Official Title: Comparison of Graston Technique With Tissue Flossing Technique in Patient With Post-Operative Knee Stiffness

Stiffness has been defined as a decrease in postoperative range of motion (ROM), including flexion contracture, accompanied by persistent pain and/or functional compromise (1). Post-traumatic stiffness may result from dense intra-articular adhesions and fibrotic transformation of periarticular structures (2). The knee joint, crucial for lower-limb biomechanics, is the most frequently injured joint in the lower extremities (3). Post-traumatic knee stiffness and loss of ROM are common complications following knee injuries. The normal ROM of the knee joint is generally accepted to be 0° (full extension) to 135° (full flexion). A stiff knee is defined as one with a total ROM of less than 50°, while an ankylosed knee is characterized by a ROM of less than 30° (4). Knee joint stiffness may result from several factors, including periarticular surgeries, traumatic injuries, inflammatory or infectious joint diseases, fractures, prolonged immobilization, and scar formation due to burns or trauma. Post-surgical procedures such as open reduction and internal fixation (ORIF) may also contribute to stiffness through scar tissue formation and reduced joint mobility (5). The choice of fixation method for femoral or tibial fractures depends on the fracture type and anatomical location. For femoral shaft fractures, intramedullary (IM) nailing is considered the gold standard. Stabilization of femoral or tibial fractures can also be achieved through ORIF using screws, plates, or rods. In cases with compromised skin integrity at the fracture site, external fixation provides a temporary solution, using external frames to align the bones (6) Diagnosis of post-operative knee stiffness is based on reduced knee flexion and extension after surgery, commonly following ORIF of femur, tibia, or fibula fractures. Literature defines stiffness as total knee ROM <50° and ankylosis when <30°. Clinical judgment with goniometric assessment and functional evaluation using WOMAC and FIM questionnaires provides valid measures. Previous studies suggest intra-articular adhesions, fibrotic changes, and prolonged immobilization as primary contributors to post-operative knee stiffness.

Various therapeutic interventions have been developed to address this issue, myofascial compression technique, i.e., Graston Technique and tissue flossing emerging as promising approaches. The Graston Technique (GT) is a therapeutic approach known as instrument-assisted soft tissue mobilization (IASTM). GT uses specialized tools to massage and scrape the skin, reducing pain and targeting tissue restrictions that cause dysfunction. The Graston Technique supports soft tissue healing by enhancing blood flow (vasodilation) to the affected area, which can accelerate recovery and reduce stiffness (7).

The Graston Technique, instrument-assisted soft tissue mobilization (IASTM), has shown efficacy in improving range of motion and reducing pain in various musculoskeletal conditions. Studies have demonstrated its effectiveness in treating chronic low back pain, with significant improvements in pain reduction and increased range of motion compared to general exercise alone (8).

The technique has also been found to be beneficial in addressing postoperative elbow stiffness, showing greater improvements in pain reduction and patient-specific function compared to other soft tissue mobilization techniques (9)

. For instance, a study on patients with anterior knee pain found that IASTM techniques, including the Graston Technique, were as effective as stretching exercises in reducing pain, improving flexibility, and enhancing lower extremity function in patients with iliotibial band tightness (10).