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Contracture

A contracture is a medical condition involving the fixed tightening or shortening of muscles, tendons, ligaments, skin, or other connective tissues, which limits joint mobility and results in stiffness or deformity.^[1]^[2] This occurs when normally elastic tissues are replaced by inelastic, fibrous tissue, preventing normal stretching and movement of the affected body part.^[1] Contractures commonly affect joints such as the hips, knees, elbows, and ankles, and can develop in various contexts, including after prolonged immobility, injury, or underlying health conditions.^[3] Contractures often arise from factors like reduced muscle use due to bed rest, paralysis, or casting; neurological disorders such as cerebral palsy, stroke, or spinal cord injury (SCI); inherited conditions like muscular dystrophy; or trauma including burns and fractures that lead to scarring.^[1]^[3] In SCI, for instance, immobility and spasticity contribute to contractures in nearly all affected individuals, with higher risk in those with quadriplegia due to limited independent movement.^[3] Symptoms typically include decreased range of motion, joint rigidity, pain during movement, and functional limitations in daily activities like dressing or transferring.^[1]^[3] Diagnosis involves a physical examination, medical history review, and possibly imaging like X-rays to assess joint structure.^[1] Management focuses on restoring function and preventing progression, with early intervention being critical.^[4] Non-surgical approaches include physical therapy with passive range-of-motion exercises and stretching (often 20-30 minutes daily or more for severe cases), splinting or bracing to maintain joint position, and positioning techniques to avoid static postures.^[3]^[4] For advanced contractures, surgical options like tendon lengthening or release may be necessary, particularly in neuromuscular diseases.^[4] Prevention emphasizes regular joint movement, proper posture, and assistive devices; studies show that consistent stretching and orthotics can slow development in conditions like Duchenne muscular dystrophy.^[3]^[4] Without intervention, contractures can worsen, leading to complications like pressure sores or further disability.^[3]

Overview

Definition

A contracture is defined as a permanent or semi-permanent shortening of muscles, tendons, ligaments, or skin, resulting in limited joint range of motion and increased stiffness that impairs normal function.^[2]^[5] This pathological process involves the replacement of elastic tissues with inelastic fibrous tissue, often leading to fixed deformities.^[6] Contractures can be distinguished as permanent, typically arising from fibrosis and structural remodeling that resists correction, or temporary and recurrent, as seen in certain metabolic myopathies where muscle shortening occurs during exertion but resolves with rest.^[6]^[7] For instance, spastic contractures in cerebral palsy involve persistent muscle shortening due to upper motor neuron lesions, contrasting with ischemic contractures like Volkmann's contracture, which result from vascular compromise leading to irreversible tissue damage.^[8]^[9] The term "contracture" originates from the Latin contractura, meaning "a drawing together," and gained prominence in medical descriptions during the 19th century, with early recognition in orthopedic literature documenting deformities from tissue shortening.^[10]^[11] Common manifestations include muscle and skin contractures, which highlight the condition's impact on soft tissues.^[12]

Epidemiology

Contractures represent a significant morbidity in various clinical contexts, with global prevalence estimates varying by underlying condition. Among stroke survivors, particularly those with severe disability, contractures affect approximately 60% within the first year post-event. In severe burn cases, the incidence can reach up to 93.5% at hospital discharge, though overall rates in adult burn patients range from 30% to 50%.^[13]^[14]^[15] Demographic patterns highlight higher incidence among specific groups. In the elderly, particularly those who are immobile or institutionalized, prevalence exceeds 20%, rising to 71% among non-ambulatory individuals due to prolonged immobility. Children with cerebral palsy face substantial risk, with over one-third developing muscle contractures and up to 44% exhibiting knee contractures by school age. Post-trauma patients, including those with brain injuries, show rates between 16% and 67%.^[16]^[17]^[18]^[19]^[12] Regional variations are pronounced, with increased rates in low- and middle-income countries stemming from limited access to rehabilitation and early intervention post-injury or surgery; one study reported a 77% prevalence of contractures among burn patients in such settings.^[20] Trends indicate a rising global incidence linked to aging populations and improved survival from conditions like strokes. The World Health Organization projects that the population aged 60 and older will double to 2.1 billion by 2050, amplifying contracture risks through increased immobility and chronic disease burden. Stroke incidence, a key contributor, doubles every decade after age 50, with enhanced survival rates further elevating prevalence.^[21]^[22]

