Haemophilia (2007), 13 (Suppl.
3), 2631
Rehabilitation of synovitis in patients with haemophilia
A. SEUSER,* P. BERDEL and J. OLDENBURG
*Orthopaedic Department, Kaiser-Karl-Klinik, Special Hospital for Rehabilitation Medicine; Department for
Orthopaedic Surgery and Traumatology University Clinic ; and Institute of Experimental Haematology and Transfusion
Medicine University Clinic, Bonn, Germany
Summary. Monitoring the synovium is a central
requirement in haemophilia. In cases of acute
synovitis, a sufficiently high dosage of coagulation
factor should be used immediately, and pain
control and anti-inflammatory treatment are essen-
tial. Severe effusion should be aspirated and
persistent inflammation should be treated with
steroid injections. In relation to physical therapy,
cryotherapy with CO2, and CP current after
Bernhard should be used, if appropriate in combi-
nation with ultrasound and phonophoresis with
Voltaren [Voltarol] Emulgel. Early functional treat-
ment is essential following a short individually
Introduction
The synovium is one of the structures central to
haemophilic arthropathy. Bleeding leads to destruc-
tion of synoviocytes by iron overload of the sidero-
somes. In general, iron and both proteolytic and
chemotactic enzymes accumulate in synovial tissue,
contributing to the death of synoviocytes. The quality
and quantity of the synovial fluid is diminished [1].
This process as a whole can be painful and passes
through acute to chronic synovitis and thus also to
destruction of cartilage [2]. In spite of prophylactic
therapy, which is now widespread, synovitis still
plays a role in the life of a haemophilic child. A study
involving 249 children with haemophilia, 195 of
whom had haemophilia A and were on average
9.8 years old, revealed a large number of silent but in
examination painful conditions a total of 4.19
findings per child [3]. In these children, the knee joint
Correspondence: Dr med. Axel Seuser, Kaiser-Karl-Klinik Bonn,
Graurheindorferstr. 137, D-53117 Bonn, Germany. Tel.: +49
228 683 3413; fax: +49 228 683 3444;
e-mail: seuser@kaiser-karl-klinik.de
All authors declare no conflict of interests.
Accepted after revision 9 June 2007
26
variable period of immobilization, with the aim of
restoring flexibility, coordination and strength
(closed chain). If the treatment is insufficient and
chronic synovitis develops, consideration must be
given after 23 month of early synovectomy, by
chemical, radio-active, arthroscopic techniques, or
by arthrotomy. The physical therapy following
operations of this sort should be regarded as the
same as for acute synovitis. The rehabilitation of
synovitis is independent of co-infections.
Keywords: haemophilia, motion analysis, rehabilita-
tion, synovitis
was affected in 31.8% of cases and the ankle joint in
31.3% . No <7.4% were cases of synovitis in the
knee joint. In the ankle, the percentage of findings of
synovitis was even higher at 26.9%. None of the
findings were commonly associated with pain.
We know that even slight bleeding is sufficient to
give rise to synovitis. Unless it is treated early, it can
set in motion the vicious circle of haemophilic
arthropathy. The best therapy of synovitis is to
avoid the first bleeding. If this is impossible by means
of moderate sporting exercise and regular physio-
therapy, to stretch the posterior side of the leg and
strengthen the anterior side of the leg, plus regular
coordination training, e.g. standing on one leg, an
intensive rehabilitation process must be initiated at
the first signs of synovitis.
Synovitis an intra- and extra-articular problem
As synovitis is accompanied by signs of inflamma-
tion, control of this inflammation is an essential
pillar of rehabilitation. For such cases, even in
children, anti-inflammatory and analgesic drugs
appropriate to the patients age should be used. A
rapid and uncompromising approach is called for
to avoid the subsequent fatal progress towards
2007 The Authors
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 REHABILITATION OF SYNOVITIS IN HAEMOPHILIA 27

haemarthropathy (target joint). It is worthwhile
accompanying analgesic therapy with the physi-
cal treatment of synovitis in a polypragmatic
approach.
A precondition for any therapy is adequate stabil-
isation with the missing factor and immobilization of
the painful joint for as short a time as possible and
for as long as necessary. The therapeutic methods,
which will be described below, are intended to be
implemented in the following order.
Physiotherapy
The way in which the function of the joints react
to bleeding or inflammation must be known so that
the precise content of the physiotherapy can be
determined. From electromyographic studies, we
know that the muscular function of the extensor
muscles of the leg is endangered when there is
swelling of the knee joint [4]. There is a loss of
function/electrical response firstly of the vastus
medialis, then of the vastus lateralis, rectus femoris
and finally of the vastus intermedius muscles. At
the same time, we know from other studies [3] that
the condition most frequently found in children
with haemophilia is shortening of the flexor mus-
cles of the thigh. This can be part of a monotonic
mechanism occurring around the knee joint when
impairment is present: weakening of the extensor
muscles and shortening of the flexor muscles of the
leg.
