Contractures are the chronic loss of joint mobility caused by structural changes in non-bony tissue, including muscles, ligaments, and tendons. They develop when these normally elastic tissues are replaced by inelastic tissues. This results in the shortening and hardening of these tissues, ultimately causing rigidity, joint deformities, and a total loss of movement around the joint.
Contractures are a final common pathway for many conditions. The most frequent cause of contracture is immobilization, but they can be also be caused by congenital conditions (e.g., Duchenne’s Muscular Dystrophy, Cerebral Palsy), muscle imbalances, arthritic conditions, heterotopic ossification, prolonged hypertonic spasticity, ulcers, burns, total knee arthroplasty (TKA), local trauma, diabetes, or in rare cases, hypothalamus-pituitary-adrenal axis (HPA) hormone deficiency.1 Manual work and vibration exposure have also been associated with the development of Dupuytren’s contracture.2,3
Epidemiology including risk factors and primary prevention
Currently, most epidemiologic information focuses on one single joint contracture; therefore, the epidemiology of joint contractures as a whole is limited. Additionally, the variance in definitions among studies used as diagnostic criteria results in a wide range of figures. It is clear, however, that there is a high prevalence of major joint contractures.4
Overall, the prevalence has been reported to be between 15% and 70% in older adults.5 Patients with acquired brain injury developed contractures between 16% and 81%.6 . 60% of stroke, 36% of cerebral palsy, and about 11 to 48% of spinal cord injury patients develop some form of joint contracture.7
Children who have an obstetric brachial plexus injury were found to have a shoulder contracture 56% of the time with elbow contracture being second most common at 48% 8,9
In institutionalized older adults, it was reported that 71% of those who were immobile were found to have a joint contracture, whereas all mobile patients remained free from contractures.10 Additionally, three fourths of the institutionalized elderly with chronic health conditions have been shown to have knee flexion contractures,and more than half of medically frail nursing home residents report major functional deficits with joint contractures.6 Similarly, one third of ICU patients develop joint contractures with a hospital stay of greater than 2 weeks, and those with ICU-developed-joint contractures had an associated mortality of approximately 3 years post discharge.
In the burn population, those patients admitted to burn units with an autograft were 23-54% likely to develop a contracture, with the shoulder being the most commonly affected joint.11 Upon hospital discharge, approximately 30% of patients with burns developed contractures with about one quarter requiring corrective surgery.12 According to a 2019 Chinese descriptive study in a large burn unit, the incidence of contracture was 94% among those with severe burns.12
Common risk factors for contracture development include motor dysfunction (hemiplegia or tetraplegia), hypoxic ischemic injury (eg, stroke), spinal cord injury, and age.13
Overall, the primary risk factor for contracture development is immobility. Spasticity is a risk factor for later development, but paralysis is foremost.14
Soft tissue changes that contribute to contractures begin very early after the onset of immobility. Protein synthesis within muscle fibers is reduced within 6 hours after a joint is immobilized. Shortening of muscle fibers occurs within 24 hours. After 48 hours, increased collagen infiltration of the perimysium appears. Chronic disuse also causes plastic rearrangements in the higher centers that further reduce the ability to voluntarily recruit motor units, further exacerbating baseline paresis.15There is a reduction in longitudinal tension in muscles in patients with brain injury who have muscles and joints that are immobilized for prolonged periods.16 In animal models, only 24 hours of unloading caused a 60% shortening of muscle fiber length.17
Contractures specific to burn injuries occur due to thermal damage from vascular insufficiency or from compressive edema or eschar causing eventual joint and myofascial deformities.22 One additional consideration is that Denmark researchers in 2016 published a comprehensive theory about how contracture develops under central motor lesions. They have proposed that the adaptation of the neuromuscular-tendon-connective tissue complex to the central motor lesion with several other factors (neural activation, bone/muscle growth mismatch, mechanotransduction, tensional homeostasis, microvascularization, genetics, epigenetics) are key to preventing and treating muscle contractures.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Most contractures begin with some insult to the body. For example, the body’s reaction to a painful joint is to immobilize it, placing it at risk for development of a contracture. Neurologic injuries increasing muscle tone or weakness cause a muscle imbalance, which results in a tonic contraction. In this way, many joint contractures are preceded by spasticity. Gone untreated, the spastic joint becomes immobilized and a contracture develops. In burns, direct thermal injury results in deformities of hands and limbs. Subsequent scar contraction of the skin crossing a joint can also result in immobility and contracture.