Pathophysiology

Mechanisms of Formation

Contractures arise primarily from prolonged muscle shortening, which induces adaptive changes such as sarcomere loss and elevated collagen content in connective tissues, reducing overall tissue extensibility. In immobilized or shortened positions, muscles undergo serial sarcomere reduction to match the functional length, leading to over-stretched remaining sarcomeres during passive stretch and diminished force generation capacity, often to about 20% of normal maximum tetanic tension. Concurrently, extracellular matrix remodeling elevates collagen content—sometimes exceeding 10% by mass—and promotes cross-linking via enzymes like lysyl oxidase, stiffening the perimysial and endomysial layers and contributing to fibrosis.^[23] A central fibrotic process in contracture formation involves the activation of myofibroblasts, specialized fibroblasts that express alpha-smooth muscle actin (α-SMA) in response to transforming growth factor-beta (TGF-β) signaling and mechanical cues, driving excessive extracellular matrix deposition. These cells secrete collagens (types I, III, V, VI), fibronectin, and proteoglycans, while their contractile properties—mediated by integrin engagement and actin polymerization—compact the matrix, further reducing tissue elasticity through enhanced cross-linking and diminished elastin turnover. In pathological states, persistent myofibroblast activity sustains this deposition, transforming provisional wound matrices into rigid, fibrotic scars that resist deformation.^[24] In ischemic pathways, reduced blood flow—often from elevated intracompartmental pressures exceeding 30 mmHg—impairs venous and arterial circulation, initiating tissue ischemia and subsequent myonecrosis in affected muscles. Prolonged ischemia triggers inflammatory responses and fibroblastic proliferation, culminating in scar formation with myotendinous adhesions and collagenous cicatrix, which shorten the muscle-tendon unit; for instance, this mechanism underlies Volkmann's ischemic contracture following compartment syndrome.^[8] Neurologically, contractures develop from spasticity induced by upper motor neuron lesions, which disrupt descending inhibitory pathways and cause velocity-dependent hypertonia through unmodulated spinal reflexes, particularly in antigravity muscles. This imbalanced muscle tone leads to sustained shortening and adaptive structural changes over time, progressively limiting joint range and fostering secondary fibrosis.^[25] In skin, hypertrophic scarring and contractures during wound healing are mediated by TGF-β signaling, where isoform TGF-β1 overexpression in fibroblasts activates the Smad2/3 pathway, upregulating collagen synthesis and myofibroblast contraction to promote excessive matrix deposition and tissue shortening. Downstream effectors like connective tissue growth factor (CTGF) amplify this pro-fibrotic response, creating a feedback loop that sustains scar contractility and reduces dermal elasticity.^[26]

Risk Factors

Immobility is a primary risk factor for contracture development, particularly in hospitalized patients undergoing prolonged bed rest or immobilization via casting. Such conditions significantly elevate the likelihood of joint contractures, with studies reporting an incidence exceeding one-third in intensive care unit patients with stays longer than two weeks.^[27] Impaired mobility has been identified as a leading independent predictor, alongside neurologic diseases and advanced age.^[28] Comorbid conditions, including diabetes, arthritis, and malnutrition, further predispose individuals to contractures through mechanisms like impaired tissue healing and metabolic dysregulation. In diabetes, long-term metabolic changes contribute to conditions such as Dupuytren's contracture, affecting hand function.^[29] Arthritis, particularly rheumatoid forms, often leads to joint stiffness and contractures due to chronic inflammation.^[30] Malnutrition exacerbates these risks by weakening musculoskeletal integrity and delaying recovery, as seen in patients with systemic inflammatory diseases.^[31] Age and genetic factors influence susceptibility, with higher risks observed in pediatric populations due to congenital syndromes like cerebral palsy, where early immobility promotes contracture formation.^[32] In the elderly, sarcopenia—characterized by age-related muscle mass loss—heightens vulnerability by reducing joint stability and mobility.^[17] Iatrogenic factors, such as overly tight casts or suboptimal post-surgical positioning, represent modifiable risks that can directly contribute to contracture onset. Tight dressings or casts may compress tissues, leading to ischemia and fibrosis, while poor positioning during recovery exacerbates imbalance.^[33] Neurological risks, including spasticity following stroke, substantially increase contracture odds; for instance, patients with certain motor recovery stages post-stroke face elevated risk of spasticity compared to those without.^[34]