It has been proven that other joints are also subject
to a similar mechanism. There is sufficient clinical
evidence in respect of the ankle joint, in which there
is a weakening of dorsiflexion and shortening of the
extensors of the foot in cases of intra-articular
problems. In the elbow, it is a weakening in triceps
strength and a shortening in the biceps muscle.
The aim was to stabilize the knee joint by
physiotherapy. This includes stretching the posterior
side of the thigh and strengthening the anterior side
to stabilize and maintain the mobility of the joint. In
this arthroneuromuscular system disturbed by
inflammation, intra- and intermuscular coordination
is severely affected. This makes intensive coordina-
tion training essential as soon as the diagnosis has
been made.
In addition, the pathogenesis of synovitis brings
with it a subtle change in the internal mechanics of the
joint. This results in a disturbed functional picture,
which can be detected in movement analyses both
when walking and when bending the knee performing
squats (Fig. 1). Typical disorders indicative of an
intra-articular problem are poor or only moderately
controlled stance phase activity of the knee joint
during walking, diminished mediolateral control of
the mechanical axis of the leg, acceleration peaks in the
direction-changing phases both when walking and

Fig. 1. Examples for typical gait and functional problems during gait and squat. (a) Knee angle during gait in a patient with haemophilia
with no synovitis present. (knee angle wx []/time T [s]). The angle is rhythmic, regular and sinusoid with a good stance phase (marked
blue). (b) Knee angle during gait in a patient with haemophilia with synovitis. (knee angle wx []/time T [s]). Loss of rhythm, regularity and
sinus. Complete loss of stance phase activity in knee joint (marked blue). (c) Knee angle during squat in a patient with haemophilia with
slight synovitis present. (knee angle wx []/time T [s]). Regular, rhythmic and sinusoid action of the knee angle during loading. (d) Angular
acceleration in the same knee joint as above (c) (wx[ s)2]/time T[s]). Still regular and rhythmic action. But loss of sinus at 20 of flexion
close to final extension (marked blue). See the additional acceleration peak (arrows) at every point of changing motion direction close to
extension. All motion disorders increase loading of the joint.
2007 The Authors
Journal compilation 2007 Blackwell Publishing Ltd Haemophilia (2007), 13 (Suppl. 3), 2631
28 A. SEUSER et al.
also when bending the knee under load, and impaired
rolling-gliding performance of the knee joint. These
functional impairments are reversible and can be
improved by appropriate physiotherapy and medical
training therapy. This was demonstrated by measuring
over 250 patients in over 20 comprehensive care
centers in Germany [5,6]. Below we will present a
detailed physiotherapy programme for motion disor-
ders according to the most common functional losses
observed in motion analysis (Fig.1).
Stance phase disorders (Fig. 1a,b)
General:
The normal stance phase works like this:
1 Heel strike with almost extended knee joint.
2 Weight transfer while bending the knee joint.
3 Toe-off with almost extended knee joint.
To re-establish the optimal stance phase, stance
phase training should be carried out:
1 Dividing the stance phase into individual sub-
phases.
a. Practising heel strike close to extension.
b. Practising weight transfer.
c. Practising the transitional phase to the
swing phase.
2 Training in the form of single repetitions.
3 Bringing the different elements together in the
form of direction-changing training.
a. Heel contact close to extension with al-
most extended knee joint.
b. Transition to weight-bearing or from
weight-bearing.
c. Transition to terminal extension phase or
from terminal extension phase.
d. Transition to swing phase or from swing
phase.
e. Transition to heel strike with almost ex-
tended knee joint.
Technical implementation should be varied:
1 Slow-motion training executing the exercise as
slowly as possible.
2 Once this exercise has been mastered in motorial
terms, either add weight-bearing in addition in
cases of mainly muscular deficit, or increase the
emphasis on coordination.
3 Combined practice on unstable surfaces in cases
of mainly coordination-related disorders.
4 Coordination and strength can also be required
to be shown simultaneously in the exercises for
advanced patients.
Haemophilia (2007), 13 (Suppl. 3), 2631
5 Only then increasing the speed of movement.
6 Increasing the range of movement, slowly at first
and then more quickly.