Contractures can also develop from disuse without a specific injury. For example, age-related muscle loss (sarcopenia) can contribute to prolonged sitting and hence hip flexion contractures.
Specific secondary or associated conditions and complications
Associated conditions include but are not limited to spasticity, heterotopic ossification, degenerative joint disease, fracture, dislocation, and cartilaginous tears. Some contractures will result in abnormal positioning (eg. in a wheelchair, in bed), predisposing one to pressure ulcers. Generally, deconditioning and loss of function frequently results. This immobility further exacerbates or creates new contractures, resulting in a vicious cycle that increases disability.
ESSENTIALS OF ASSESSMENT
History should include the etiology of the contracture, its natural course, and its impact on the patient’s functionality. This includes pain, difficulties in mobility and transfers, activities of daily living (ADLs), and hygiene. Details regarding caregiver burden should also be explored.
Ideally, the patient should be free from pain that may interfere with the examination. Inspect the patient for joint size, symmetry, and resting position compared with the contralateral side. A goniometer can measure residual range of motion and document changes over time. Joint deformities may also be present and palpable, and skin must be inspected for scars or thickening that may contribute to, or be the source of, contractures (eg. burns). Pressure ulcers may also be present. Skinfolds must be inspected frequently for opportunistic bacterial and fungal infections. A sensory examination must be performed as this will guide the choice of treatment modalities (eg. therapeutic heat). Altered proprioception and unilateral neglect should also be assessed.
The most important diagnostic element, however, is passive range of motion (PROM). Any muscle imbalance or weakness with or without an increase in tone should be noted. To rule out a true contracture in the presence of spasticity, prolonged passive stretch, with or without heat modalities, can overcome increased tone and result in further range of motion. PROM at slow, intermediate, and rapid speeds of stretch can further distinguish among hypertonicity, rigidity, and true contracture.
Active range of motion (AROM) should be assessed, as should strength, as this may play a role in determining why the contracture arose, and helping to guide treatment.
Observing the patient ambulating, transferring, and performing ADLs characterizes the patient’s deficits and their impact on function. If bracing is used as a functional aid, it must be inspected for proper fit and pressure points because the contracture may have shifted, and the brace may need to be refitted.
Diagnosis is based largely on clinical examination. There are no blood markers or laboratory studies that contribute to the diagnosis of a contracture. Other laboratory markers, including alkaline phosphatase, erythrocyte sedimentation rate, etc. can be used to identify underlying conditions such as heterotopic ossification, myopathy, etc.
Radiologic studies (eg. x-rays, bone scans) can be obtained to discern exacerbating pathology (eg, bony deformities, heterotopic ossification, fractures, dislocations, ankylosis). Magnetic resonance imaging and diagnostic ultrasound can be used to visualize soft tissue structures which reveal fibrotic changes, such as fatty tissue infiltration.
Supplemental assessment tools
There are no validated assessment tools in contractures, however, tools do exist for spasticity. The two most common assessments for spasticity are the Modified Ashworth Scale (MAS) and Tardieu Scale. It was found that the MAS frequently overestimated spasticity in the setting of a contracture, confounding it, whereas the Tardieu scale was better at differentiating the two.18
Early predictions of outcomes
There are currently no validated prognostic indicators for contractures. There are, however, many different outcome measures used to evaluate contractures and their treatment in the literature. There is not one concise tool to provide concrete predictions.
Living with a contracture has a significant effect on one’s life. Complications range from hygiene issues in higher functioning individuals to debilitating contractures resulting in limited independence and permanently immobility.
Social role and social support system
The presence of contractures can increase the burden to family members and caregivers in caring for patients. The patient and the caregivers should be included in the assessment, specifically in how this/ these contractures are affecting their daily function, as well as their goals for treatment of the contracture.
Because contractures are considered largely preventable, there are many professional issues that arise in their development. Among these are inadequate care in nursing homes and suboptimal management of spasticity, including in children.