Types

Muscle Contractures

Muscle contractures involve the permanent shortening of skeletal muscle fibers and associated tendons, resulting in reduced elasticity and limitations in joint range of motion, often manifesting as deficits in flexion or extension. This shortening primarily arises from a decrease in the number of sarcomeres in series within the myofibrils, leading to adaptive changes in muscle length that impair normal function.^[35]^[23] In severe cases, these changes restrict joint mobility, contributing to functional deformities without involving joint capsule fibrosis.^[36] Common sites for muscle contractures include the muscles around the elbow, knee, and hand, where prolonged positioning or imbalance leads to tissue adaptations. For instance, biceps contracture is frequently observed in individuals with cerebral palsy, where spastic elbow flexion shortens the muscle-tendon unit, limiting extension and affecting upper limb function.^[37]^[38] Knee contractures, often involving the hamstrings or quadriceps, similarly arise in conditions of immobility or neurological impairment, while hand muscles may develop shortening that compromises grip and dexterity.^[17] The progression of muscle contractures typically begins with adaptive shortening of muscle fibers, which can occur rapidly within 24 hours of disuse or immobilization, followed by collagen infiltration into the perimysium after about 48 hours. Over time, this evolves into a fixed deformity characterized by extensive collagen proliferation and fibrosis, rendering the muscle-tendon unit resistant to stretching and establishing permanent structural changes.^[17] A specific example is myostatic contracture resulting from disuse, where muscles adapt to a shortened position through non-inflammatory structural remodeling, distinct from spastic contractures driven by upper motor neuron lesions.^[12]^[39] Ischemic variants, such as those seen in compartment syndromes, can accelerate this process through vascular compromise.^[6]

Joint Contractures

Joint contractures involve the thickening and fibrosis of the joint capsule, ligaments, and synovial tissues, which progressively limit passive range of motion. This process primarily affects intra-articular structures, leading to stiffness and reduced joint mobility, often as a secondary consequence of prolonged immobility. Unlike muscle contractures, which involve shortening of extra-articular muscle fibers, joint contractures are characterized by intra-articular changes such as capsular adhesions and synovial proliferation that restrict gliding between joint surfaces.^[27]^[40] Common sites for joint contractures include the shoulder, where adhesive capsulitis—commonly known as frozen shoulder—manifests as a thickened capsule with adhesions that severely impair abduction and external rotation. In post-stroke patients, hip joint contractures frequently develop, contributing to flexion deformities and complicating mobility, with overall contracture rates around 9% in chronic cases.^[41]^[42]^[43] The progression of joint contractures typically begins with adhesion formation within 4 weeks of immobilization, as synovial tissues become adherent and fibrotic, potentially leading to near-complete loss of motion or ankylosis if left untreated. Early intervention is critical, as adhesions can become increasingly resistant to stretching beyond 6 weeks, resulting in permanent structural alterations. Joint contractures may also arise following trauma, involving similar fibrotic responses in the capsule.^[44]^[45]

Skin Contractures

Skin contractures arise from pathological scarring in the dermal and subcutaneous tissues, primarily manifesting as hypertrophic scars that limit skin extensibility and impose mechanical tension on underlying structures. These contractures are characterized by the formation of raised, firm scar tissue confined to the original wound boundaries, which progressively shortens and thickens, reducing skin elasticity and thereby restricting the range of motion at adjacent joints. Unlike keloid scars, which extend beyond the wound edges and rarely cause contractures, hypertrophic scarring specifically leads to tissue contraction through myofibroblast-mediated forces, resulting in functional deformities such as limited abduction or flexion.^[46] The most common etiology of skin contractures is burn injuries, particularly those involving deep partial-thickness or full-thickness damage, where the destruction of dermal appendages disrupts normal wound healing and promotes excessive fibrosis across flexion creases. Common sites include the neck, where anterior scarring can cause mentosternal contractures limiting head extension, and the axilla, where circumferential burns lead to adduction deformities impairing arm elevation. In these areas, the scar tissue aligns perpendicular to the lines of tension, exacerbating the pulling effect on joints and potentially causing secondary musculoskeletal adaptations if untreated.^[47]^[48] The progression of skin contractures begins during the proliferative phase of wound healing, approximately 4-8 weeks post-injury, when dermal fibroblasts hyperactivate and differentiate into myofibroblasts, overexpressing alpha-smooth muscle actin (α-SMA) under the influence of transforming growth factor-beta (TGF-β). This leads to excessive deposition and alignment of type I and III collagen bundles in a dense, parallel orientation, replacing the normal basketweave pattern of the dermis and diminishing tissue compliance. Over 6-8 months, the scar peaks in thickness and contractility, driven by sustained myofibroblast contraction and extracellular matrix remodeling, ultimately resulting in inelastic plaques that tether and deform nearby joints.^[47]^[46] Post-burn skin contractures affect a significant proportion of severe burn cases; for instance, hypertrophic scarring leading to contractures occurs in 32-72% of patients with deep partial-thickness burns, highlighting the clinical burden in burn rehabilitation.^[47]

