Joint Contracture

What happens in a contracture

Joints stay flexible because the surrounding soft tissues are regularly stretched through their full range. When a joint is held in one position for long periods, the muscles shorten, collagen in tendons, ligaments and the joint capsule stiffens and cross-links, and the joint loses range. Spasticity (overactive muscles from nerve damage) and scarring speed this process.

Contractures can develop within 2 to 3 weeks of immobility and become harder to reverse the longer they last.

Causes

Symptoms

• reduced range of motion in one or more joints
• a joint held in a fixed position, most often bent (flexion contracture)
• stiffness and sometimes pain when trying to move the joint
• muscle tightness or a cord under the skin (in Dupuytren's)
• difficulty walking, standing, sitting, reaching, dressing or washing
• skin breakdown or infection in tight skin folds, such as the palm, armpit or groin

Common contractures and their effects

• Hip and knee flexion contractures: hard to stand upright and walk; common after long bed rest or in wheelchair users
• Ankle (equinus) contracture: the foot points down, causing toe walking or tripping
• Elbow and wrist flexion: after stroke, making dressing difficult
• Finger contractures: difficulty with grip, putting hands in pockets or washing
• Shoulder: limited reaching and dressing

Diagnosis

A doctor or physical therapist measures range of motion with a goniometer, assesses muscle tone and strength, and looks for skin, scar or joint causes. X-rays or ultrasound can show joint damage. Testing under anesthesia or after a nerve block helps distinguish spasticity (which relaxes) from a fixed contracture (which does not).

Treatment

Physical therapy and stretching

• daily passive and active range-of-motion exercises
• sustained stretching, often for 20 to 30 minutes or more
• strengthening the opposing muscles
• heat before stretching to improve tissue flexibility

Splints and casting

• Static or dynamic splints worn at night or for set periods
• Serial casting: a series of casts, each applied with the joint stretched a little further, used especially for ankles and elbows

Spasticity management

• Botulinum toxin injections relax overactive muscles for about 3 months, usually combined with stretching or casting
• Oral medicines such as baclofen or tizanidine
• Intrathecal baclofen pumps for severe, widespread spasticity

Specific treatments

• Dupuytren's: needle fasciotomy, collagenase injections or surgery when fingers cannot lie flat
• Frozen shoulder: time, therapy, steroid injections, and sometimes release
• Burn scars: pressure garments, scar massage and silicone, and surgical release with skin grafts

Surgery

For severe contractures that limit function, options include tendon lengthening, releasing the joint capsule or scar tissue, and occasionally joint replacement or fusion.

Prevention

Preventing contractures is easier than treating them:

• move every joint through its full range several times a day during illness or bed rest
• change position at least every 2 hours if you cannot move yourself
• use pillows and splints to keep joints in good positions (for example, ankles at 90 degrees)
• start physical therapy early after stroke, surgery or injury
• avoid long periods sitting with hips and knees bent

Frequently asked questions

What is a joint contracture?

It is a permanent shortening and stiffening of the tissues around a joint that stops it moving through its full range, so it becomes stuck in a bent or straight position. It is often caused by immobility, nerve conditions, burns or arthritis.

How quickly can contractures develop?

Contractures can begin within 2 to 3 weeks of a joint being held still, for example in bed rest, a cast or after a stroke. Daily movement and stretching during these periods help prevent them.

Can contractures be reversed?

Early contractures often improve with stretching, splints and serial casting. Long-standing contractures are harder to reverse and may need injections or surgery. The sooner treatment starts, the better the chance of regaining movement.

How do you prevent contractures in bedridden patients?

Move each joint through its full range at least daily, change position regularly, support joints with pillows or splints in neutral positions, and involve a physical therapist early. Caregivers can be taught simple range-of-motion routines.