REHABILITATION MANAGEMENT AND TREATMENTS
General approach to Contractures: Key principles
The best treatment is to slow or prevent contracture formation. Clinically, this largely involves PROM and stretching exercises daily. However, some evidence-based research has made these longstanding interventions controversial. Cochrane review articles have suggested that passive movements are not effective for the prevention and treatment of contractures,19 and stretch does not prevent or reverse joint contractures in people with neurologic conditions.20 Many argue, however, that these clinical trials did not provide a sufficient dose or have not combined modalities together. As such, PROM, proper positioning, and stretching are still the clinical mainstays of treatment and prevention.
Any weakness of musculature should be strengthened, particularly the antagonist of the contracted muscle, if applicable. Additional measures include the effective management of spasticity and edema. Edema can be prevented using massage, elevation, and compression garments.
An NIH article looked at the prevention and management of limb contractures in neuromuscular diseases and recommended to keep in mind six concepts when approaching contractures:
- Prevention of contractures requires early diagnosis and initiation of passive range of motion (PROM) and splinting while contractures are mild
- In some Neuro Muscular Disorders (NMD) contractures are inevitable
- Advanced contractures become fixed and may show little response to conservative treatment and may require surgical intervention
- Controlling lower limb contractures is important to minimize their adverse effects on independent ambulation
- Static positioning of both upper and lower limbs is an important cause of contracture formation
- Mild upper limb contractures may not negatively impact function21
Approach to contractures at different stages
Once a contracture has developed, prolonged and continuous stretching of the joint is accomplished through dynamic bracing or serial casting. After maximal stretching, an orthotic or cast is applied to fix the joint at that position. The device is removed every few days, and the process is repeated at an enhanced angle. Stretching can be further facilitated through therapeutic heating modalities. Heating the soft tissue structures around the joint improves elasticity, achieved through hot packs or therapeutic ultrasound. Hydrotherapy and paraffin baths can be used for smaller joints. Care should be taken in using such modalities, especially in patients who are unable to verbalize pain or heat intolerance. Spasticity must be managed if it is thought to be maintaining the contracture. In truly fixed contractures that significantly impact function and have failed conservative therapy, surgical options are considered. These include surgical release of affected muscles, tenotomy or tendon lengthening, joint capsule release, or total joint replacement. In some cases, heterotopic bone can be removed.
Surgery can also entail fasciectomy and fasciotomy with skin flap replacements. After surgery, patients undergo rehabilitation, sometimes more aggressively to help maintain functionality and prevent further scar formation and enable wound healing. Surgery is slowly being transitioned to more minimally invasive procedures due to risks of complications with major operations. 22
Treatment of upper extremity contractures
An injectable collagenase enzyme derived from the bacteria Clostridium histolyticum (collagenase clostridium histolyticum) is FDA approved in the treatment of Dupuytren’s contracture and as an alternative to surgery. 22 The clinical outcome with collagenase injections are similar to surgery but has fewer complications, faster recovery, and are more tolerable for patients. Limitations to collagenase injections are that they are usually single site, require monthly injections, and are associated with a risk of autoimmune reaction with injections. There is research to indicate that multiple injections can provide clinically significant outcomes. 22
Rarely, upper extremity contractures require surgical intervention. Typically these surgeries are only indicated if the ROM is impeding care and hygiene or if the contracture is leading to skin breakdown or intolerable pain.
Treatment of lower extremity contractures
Prevention again is key in preventing contractures. Four key concepts can be applied to the management of the lower limb contractures:
- Regular periods of standing and/ or walking
- Passive stretching of muscles and joints
- Positioning to promote extension and oppose flexion
Despite these interventions, at time it may be necessary to refer these for surgical management. A thorough assessment of the contractures and their role in the patient’s ambulation must be fully understood. The ability to have the foot flat on the ground contributes to the safety of standing transfers. There have been cases after isolated Achilles tendon lengthening procedures leading to overcorrection (overlengthening) of the heel cord and the loss of an ability to walk.21 Distal lower limb surgical interventions are often utilized; surgical intervention may be required to obtain a plantigrade foot. The Coleman block test is used in cavovarus feet to determine which part of the foot the contracture involves. 21
Coordination of care
The rehabilitation team consisting of a physiatrist, physical, occupational, and recreational therapists, and persons in social work and case management function are the unit to manage a patient’s contracture. This includes evaluation, therapeutic exercise, placement of adaptive equipment, and managing functional limitations as they pertain to participation restrictions and enhance quality of life.