Other Specific Types

Dupuytren's contracture is a myofibroblastic disorder characterized by progressive thickening of the palmar and digital fascia, resulting in the formation of painless nodules and cords that lead to irreversible flexion contractures of the fingers, most commonly affecting the ring and little fingers.^[49] This condition typically manifests in middle-aged or older individuals and is more prevalent among those of Northern European descent, with a male-to-female ratio of approximately 2:1 and higher severity in men. Studies report prevalence ranging from 22% to 32% in certain Northern European populations, such as the Netherlands and Flanders.^[49]^[50] Genetic factors play a significant role, with heritability estimated at 80% and associations identified at 26 genetic loci, including those involved in Wnt signaling pathways.^[49] Congenital contractures represent another distinct category, often arising from reduced fetal movement in utero due to various neuromuscular or connective tissue abnormalities. Arthrogryposis multiplex congenita (AMC) is a prime example, defined as a nonprogressive syndrome featuring multiple joint contractures in two or more body areas present at birth, affecting approximately 1 in 3,000 live births.^[51] These contractures result from intrauterine positioning constraints or underlying etiologies such as central nervous system disorders, maternal factors, or genetic mutations that impair muscle development and joint mobility.^[52] AMC can involve the limbs, spine, and jaw, leading to deformities like clubfoot or fixed limb positions that persist without intervention.^[53] Rare syndromic forms further illustrate the spectrum of specific contractures. Freeman-Sheldon syndrome, also known as distal arthrogryposis type 2A, is an autosomal dominant disorder caused by mutations in the MYH3 gene, presenting with characteristic facial features such as a "whistling face" (microstomia and pursed lips) alongside multiple congenital contractures, particularly in the hands (camptodactyly) and feet (clubfoot).^[54] These contractures stem from abnormal muscle and connective tissue development, restricting joint movement from birth and often accompanied by scoliosis or respiratory issues.^[55] As a variant of ischemic contracture, Volkmann's ischemic contracture involves a claw-like deformity of the forearm and hand following prolonged ischemia, typically from untreated compartment syndrome after trauma, leading to muscle necrosis and fixed flexion of the wrist and fingers.^[8] Hereditary contractures linked to genetic defects in extracellular matrix components provide insight into familial patterns. Bethlem myopathy, a slowly progressive muscular dystrophy, features proximal muscle weakness and early-onset joint contractures due to mutations in the COL6A1, COL6A2, or COL6A3 genes encoding type VI collagen, which disrupts the muscle-basement membrane interface.^[56] This autosomal dominant condition typically begins in childhood with contractures in the elbows, ankles, and fingers, affecting connective tissue integrity and leading to gradual limitation in range of motion.^[57] Such collagen VI-related mutations highlight how extracellular matrix alterations can manifest as lifelong contractures in multisystem disorders.^[58]

Causes

Traumatic and Ischemic Causes

Traumatic contractures arise from direct physical injuries, such as fractures, soft tissue damage, or burns, which initiate a cascade of hematoma formation, inflammation, and subsequent fibrosis that restricts joint mobility. In fractures, bleeding into surrounding tissues creates a hematoma that organizes into fibrous tissue, while soft tissue injuries disrupt muscle fibers and trigger fibroblast activation, leading to excessive collagen deposition and scarring. Burns, particularly deep second- or third-degree, cause contractures through hypertrophic scarring and wound contraction, affecting areas like the neck, axilla, or joints, with prevalence in 18-50% of severe burn cases.^[59] This process is exacerbated by post-injury immobilization, as seen in post-cast elbow contracture following humeral fractures treated with prolonged casting, where capsular and extra-articular fibrosis limits extension and flexion.^[60]^[61]^[60] Ischemic contractures result from compromised blood supply, most notably in compartment syndrome, where elevated intracompartmental pressure exceeds capillary perfusion, causing muscle ischemia and necrosis. A classic example is Volkmann's ischemic contracture, which develops in the forearm following ischemia after supracondylar humerus fractures in children, leading to shortening and fibrosis of the flexor muscles, resulting in a characteristic claw-hand deformity. If reperfusion is delayed beyond the critical window—typically requiring fasciotomy within 4-6 hours of onset—irreversible myonecrosis progresses, with contracture manifesting within 2-4 weeks as fibrotic replacement of necrotic tissue occurs.^[8]^[8]^[62] The incidence of such contractures in severe orthopedic trauma varies by site and severity; for instance, approximately 12% of patients with traumatic elbow injuries develop joint contractures limiting functional range of motion, while Volkmann's contracture occurs in about 0.1-0.5% of all orthopedic cases but up to 33% of displaced pediatric supracondylar or forearm fractures complicated by compartment syndrome. These fibrotic changes align with broader mechanisms of collagen disorganization and myofibroblast proliferation seen in contracture formation.^[63]^[8]^[64]

