The purpose of this study was to compare the effects of Graston Technique and Tissue Flossing Technique in patients with post-operative knee stiffness on pain, range of motion, and functional outcomes. A randomized controlled trial was conducted at Benazir Bhutto Hospital, Rawalpindi. The total sample size was 48, divided into three groups. The study duration was six months. Purposive sampling was applied for recruitment, and group randomization was performed by lottery method. Only patients with post-operative knee stiffness meeting the inclusion criteria were enrolled. Outcome measures included goniometer, Functional Independence Measure (FIM), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires. Data was collected at baseline and after interventions, and analysis was performed using SPSS version 23.

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).

Similarly, compressive myofascial release techniques have demonstrated effectiveness in increasing ankle dorsiflexion range of motion (11).

Tissue flossing, on the other hand, utilizes a floss band that is elastic rubber band designed to wrap around joints or muscle groups before or during exercise or stretching. The primary mechanism involves blood flow restriction (BFR), creating temporary tissue ischemia, followed by blood flow reperfusion upon removal, which can boost metabolic responses (3).

Tissue flossing is a novel technique gaining popularity in athletic training and rehabilitation for its potential effects on joint range of motion (ROM) and muscle function. Studies have shown that floss band application on limbs, soft tissues, or joints with approximately 50% tension wrapping pressure can have small to medium effects on ROM, muscle stiffness, and strength (12).

Research on the effects of tissue flossing on joint stiffness has produced mixed results. Some studies have reported positive outcomes, such as increased ankle ROM and improved jump and sprint performance in recreational athletes (13).

The Graston Technique and tissue flossing are two techniques that aim to improve soft tissue mobility and joint function through distinct mechanisms. The former employs specialized instruments for soft tissue mobilization, while the latter uses compression and subsequent modulation of blood flow.

The lack of direct comparisons between these techniques underscores the potential significance of study investigating their comparative efficacy in treating post-operative knee stiffness. Such research could substantially contribute to the existing body of knowledge regarding soft tissue mobilization techniques and their applications across various musculoskeletal conditions, thereby providing clinicians with valuable insights.

Inclusion Criteria:

1. Age group between 20 to 40 years.
2. Both male and female.
3. Patients with 6 weeks post-operative following open reduction and internal fixation (ORIF) of femur, tibia, or fibula shaft fracture
4. Decreased in knee Flexion & Extension (A minimum of 20° or above).

Exclusion criteria:

1. Those patients who have allergies to latex
2. Malignant or metabolic cause of knee fracture
3. Venous Thrombotic disease/ Varicose veins.
4. Cardiopulmonary illness and hypertension.
5. Skin diseases/ metabolic disorders.
6. Patient with arthroplasty and arthroscopy.
7. Patellar fracture/ ACL/ PCL/ MCL/ LCL rupture/ injuries.
8. Any pathological condition having effects on knees.