Patient & family education
Patients and family should be educated regarding risk factors of contractures and strategies in prevention, including proper positioning and range of motion exercises. Discussions are necessary about the sequelae of a joint contracture and treatment options available. Patient goals are discussed with the rehabilitation team and concerns addressed.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
Prevention is key. Appropriate positioning in bed is a simple yet effective preventative measure. For example, one should avoid placing pillows under the knees while supine to prevent knee flexion contractures, and prone lying can force the hip into extension to prevent hip flexion contractures. Shoulder range of motion can be preserved with 30 minutes of positioning using a sling attached to the bed, holding the arms in maximal external rotation and abduction.23,24
CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
In one animal model, radiofrequency treatments successfully treated underlying collagen contractures and helped in new collagen formation.25 In another study comparing speed and torque in range of motion exercises using rats, high torque and long-duration static stretching were most effective.26
Low level laser therapy (LLLT), whole or local vibration therapy, as well as therapeutic ultrasound are possible treatment modalities for contractures but have not yet been elucidated in the literature to be clinically effective.27
A new 2019 mouse study revealed that bortezomib may be an additional emerging treatment for muscle contractures in children with neuromuscular conditions.28 In another recent rabbit study, intraarticular injection of substance P inhibitor were shown to express genes that reduced post-traumatic joint contractures.29
Adipose derived stem cells injections have been proposed as an accelerant for wound healing with improved range of motion in patients with radiation induced neck burn contractures and as an alternative to surgical intervention.30
GAPS IN THE EVIDENCE-BASED KNOWLEDGE
Gaps in the evidence-based knowledge
There is a lack of knowledge about the pathophysiology and disease course that lead to contractures. Due to the lack of standardization in assessment, quantification of disability, and evidence-based treatment, there remains a tremendous amount of individual interpretation without many unifying theories or clinical research studies. Clinical studies vary widely in what constitutes a contracture. Even still, evidence-based treatment options remain controversial, putting into question longstanding traditional interventions. There are no concise outcome measures that have been validated that can predict the prognosis or the effect of treatments, and criteria need to be developed to allow for better assessment, prognosis, and measure of outcomes.
- Syriou V, Moisidis A, Tamouridis N, Alexandraki KI, Anapliotou M. Isolated adrenocorticotropin deficiency and flexion contractures syndrome. Hormones (Athens). 2008;7(4):320-4.
- Descatha A, Jauffret P, Chastang JF, Roquelaure Y, Leclerc A. Should we consider Dupuytren’s contracture as work-related? A review and meta-analysis of an old debate. BMC Musculoskelet Disord. 2011;12:96.
- Fadel M, Leclerc A, Evanoff B, Dale AM, Ngabirano L, Roquelaure Y, Descatha A . Association between occupational exposure and Dupuytren’s contracture using a job-exposure matrix and self-reported exposure in the CONSTANCES cohort. Occupational and Environmental Medicine. 2019;76:845-848.
- Fergusson D, Hutton B, Drodge A. The epidemiology of major joint contractures: a systematic review of the literature.ClinOrthop Relat Res. 2007;456:22-29.
- Gnass I, Bartoszek G, Thiesemann R, Meyer G. [Joint contractures in older age. A systematic literature review] [German].Z Gerontol Geriatr. 2010;43(3):147-157.
- Pohl M, Mehrholz J. A new shoulder range of motion screening measurement: its reliability and application in the assessment of the prevalence of shoulder contractures in patients with impaired consciousness caused by severe brain damage. Arch Phys Med Rehabil. 2005;86(1):98-104.
- Pingel J, Bartels EM, Nielsen JB. New perspectives on the development of muscle contractures following central motor lesions. J Physiol. 2017 Feb 1;595(4):1027–1038.
- Hoeksma AF, Ter Steeg AM, Dijkstra P, Nelissen RG, Beelen A, de Jong BA. Shoulder contracture and osseous deformity in obstetrical brachial plexus injuries.J Bone Joint Surg Am. 2003;85(2):316-322.
- Olofsson PN, Chu A, McGrath AM. The Pathogenesis of Glenohumeral Deformity and Contracture Formation in Obstetric Brachial Plexus Palsy—A Review. J Brachial Plex Peripher Nerve Inj. 2019;14(1):e24–e34.
- Selikson S, Damus K, Hamerman D. Risk factors associated with immobility.J Am Geriatr Soc. 1988;36(8):707-712.