Neurological Causes

Neurological causes of contractures arise from dysfunction in the central or peripheral nervous system, leading to imbalances in muscle tone, innervation, and subsequent tissue adaptations that result in permanent shortening of muscles, tendons, or joint capsules. These contractures develop as secondary consequences of disrupted neural control, where altered motor neuron activity promotes uneven muscle forces and fibrosis over time. Inherited neuromuscular disorders, such as muscular dystrophies (e.g., Duchenne muscular dystrophy), also contribute through progressive muscle degeneration and replacement by fibrotic tissue, leading to joint contractures despite not being primarily neural.^[65]^[66]^[67] Spasticity-related contractures are primarily linked to upper motor neuron (UMN) lesions, which disrupt descending inhibitory pathways from the brain, resulting in hypertonia, exaggerated stretch reflexes, and imbalanced muscle tone that favors shortening in antagonist muscles. Common conditions include stroke, where hemispheric damage leads to unilateral spasticity and progressive joint limitations, and cerebral palsy, a non-progressive disorder from perinatal brain injury that often manifests with lifelong spastic diplegia or hemiplegia, causing equinus foot deformities and hip adductor tightness due to persistent hypertonia. In multiple sclerosis, an autoimmune demyelinating disease affecting the central nervous system, up to 56% of patients develop contractures in at least one major joint, predominantly the ankle, driven by progressive spasticity and weakness that exacerbate muscle imbalances.^[68]^[69]^[70] Lower motor neuron (LMN) lesions, by contrast, involve direct denervation of muscles, initially causing flaccid paralysis and atrophy, but over time leading to fibrotic contractures as unopposed antagonists and connective tissue proliferation shorten the affected structures. In spinal cord injuries, particularly those involving LMN pathways at the level of the lesion, denervation results in initial hypotonia followed by secondary contractures in paralyzed limbs due to disuse and intramuscular fibrosis. Similarly, peripheral neuropathies such as Charcot-Marie-Tooth disease, a hereditary LMN disorder, promote progressive muscle wasting and joint deformities, including pes cavus and hammertoes, through chronic denervation and imbalanced foot intrinsics. A key progression in these LMN scenarios is the paradoxical development of contractures despite initial flaccid weakness, where the absence of active muscle lengthening allows passive tissue shortening to dominate, often within months of onset.^[67]^[71]^[72] Iatrogenic contractures arise from medical interventions that inadvertently promote tissue shortening or fibrosis, such as improper application of splints or casts, which can elevate compartmental pressures and induce ischemia in underlying muscles and nerves.^[73] This pressure-related ischemia disrupts blood flow, leading to muscle necrosis and subsequent fixed deformities if not promptly addressed.^[74] For instance, tight casts or splints applied post-fracture may cause Volkmann's ischemic contracture, characterized by forearm muscle shortening due to vascular compromise.^[75] Prolonged immobility, often resulting from bed rest or joint immobilization following surgery, triggers adaptive shortening of muscles, tendons, and joint capsules, ultimately forming contractures.^[76] In postoperative settings, such as after anterior cruciate ligament (ACL) reconstruction, immobilization exacerbates arthrogenic and myogenic contractures by promoting inflammation and fibrosis in the joint, with studies showing stabilization of myogenic components within two weeks and arthrogenic changes by four weeks.^[77] These changes reduce range of motion and can persist even after mobilization if immobility exceeds recommended durations.^[78] A notable example occurs in intensive care unit (ICU) patients requiring mechanical ventilation, where immobility contributes to ICU-acquired weakness and joint contractures in approximately one-third of cases following stays longer than two weeks.^[79] This prevalence underscores the rapid onset, with contractures developing in major joints like the elbows and ankles due to sustained positioning without intervention.^[17] Contributing to these immobility-related contractures, pain avoidance often leads patients to adopt guarded postures, where muscles remain in a shortened, protective state, fostering progressive stiffness and limiting joint excursion over time.^[12] Such postures, common in postoperative or critically ill individuals, amplify disuse atrophy and connective tissue adaptations, making early mobility essential to mitigate progression.^[80]

