when concern is warranted.

A common pattern is that extension briefly improves but does not hold. You may work for ten, twenty, or even sixty minutes to regain it, only to lose it again after sitting or bending the knee. It may not be a dramatic loss, but instead a subtle regression from hyperextension back to zero or a few degrees short. Many athletes recognize this immediately because it feels familiar. While these experiences will resonate with many people, this is not a call to immediately run to your surgeon or physical therapist, declaring a problem. It is, however, a reminder to listen to your gut when something consistently does not add up.

One possible explanation for this pattern is arthrofibrosis, which is excessive scar tissue formation in the knee. Scar tissue is a real and natural byproduct of the inflammatory healing process after surgery. Sometimes that tissue interferes with normal movement. It can present as a cyclops lesion, where tissue builds up in front of the ACL and limits full extension. In my experience, this occurs more frequently than the research suggests and may be more common with quadriceps autografts, potentially due to graft thickness and stress responses in the tissue.

Scar tissue can also accumulate in other areas of the knee, including around the patella, fat pad, or anterior compartment. In some cases, clean-out procedures or releases are necessary, particularly when extension or flexion remains limited over time. There are athletes whose range of motion is severely restricted for months, such as being stuck at seventy or ninety degrees of flexion or lacking five to ten degrees of extension. This can lead to pain, swelling, altered walking mechanics, and difficulty progressing with strength. While arthrofibrosis is reported in roughly two to ten percent of ACL reconstruction cases, it is difficult to define and measure, and it exists on a wide spectrum.

One of the challenges is that issues like cyclops lesions do not always develop early and may appear months later, depending on the athlete and their situation. The percentage may seem small, but many people experience some variation of this. This is why it is critical to have a surgeon and physical therapist who are consistently assessing both objective measures and subjective symptoms. There is also an important distinction between athletes who are fully compliant with rehab and those who are not. If the work is not being done, range-of-motion limitations may be related to compliance rather than internal knee issues.

However, if you are doing everything consistently and correctly, it is important to analyze what is happening and trust your instincts. These issues can significantly limit range of motion, prolong pain and swelling, alter movement mechanics, and even affect basic walking, often resulting in a noticeable limp. This can severely impede strength gains and overall progress. Rather than defaulting to the idea that everything will improve with time, it is essential to take a holistic view of the rehab process.

In our work, we constantly evaluate both how the knee looks objectively and how it feels subjectively. The goal is never to waste an athlete’s time. Extension issues can appear to improve temporarily, leading athletes to convince themselves things are getting better, even when measurements show otherwise. This is not a failure on the athlete’s part, but a reflection of the complex biological healing process the knee is undergoing. Surgery is a powerful medical intervention, but bodies respond differently, and listening closely to what your body is telling you can make all the difference.

There can be side effects after surgery, including issues related to scar tissue as a byproduct of the inflammatory healing process. I see many situations where, around the three-month mark, things are not adding up, and the athlete goes back to the surgeon. Often, the response is to keep working on it because it seems to be getting better. Surgeons usually do not remember where your extension was previously and are relying on a brief five- or ten-minute exam. In some cases, that reassurance is appropriate. In many others, I have seen athletes working extremely hard at months three and four with no meaningful improvement.

Instead of hoping it will get better with time, this is where getting answers matters. What has always confused me is how quickly imaging is ordered when an ACL is torn, yet when a patient, parent, or physical therapist has a strong concern later on, imaging is often dismissed. Unless the idea comes from the surgeon, it can feel like the request is shut down. That puts people in a very difficult position, even though patients do have the right to advocate for imaging through the medical system. In some cases, paying out of pocket may even be worth it if no one is willing to order it.

The best-case scenario is that the imaging comes back clean and the ACL is healing well. That outcome is a win, because it confirms the knee is structurally sound and allows everyone to confidently adjust rehab and push forward. However, in my experience, when we track symptoms carefully and follow both the athlete’s gut and our own, imaging often reveals a cyclops lesion or significant scar tissue. While I do not have an exact statistic, I would estimate that this happens close to ninety percent of the time in these specific cases. This is higher than what the research suggests, and it reinforces that real-world presentations often differ from published averages.