Stability of the mechanical axis of the leg
General:
There are basically two possibilities:
1 Rotational deviations 1015.
2 Lateral deviations 1015.
Mechanical axis training
Approach as for stance phase training, but this time
with closer attention paid to maintaining the mecha-
nical axis of the leg in relation to rotation and lateral
stability. Exercising slowly at first and breaking down
the exercise into individual subphases, then training
in the transitional phases, then in the entire sequence
of movements, initially in slow motion, then either
using external resistance or higher coordination
standards. Then, if appropriate, combining coordi-
nation and strength, and only then increasing the
speed of movement and/or range of movement.
Direction-changing difficulty (Fig 1 c, d)
General:
Kinematically, the most problematical phases of
movement are the direction-changing phases, in
which the kinetic energy is redirected from one
direction of movement into another. For example,
from the terminal extension of the knee joint to
incipient flexion or from terminal flexion to incipient
extension.
Direction-changing training
This can be carried out both when walking and when
bending the loaded knee. Direction-changing train-
ing when bending the knee under load:
Starting in the range of the direction-changing
disorder with a very small range of movement,
carried out in slow motion.
Once this has been mastered, additional weight-
bearing by means of external weights or additional
demands by requiring higher standards of coordi-
nation.
For advanced patients, combining strength and
coordination. Only then increasing the range of
movement and only then increasing the speed of
movement.
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 REHABILITATION OF SYNOVITIS IN HAEMOPHILIA
Stability of the mechanical axis of the leg when
bending the knee
General:
There is a more or less major deviation of the
mechanical axis of the leg even during everyday
movements when bending the knee. If this is not
regular and rhythmical or sinusoidal, training should
be carried out to increase coordination and stability
of the mechanical axis of the leg.
Therapy for stability of the mechanical axis of the
leg when bending the knee:
1 Starting initially within a small range of move-
ment close to extension.
2 Variation of the exercise, starting with sup-
ported exercises:
a. First with feet close together.
b. Then with feet further apart.
3 First increase: either with additional strength
required or with additional coordination re-
quired.
4 Second increase: combining strength and coor-
dination.
5 Third increase: starting with isotonic exercising,
slowly at first,
6 Then slowly increasing the range of movement.
7 Only then increasing the speed of movement.
Rollinggliding in the knee joint
General:
Rollinggliding should have a large rolling com-
ponent. As soon as the gliding component predom-
inates, the forces begin to act obliquely. The main
causes are inadequate muscle activation within this
range, lack of coordination, lack of strength and lack
of rotation capacity.
Therapy for gliding:
1 Starting from the angle of flexion from which
the gliding component increases:
a. Strength training first of all.
b. With small deflections analogous to
direction-changing training.
It is important to increase the kinaesthesia and
consciousness of the actual position of the knee joint
in space.
1 First increase: additional introduction of exter-
nal force from strength endurance training to
submaximal strength.
2 Increase in coordination required.
3 Combining strength, endurance and coordina-
tion or submaximal strength and coordination,
2007 The Authors
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29
4 Then increasing the distance of movement in the
direction of an increasing gliding component.
Therapy of negative rolling
General:
Negative rolling is rolling against the direction of
movement and thus the most damaging movement
for the internal structures of the knee.
1 At the transitional range in the angle, which
demarcates the transitional range to negative
rolling.
2 Using physiotherapy with manual therapy for
rotation.
Based on the idea that negative rolling is a
compulsive movement of the knee joint because of
restricted movement, including rotational range,
manual therapy should be carried out, starting
within the angular range of the knee joint in which
rolling changes into negative rolling or gliding
changes into negative rolling, and including rotation
(inwards and outwards).
As rotation is a fundamental component of the
movement of the knee and extends over the entire
range of knee flexion, the manual therapy should be
repeated in rotation for every 10 of flexion of the
knee. Following the manual therapy, tonicising
treatment and therapy as for the treatment of the
gliding component can be applied.
Particular aspects of physiotherapy when the elbow
joint is involved
Motion analyses of haemophiliacs with different
degrees of haemarthropathy have shown that there
is restriction of the rotational capability of the elbow
joint before the capability for extension or flexion is
restricted because of intra-articular problems such as
synovitis, for example. This restriction is subtle and
found in a different degree of joint flexion in every
patient. For this reason, manual therapy on the elbow
joint should include the rotational component in
cases when symptoms of synovitis persist, especially
in the region of the head of the radius. In practice,
pronation and supination should be treated with
manual therapy at every 10 of elbow flexion [7].
Rotational mobilisation of the knee joint
A similar principle applies to the knee joint as to the
elbow joint. A study in haemophiliacs with different
degrees of haemarthropathy and synovitis showed
Haemophilia (2007), 13 (Suppl. 3), 2631
30 A. SEUSER et al.
that rotation of the knee joint is restricted before its
capability for extension and flexion are restricted.