- Lewinson RT, Capozzi LC, Johnson K, Harrop AR, Fraulin FOG, Nickerson D. A Review of Perforator Flaps for Burn Scar Contractures of Joints. Plast Surg (Oakv). 2019;27(1):66–77.
- Tan J, Chen J, Zhou J, Song H, Deng H, Ao M, Luo G, Wu J. Joint contractures in severe burn patients with early rehabilitation intervention in one of the largest burn intensive care unit in China: a descriptive analysis. Burns Trauma. 2019;7:17.
- Zafonte R, Elovic EP, Lombard L. Acute care management of post-TBI spasticity.J Head Trauma Rehabil. 2004;19(2):89-100.
- Ada L, O’Dwyer N, O’Neill E. Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: anobservational study.Disabil Rehabil. 2006;28(13-14):891-897.
- Gracies JM. Pathophysiology of spastic paresis. I: Paresis and soft tissue changes.Muscle Nerve. 2005;31(5):535-551.
- Gracies JM. Pathophysiology of impairment in patients with spasticity and use of stretch as a treatment of spastic hypertonia.Phys Med Rehabil Clin N Am. 2001;12(4):747-768, vi.
- McLachlan EM, Chua M. Rapid adjustment of sarcomere length in tenotomized muscles depends on an intact innervation.Neurosci Lett. 1983;35(2):127-133.
- Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it.Clin Rehabil.2006;20(2):173-182.
- Prabhu RK, Swaminathan N, Harvey LA. Passive movements for the treatment and prevention of contractures.Cochrane Database Syst Rev. 2013 Dec 28;12:CD009331.
- Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures.Cochrane Database Syst Rev. 2010 Sep 8;(9):CD007455.
- Skalsky AJ, McDonald CM. Prevention and management of limb contractures in neuromuscular diseases. Phys Med Rehabil Clin N Am. 2012;23(3):675–687. doi:10.1016/j.pmr.2012.06.009
- Degreef I. Collagenase Treatment in Dupuytren Contractures: A Review of the Current State Versus Future Needs. Rheumatol Ther. 2016;3(1):43-51.
- Ada L, Goddard E, McCully J, Stavrinos T, Bampton J. Thirty minutes ofpositioning reduces the development of shoulder external rotation contractureafter stroke: a randomized controlled trial.Arch Phys Med Rehabil. 2005;86(2):230-234.
- de Jong LD, Nieuwboer A, Aufdemkampe G. Contracture preventive positioning ofthe hemiplegic arm in subacute stroke patients: a pilot randomized controlledtrial.Clin Rehabil. 2006;20(8):656-667.
- Choi S, Cheong Y, Shin JH, Jin KH, Park HK. Inflammatory effect of monopolar radiofrequency treatment on collagen fibrils in rabbit skins.J BiomedNanotechnol. 2013;9(8):1403-1407.
- Moriyama H, Tobimatsu Y, Ozawa J, Kito N, Tanaka R. Amount of torque and duration of stretching affects correction of knee contracture in a rat model ofspinal cord injury.Clin Orthop Relat Res. 2013;471(11):3626-3636.
- Yang X, Wang J. Commentary 1: Prevention and Management of Joint Contractures. Top 25 Commentaries on Surgery. Avid Science. 2017;1-17. https://www.avidscience.com/wp-content/uploads/2017/10/prevention-and-management-of-joint-contractures.pdf.
- Nikolaou S, Cramer AAW, Hu L, Goh Q, Millay DP, Cornwall R. Proteasome inhibition preserves longitudinal growth of denervated muscle and prevents neonatal neuromuscular contractures. JCI Insight, 2019.
- Morrey ME, Sanchez-Sotelo J, Lewallen EA, et al. Intra-articular injection of a substance P inhibitor affects gene expression in a joint contracture model. J Cell Biochem. 2018;119(2):1326–1336.
- Akita S, Hayashida K, Takaki S, Kawakami Y, Oyama T, Ohjimi H. The neck burn scar contracture: a concept of effective treatment. Burns Trauma. 2017;5:22.
Original Version of the Topic
Adrian Cristian, MD, Ashish Khanna, MD, Richard Kim, MD. Contractures. Originally published: 9/20/2014
Benjamin J. Seidel, DO
Nothing to Disclose
Lawrence Chang, DO
Nothing to Disclose
Tiffany M. Lau, MD
Nothing to Disclose