Clinical Features

Symptoms

Contractures primarily manifest as a reduction in joint range of motion, where affected individuals experience limitations in extending or flexing the joint fully due to shortening of muscles, tendons, or surrounding soft tissues.^[6]^[1] This is often accompanied by stiffness in the muscles, joints, or other soft tissues, which can make movements feel rigid or resistant.^[6] Pain or discomfort typically arises during attempted movement, particularly when stretching the contracted area, though some cases, such as certain fibrotic types, may be painless initially.^[6]^[1] These symptoms lead to significant functional impacts, impairing daily activities that require joint mobility. For instance, upper limb contractures may hinder tasks like dressing, grasping objects, or personal hygiene, while lower limb involvement can cause difficulties with walking, balance, or transferring positions, thereby reducing overall independence and mobility.^[4] In ischemic contractures, such as Volkmann's type, sensory changes like paresthesia—manifesting as tingling, numbness, or decreased sensation—may occur due to nerve compression or ischemia in the affected area. Chronic contractures often involve muscle atrophy, where prolonged disuse or fibrosis leads to wasting and weakening of the muscle tissue, further exacerbating the loss of function.^[81] The progression of contractures typically begins with subtle flexibility loss, where joints feel increasingly tight during routine motions, gradually evolving into a fixed deformity that permanently restricts movement if unaddressed.^[82] In severe, prolonged cases, this can contribute to secondary complications like pressure ulcers over bony prominences due to immobility.^[4]

Complications

Contractures can lead to secondary osteoarthritis through altered joint biomechanics, where limited range of motion increases uneven loading on cartilage and accelerates degeneration. In the knee, flexion contractures are associated with a 31% higher odds of radiographic osteoarthritis incidence (odds ratio 1.31, 95% CI 1.04–1.64) and contribute to disease progression, with an effect size of 0.31 on Kellgren-Lawrence grading. Severe contractures elevate the risk of needing total knee arthroplasty by up to 3.76 times (odds ratio 3.76, 95% CI 1.67–8.45).^[83] In immobile patients, contractures promote skin breakdown by causing persistent pressure and shear forces over bony prominences, increasing the likelihood of pressure ulcers. Abnormal positioning from joint limitations, such as in spastic or fixed postures, repeatedly traumatizes tissues and hinders repositioning, a key preventive measure. Patients with contractures are predisposed to ulceration in areas like the heels or sacrum, with studies showing those developing ulcers have significantly higher contracture rates (14.1% vs. 7.1%, P=0.05).^[84]^[17]^[85] Chronic pain from contractures often results in systemic effects, including depression due to persistent discomfort, sleep disruption, and functional limitations. Up to 85% of individuals with chronic pain experience depressive symptoms, with contracture-related pain exacerbating this through reduced quality of life and social isolation. Additionally, diminished mobility from contractures heightens fall risk; for instance, hip limitations correlate with increased falls, akin to the 2.5-fold elevated risk seen in arthritis patients with similar mobility impairments.^[86]^[87]^[88] In severe cases, particularly burns, untreated contracture progression can necessitate amputation to address irreversible deformity, vascular compromise, or infection. Amputation rates following major burns reach approximately 2% overall, rising to 20–50% in high-voltage electrical injuries where contractures contribute to tissue necrosis. Contractures occur in 39% of major burn survivors, with severity linked to factors like extensive grafting and inhalation injury, underscoring the need for early intervention to avert such outcomes.^[89]^[90]^[91]

Diagnosis

Physical Examination

Diagnosis of contracture typically begins with a detailed medical history review to identify underlying causes, risk factors such as immobility or neurological conditions, onset and progression of symptoms, and any prior treatments or injuries.^[1] The physical examination for contractures begins with a systematic assessment of the affected joints and surrounding soft tissues to identify limitations in mobility, tissue abnormalities, and functional impairments. Clinicians typically inspect the area for visible deformities, asymmetry, or skin changes before proceeding to hands-on evaluation, ensuring the patient is positioned comfortably to minimize discomfort or guarding. This bedside approach allows for immediate quantification of deficits and differentiation between muscular, capsular, or neurological contributions to the contracture.^[92] Range of motion (ROM) testing is a cornerstone of the examination, distinguishing between active ROM—where the patient voluntarily moves the joint—and passive ROM, where the examiner gently manipulates the limb to its full extent. A goniometer, a protractor-like device aligned with the joint's axis, is used to measure angular displacement in degrees, comparing the affected side to the contralateral or normative values to quantify the deficit; for instance, elbow flexion limited to less than 90° indicates a significant contracture. Passive ROM is particularly informative for isolating joint restrictions from muscle weakness or pain, as it reveals end-range resistance or "end-feel" characteristics, such as a firm block from capsular tightness. Limitations in ROM must be assessed across all planes (flexion-extension, abduction-adduction, rotation) to fully characterize the contracture's impact.^[92] Palpation follows ROM testing to evaluate the quality of tissues involved, applying light to deep pressure along muscle bellies, tendons, and joint lines to detect tightness, fibrosis, or crepitus. In contractures, palpation identifies increased muscle tone or fibrous shortening, often presenting as a firm, non-yielding texture in the affected area, while crepitus—a grating sensation or sound—may signal underlying joint degeneration contributing to the restriction. This technique helps localize the pathology, such as perarticular fibrosis in prolonged immobility-related contractures, and assesses for associated warmth or swelling that could indicate inflammation. Bilateral comparison ensures subtle asymmetries are not overlooked.^[93]^[92] Functional tests provide insight into the contracture's effect on daily activities, particularly in ambulatory patients. For lower extremity contractures, observation of gait reveals compensatory patterns, such as circumduction or Trendelenburg sign due to hip or knee limitations, while upper extremity involvement is evaluated through grip strength assessment using a dynamometer to measure force in kilograms. These tests quantify practical deficits, like reduced stride length from ankle equinus, helping correlate anatomical findings with real-world impairment.^[92] For contractures associated with spasticity, such as those from neurological conditions, grading scales like the Modified Ashworth Scale (MAS) are employed during passive ROM to quantify hypertonia. The MAS rates resistance to movement on a 0-4 scale, where 0 denotes no increase in tone, 1 indicates a slight catch with minimal resistance, and 4 signifies rigidity in flexion or extension; the patient is typically supine, and the limb is moved at a consistent speed to elicit the response. This scale aids in distinguishing spastic contractures from non-neurological types and guides further management.^[94]