Normal rotational capability is individually changing
with the degree of flexion of the knee joint. It is
minimized or even absent on an individual basis in
patients depending on the condition of their disease.
In principle, the same approach applies as for the
elbow joint [7].
Medical training therapy [8]
When the first maximum isometric tension is possible
without pain, the indication exists for further
isotonic training in medical training therapy. The
aim was to subject the muscles of the affected joint to
training stimuli at an early stage and to restore both
inter- and intra-muscular coordination.
The primary objective is to restore strength endur-
ance. This involves exercises on the leg press [9] in the
range of the knee joint close to extension, carried out
initially with small deflections. The resistance should
be chosen such that 2030 repetitions are possible
without pain. Training should mean completing three
to four sets with this number of repetitions and
weights. If appropriate, it can also be carried out as a
combined training exercise on the same equipment
for both the knee joint and the ankle joint.
As training proceeds, the weight should be
increased first with appropriate factor substitution
up to the submaximal range (12 repetitions with a
weight of up to 80% of maximum strength). This
phase can be started at the earliest after 46 weeks of
strength endurance training. The scope of movement
should only be increased once this has been mas-
tered.
The range of movement follows the physiological
range of movement in the stance phase which
encompasses 1020 of angular movement. The
exertion demanded will also depend on the everyday
demands made on the ankle and knee joint. The
coordination requirements during medical training
therapy can be increased slowly following the
strength endurance phase [6].
Treating symptoms
Apart from the specific physiotherapy and medical
training therapy applied, synovitis causes symptoms,
which should be treated.
Hot or cold [1014]
In principle, cold should be applied for acute
processes and heat should be used for chronic
Haemophilia (2007), 13 (Suppl. 3), 2631
processes. However, synovitis is always a problem
with locally increased blood flow and therefore with
elevated metabolic activity. As a consequence, this
leads primarily to overheating of the joint affected.
Cryotherapy with maximum vasoconstriction at
15C skin temperature is therefore indicated for the
direct treatment of. In addition there are the effects
of cold on the muscle spindles and on Golgis organ
with a reduction in activity. Thus there is less
concern that reflex muscle tension will occur than
after heat treatment. The diminished conductivity of
the nerves lowers the pain threshold and reduces the
excitability of the free nerve endings and of the
peripheral nerves. Thus, it also reduces swelling and
produces an anti-inflammatory effect, and also a
reduction in pain.
The local vasoconstriction is accompanied by a
reduction in blood supply and in lymphostasis as
well as a reduction in oedema formation. In addition,
phagocytosis and leucocytosis and the entire meta-
bolic activity are depressed. In our centre, we
recommend the use of dry cold, especially CO2
combined with pressure of 50 bar.
Deep friction
The adhesions that accompany inflammation should
be loosened with careful deep friction, especially in
the upper recess of the knee joint and also on the
ventrolateral and ventromedial capsule of the ankle
joint [15].
Electrotherapy and ultrasound [1620]
In electrotherapy, the CP current after Bernhard is
the principal component as a potent detumescent and
pain-relieving current. In addition, ultrasound/pho-
nophoresis with Voltaren [Voltarol, Novartis
GmbH, Nurnberg, Germany] can be applied as a
simultaneous therapy with the CP current. The anti-
inflammatory action of Voltaren [Voltarol] Emulgel
is introduced into deeper tissue layers and can have a
more potent effect. Micromassage by the ultrasound
loosens adhesions and produces a slight local warm-
ing effect with improved blood supply.
Polypragmatic approach to therapy
In general, it makes sense to combine all of the
above-mentioned measures in the order described.
Immobilization should be as short as possible and
as long as necessary. The therapy should be contin-
ued for 46 weeks after symptoms have disap-
peared. If possible, superficial electromyography
2007 The Authors
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 REHABILITATION OF SYNOVITIS IN HAEMOPHILIA
and monitoring joint function by motion analysis can
be used to optimise the individuals treatment and to
record the success of the therapy.
Particular aspects in relation to patients with HIV
and HCV co-infection
In the particular case of HIV and HCV co-infection,
one needs to establish that there is no increased
incidence of synovitis on account of an HIV infec-
tion. Since 1996 the quality of life of patients co-
infected with HCV and HIV has been markedly
improved and there is, in principle, no difference in
the therapy of synovitis between HIV/HCV positive
or negative patients with haemophilia. HIV itself has
a powerful inflammatory component and anti-
inflammatory therapy with steroids or NSAIDs will
help to reduce the synovitis and raise the CD4 count.
Arrangements should be made to ensure adequate
monitoring of laboratory liver parameters [21].
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