MUA Manipulation Under Anesthesia After Total Knee Replacement

MUA Manipulation Under Anesthesia is a technique for treating stiffness and poor range of motion following knee replacement, knee revision, or other surgeries like patellar fracture.

It is a non-surgical knee bending procedure performed in a hospital or outpatient clinic. A patent is usually under general anesthesia.

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During knee surgeries interior tissues of the body are exposed to the air causing essential lubricating fluids within the body’s tissues to evaporate. If these crucial fluids are not quickly replenished after surgery, affected muscles which normally glide over each other may bind together.These muscles form adhesions, the ‘adhese’ to one another. This can cause great pain. But most important adhesions significantly limit your ability to move the affected joint.

You can solve light adhesions with physical therapy and therapeutic massage or fascia manipulation techniques. If, however, the adhesions are large and thick, the situation becomes a lot more serious and can compromise your recovery. In this case the recommended treatment to free the joint will likely be orthopedic Manipulation Under Anesthesia. For knee replacement patients, the incidence of adhesions and scar tissue requiring orthopedic MUA is low. The incidence of MUA is between 4 and 7% of all knee replacement patients.

The MUA Procedure

A manipulation uses specific maneuvers and physical techniques to break up fibrous adhesions around the joint and surrounding tissue. But you do not feel anything during the procedure: you are completely unaware of what is happening due to the anesthesia.

During an MUA after knee replacement you are positioned on your back and your hip is flexed to 90 degrees. With you leg held close to the knee joint, steady progressive pressure is applied until your surgeon can hear and feel your adhesions breaking away. The knee is held in this position for 20 to 30 seconds. It is then flexed and extended all the way to the maximum position several times.

Once Completed

When the procedure is complete you are released to go home. This is typically on the same day although some surgeons prefer to keep a patient overnight. In these instances the surgeon wants to ensure adequate pain management

After the procedure, active assisted physical therapy is recommended to keep the joint flexing and retard the formation of new adhesions. A machine like the X10 can be used to help a patient regain the extension and flexion the surgeon found in the MUA. In some instance the X10 is able to move the knee beyond what the surgeon was able to achieve during the procedure.

Pain Afterwards

It is not uncommon to experience significant pain following an MUA. You can make the pain manageable with icing of the knee and prescribed pain medication. There may be some swelling of the knee area. At first do not be surprised if the procedure results in poor flexion. While this might be worrisome, it is normal. Within a few weeks of pain management, icing and elevation, the stiffness will likely subside, and you should find greater range of movement.

Risks Associated with MUA

Complications are rare.  However if there are complications from MUA, they are often related to the force used to manipulate the knee resulting in bone fracture or wound rupturing. Applying enough force to break the adhesions without breaking bones is a skill and prudent surgeons will caution their patients about this risk.

Other considerations which may preclude an individual from undergoing MUA include: osteoporosis or other bone weakening disorder, heart disease, advanced age, circulatory disease, and acute arthritis.

Timing of an MUA

Surgeons most often perform an MUA between 4 and 12 weeks after surgery. In some instances they may take a patient through the procedure six months or even a year later, but these occasions are rare and have greater risks associated with them.

If an MUA becomes out of the question a surgeon may turn to an Arthroscopy and MUA.




MUA is Not Always Successful

Most people experience an increase in range of motion after MUA, even though there is some temporarily added muscle soreness. In cases involving muscle adhesions and shortened tissues, there should be a significant change, either immediate or within a few weeks following the procedure.

Approach an MUA with great care. As much as 25% of MUA patients require a followup procedure like a second MUA to treat knee stiffness. And some surgeons simply will not perform MUA as they do not believe they are effective.

Resources for You

Assess your current knee condition right now. Click here.

Join Manipulation Under Anesthesia/Urgent Care on Facebook. This is a private discussion group. To join click here.

Sign up for a free post-surgery email series intended to help you bend, straighten and strengthen your knee. Click here to subscribe – it’s free.

Visit our Knee Recovery Library of Educational Resources.


  • Alejandro González Della Valle, MD, Alejandro Leali, MD, and Steven Haas, MD, “Etiology and Surgical Interventions for Stiff Total Knee Replacements”
  • Ingmar Ipach, Falk Mittag, Julia Lahrmann, Beate Kunze and Torsten Kluba, “Arthrofibrosis after TKA – Influence factors on the absolute flexion and gain in flexion after manipulation under anaesthesia”
  • I. Ipach, R. Schäfer, J. Lahrmann, T. Kluba, “Stiffness after knee arthrotomy: Evaluation of prevalence and results after manipulation under anaesthesia”
  • Sean E. Fitzsimmons, MD, Edward A. Vazquez, BS, and Michael J. Bronson, MD, “How to Treat the Stiff Total Knee Arthroplasty?: A Systematic Review”
  • X10 Knee Recovery System™ Proprietary Research, 2012-2019, Dr. David Halley, Dr. Carl Freeman
  • Physical Impairments and functional limitations: A comparison of individuals 1 year after Total Knee Arthroplasty with control subjects. Walsh M. Woodhouse LF, Thomas SG, Finch E. 
  • How often is functional range of motion obtained by manipulation for stiff total knee arthroplasty? Ho-Rim Choi & John Siliski & Henrik Malchau & Andrew Freiberg & Harry Rubash & Young-Min Kwon
  • Manipulation Under Anesthesia After Total Knee Arthroplasty is Associated with An Increased Incidence of Subsequent Revision Surgery Brian C. Werner, MD, James B. Carr, MD, John C. Wiggins, BS, F. Winston Gwathmey, MD, James A. Browne, MD
  • Clinical, Objective, and Functional Outcomes of Manipulation Under Anesthesia to Treat Knee Stiffness Following Total Knee Arthroplasty Kimona Issa, MD, Bhaveen H. Kapadia, MD, Mark Kester, PhD, Harpal S. Khanuja, MD, Ronald E. Delanois, MD, Michael A. Mont, MD
  • Continuous Passive Motion After Knee Replacement Surgery, Cochrane Collaboration Musculoskeletal Group Harvey LA, Brosseau L, Herbert RD