Imaging and Other Tests

Imaging modalities play a crucial role in confirming and characterizing contractures by visualizing soft tissue changes, joint structures, and potential bony abnormalities beyond what is observable through physical examination. X-rays are commonly employed as an initial imaging tool to exclude osseous contributions to contracture, such as bony ankylosis or heterotopic ossification, which can mimic or complicate soft tissue contractures. For instance, in cases of suspected heterotopic ossification following trauma or immobility, plain radiographs reveal mature bone formation in soft tissues with sharp demarcation from surrounding structures, typically becoming visible 3-8 weeks after onset.^[95]^[96] Ultrasound serves as a noninvasive, real-time method for assessing soft tissue fibrosis, particularly in superficial contractures like those involving the deltoid or palmar fascia in Dupuytren's disease. It detects increased echogenicity and altered dimensions of fibrotic lesions, allowing dynamic evaluation of tendon and muscle involvement without radiation exposure.^[97]^[98] Shear wave elastography, an advanced ultrasound technique, quantifies tissue stiffness in fibrotic areas, aiding in the diagnosis of immobilization-induced contractures by measuring elevated shear wave velocities indicative of fibrosis.^[99] Magnetic resonance imaging (MRI) provides detailed visualization of deeper structures, such as joint capsule thickening and adhesions, which are hallmarks of contractures like adhesive capsulitis (frozen shoulder). Non-contrast MRI identifies capsular thickening greater than 4 mm in the axillary recess and axillary pouch signal abnormalities, enabling staging from early inflammation to chronic fibrosis with high diagnostic accuracy.^[100]^[101] In neurological contractures, MRI can delineate muscle atrophy or fibrosis patterns to support differential diagnosis. Electromyography (EMG), often combined with nerve conduction studies, is valuable for distinguishing neurogenic contractures (arising from nerve damage) from myogenic ones (due to primary muscle pathology). In neurogenic cases, EMG shows denervation patterns with reduced motor unit potentials and fibrillations, whereas myogenic contractures exhibit short-duration, low-amplitude polyphasic potentials during voluntary contraction.^[102]^[103] Muscle biopsy is infrequently required but may confirm fibrotic tissue composition in atypical or refractory presentations where imaging is inconclusive. Histological analysis reveals collagen deposition and myofibroblast proliferation in fibrotic contractures, helping to rule out inflammatory myopathies or other neuromuscular disorders.^[104]