The decision then becomes whether the findings are significant enough to intervene. If the range of motion, symptoms, strength development, or basic function, like walking, are being impacted, something needs to be addressed. This is especially true when the athlete is consistent, and the knee is simply not improving. I worked with an athlete last year who had an extension issue after a quadriceps autograft, and we worked together from day one. By six to eight weeks, I had a strong hunch she had a cyclops lesion because the knee just did not feel right despite consistent effort.

We gave it time and worked through the gray area until about the three-month mark, adjusting swelling management, compression, step counts, and rehab variables. The extension issues and intermittent pain persisted, and my concern grew stronger. When I communicated this to the athlete, parents, and surgeon, it was initially dismissed with the recommendation to keep working through it. Eventually, after significant frustration, the surgeon agreed to proceed, and once inside the knee, there was extensive scar tissue and a large cyclops lesion. The entire situation could have been avoided with an earlier investigation.

This experience highlights why pushing through can backfire. If the limitation is muscular or capacity-based, rehab can address it. If scar tissue is mechanically blocking the joint, no amount of extra exercise will fix it. Scar tissue cannot be broken up by aggressive techniques or grinding harder, regardless of what anyone claims. Research also shows that delayed recognition of arthrofibrosis leads to longer rehab timelines, worse movement outcomes, and higher frustration and dropout rates. Pushing harder only inflames the issue further. 

I recently spoke with a parent whose daughter worked for months while saying her knee did not feel right, hoping someone would catch it. This is not about blaming the athlete, parent, therapist, or surgeon, but about recognizing when objective findings and subjective feelings do not align. Even with good physical therapy, athletes must be their own advocates and speak up, especially when progress stalls.

Listening early leads to better outcomes. Athletes who speak up and are properly evaluated tend to do better long term, particularly when intervention happens sooner rather than later. That intervention may be adjusting rehab, reducing load, getting imaging, or, in some cases, a minimally invasive cleanup. The goal is not surgery. The goal is not to waste months fighting the wrong problem and blaming yourself for something you cannot control.

If your gut says something is not right, listen to it. If strength is improving but motion, comfort, or symptoms are not trending in the right direction over time, that feedback matters. Advocating for yourself is not being difficult; it is being informed. Your knee is giving you information for a reason, and progress is not about grinding harder at all costs.

You need to be smarter in this process. This is challenging from the athlete’s side, the parents’ side, and the support system’s side because you are trusting the professionals who are supposed to be in your corner. You are listening to the people guiding your rehab and assuming all the important details are being monitored. Unfortunately, details do get missed. It should not be your responsibility to know exactly when something is wrong or when to escalate concerns. That responsibility belongs to your ACL team, but as we all know, this process is messy and imperfect.

There are many subjective feelings involved in ACL rehab, along with daily symptoms that fluctuate and are hard to interpret. Range of motion, in particular, often gets pushed to the back burner. There is a common assumption that it will improve with time, but in this process, it rarely does on its own. Many of you know this firsthand and can nod your head while reading this. When something is not improving, doing nothing is still a decision, and it usually leads to more frustration. That is why action matters when things are not adding up.

Listening to your body and speaking up early can save you months of frustration and keep rehab moving forward. Even if these issues show up later, around months six, seven, or eight, that is okay, and it does happen. The key is communicating clearly with the people you are working with and making sure they understand what you are feeling. Do not allow something that feels wrong to quietly become the new normal. The longer it goes unaddressed, the harder it can be to correct.

If this resonates with you, then do something about it. Trust your gut and advocate for yourself, especially if you are working as hard as possible and the knee still does not make sense. Support matters in this process, and having people who will listen and help you think through the next steps is critical. The goal is not to rush or panic, but to be intentional and informed.

We want this to be the shortest and most efficient rehab process possible so you can get back to doing what you love. No one should spend months grinding through frustration while the needle barely moves. Often, when that happens, it is because something else needs to be examined more closely. Advocating for yourself is the name of the game in healthcare and especially in ACL rehab. You have to look out for yourself while also surrounding yourself with a team that truly supports you every step of the way. That balance is what leads to better outcomes and less wasted time.

Until next time, this is your host, Ravi Patel, signing off.