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Alternatively, a nonaggressive approach might include exercise of other areas, stretching, and manual therapies that all stay well within boundaries for pain and injury. The disadvantage to this approach is that it is slow, and improvement may take place only over a period of months or longer. Many variables can inf luence the outcomes of arthrofibrosis treatment. These include how long it was since the triggering event, how much of the joint is affected, and the individual's unique immune and inf lammatory responses. Some patients appear to tolerate aggressive interventions well, and others react badly, sometimes with permanent damage. This suggests some differences in those internal chemical environments, and those differences are impossible to predict. The future of arthrofibrosis treatment may look extremely different than it does today. As we learn more about myofibroblastic activity and inf lammatory cytokines, we may also learn how to inf luence those signals and cellular activities in ways that can reduce the hyper- production of scar tissue that impairs function. MASSAGE FOR ARTHROFIBROSIS? Arthrofibrosis is a problem that usually starts inside large synovial joints—beyond the reach of our hands. However, external ligaments, fat pads, bursae, tendons, and muscles may also become constricted, adhered to each other, and pathologically fibrotic. Further, the muscular patterns that develop around a joint with a limited ROM may reinforce that constraint: Proprioceptors adapt to limitations, so the neuromuscular signals may perpetuate and even advance the problem as the tight muscles further compress and irritate the joint structures. Massage therapy cannot undo the results of an overactive inf lammatory response with the accumulation of excessive scar tissue, but our work could probably help with many of the auxiliary consequences. What are some possible risks related to working with a client who has arthrofibrosis? If the injury or surgery is still in the healing phase, it's not appropriate to disrupt those tissues, of course. Manual therapies for frozen shoulder sometimes recommend aggressive stretching to try to "break through" the scar tissue and reestablish a normal range of motion. Given what we know about inf lammation and scar tissue accumulation, I propose that this is not in the client's best