Reluctant knee: understanding and managing stiffness after total knee arthroplasty

PURPOSE: Post-total knee arthroplasty (TKA) stiffness remains a clinically important cause of pain, restricted range of motion (ROM), functional limitation, and reintervention. This narrative review synthesises current evidence on the pathophysiology, evaluation, and staged management of post-TKA stiffness, with particular emphasis on manipulation under anaesthesia (MUA). METHODS: A narrative review was performed using literature relating to post-TKA stiffness, arthrofibrosis, diagnostic evaluation, rehabilitation, MUA, lysis of adhesions, and revision TKA. Evidence was synthesised thematically to support a practical diagnostic and management framework. RESULTS: Acquired idiopathic stiffness occurs in approximately 3.6% to 4.0% of TKAs, while MUA is required in roughly 2.6% to 3.6% of cases. The available literature supports a diagnosis-of-exclusion approach, in which infection, component malposition, instability, and other secondary causes are excluded before arthrofibrosis is diagnosed. MUA remains the principal first-line procedural intervention once early conservative measures fail. Earlier MUA, generally within 6-12 weeks, is associated with greater ROM gain than delayed intervention, although outcomes remain influenced by baseline ROM severity, patient selection, and the quality of post-manipulation rehabilitation. CONCLUSION: Post-TKA stiffness is a heterogeneous complication requiring structured evaluation and staged management. When MUA fails, escalation to arthrolysis or revision TKA should be individualised and guided by the distinction between persistent soft-tissue fibrosis and correctable mechanical pathology. A practical algorithm is proposed to support diagnosis, timing of intervention, and escalation after failed MUA.