Treatment

Conservative Management

Conservative management of contractures focuses on non-invasive strategies to preserve or restore joint mobility, primarily through targeted physical therapy, pharmacological aids for spastic types, and adjunctive physical modalities. These approaches aim to apply controlled stretch to shortened tissues while minimizing discomfort and secondary complications, often serving as the initial line of treatment before considering more invasive options. Evidence supports their use in early-stage contractures, where compliance and timely intervention can yield modest improvements in range of motion (ROM). Physical therapy forms the cornerstone, employing techniques like serial casting and dynamic splinting to gradually elongate contracted muscles, tendons, and fascia. Serial casting involves the sequential application of plaster or fiberglass casts, changed weekly to incrementally increase stretch, resulting in an average ROM gain of 22° for elbow flexion contractures in adults with traumatic brain injury over two weeks, though gains may diminish without ongoing maintenance.^[105] Dynamic splinting utilizes adjustable, spring-loaded devices that deliver low-load, prolonged passive stretch, typically worn for several hours daily; systematic reviews confirm its safety and efficacy in reducing lower extremity contractures, with joint-specific protocols achieving greater ROM improvements than standard stretching alone.^[106] These methods prioritize gradual progression, often targeting 1-2° weekly gains in responsive cases, and are most effective when combined with patient education on positioning to prevent progression. For spastic contractures, often seen in neurological conditions like cerebral palsy or stroke, botulinum toxin type A (BoNT-A) injections offer a targeted pharmacological intervention by temporarily inhibiting acetylcholine release at neuromuscular junctions, thereby reducing muscle tone and facilitating stretch. In children with cerebral palsy, BoNT-A significantly lowers spasticity scores on the Modified Ashworth Scale and increases passive ankle dorsiflexion ROM for 3-6 months post-injection, particularly in younger patients under 4 years with equinus deformity.^[107] Similar benefits occur in post-stroke upper limb spasticity, where repeated injections maintain reduced tone and improved hand function over extended periods (up to several years) when integrated with therapy.^[108]^[109] Injections are typically guided by electromyography for precision and dosed based on muscle mass, with effects peaking at 2-4 weeks. Adjunctive physical modalities enhance tissue extensibility and comfort during therapy. Heat therapies, such as infrared or therapeutic ultrasound, promote collagen softening and increased blood flow; when applied before stretching sessions (e.g., 10-15 minutes at 1-3 MHz for ultrasound), they yield greater knee extension ROM improvements than stretching without heat in animal models of joint contracture.^[110] Electrical stimulation, including transcutaneous electrical nerve stimulation (TENS), modulates spasticity by activating sensory afferents; applications exceeding 30 minutes over affected nerves or muscles provide strong evidence of reduced lower limb tone in neurological populations.^[111] Protocols emphasizing low-load prolonged stretch—via splints or positioning for 30-60 minutes daily—demonstrate small but consistent joint mobility gains (mean difference of 2°, 95% CI 0-3) across various contracture types, underscoring their role in early intervention despite limited long-term preventive effects.^[112]

Surgical Options

Surgical options for contracture primarily involve procedures to release tightened tissues, restore joint mobility, and prevent deformity progression when conservative measures prove insufficient. These interventions target muscles, tendons, joint capsules, and skin, with techniques selected based on the contracture's etiology, severity, and location.^[6] Release techniques include tenotomy, which involves cutting or perforating the tendon to alleviate tension and allow lengthening during healing, commonly used for muscle and tendon contractures such as those affecting the Achilles tendon.^[113] Capsulotomy, the incision or release of the joint capsule, addresses capsular contractures by facilitating deformity correction and restoring tendon balance, often applied in cases like hammertoe or post-burn joint stiffness.^[114] For skin contractures, Z-plasty employs triangular flap transposition to elongate scars and redistribute tension, effectively lengthening mild contractures while minimizing recurrence.^[115] In burn-related skin contractures, excision of scarred tissue followed by skin grafting is a standard approach to reconstruct defects and improve joint function. Full-thickness skin grafts are preferred for severe cases due to better texture matching and lower recontracture rates compared to split-thickness grafts, with flaps used for enhanced durability in high-mobility areas.^[116] Advanced procedures encompass tendon lengthening, often achieved through controlled tenotomy or Z-lengthening incisions to gradually extend shortened tendons in fixed deformities, and arthrodesis, which fuses the joint in a functional position for severe, recurrent contractures unresponsive to release.^[6]^[117] Surgical outcomes typically demonstrate substantial gains in range of motion, with studies reporting 70-80% improvement in joint arc following release procedures, such as from 74° to 129° in elbow contractures.^[118] However, recurrence risks vary by method, ranging from 5-27% at one to five years post-surgery, higher with grafts (up to 27%) than flaps (around 5-10%), emphasizing the need for adjunct therapies to mitigate re-contracture.^[119]^[120]

Rehabilitation

Rehabilitation for contractures encompasses multidisciplinary programs designed to restore joint mobility, strength, and overall function after initial management interventions. These programs emphasize coordinated care to address the complex interplay of physical impairments and functional limitations, promoting long-term independence.^[121] Occupational therapy is integral to these efforts, particularly post-contracture release, where therapists introduce adaptive devices such as custom orthoses and assistive tools to facilitate daily activities and prevent compensatory patterns. Strengthening exercises, tailored to the affected limb, are prescribed to enhance muscle endurance and joint stability, with progressive resistance training helping to counteract residual weakness.^[122]^[123] The rehabilitation timeline generally includes an intensive phase during weeks 1-6, characterized by daily splinting to sustain joint extension or flexion gains, combined with frequent therapy sessions for range-of-motion maintenance. This period transitions to a maintenance phase beyond week 6, focusing on independent exercises and periodic monitoring to consolidate improvements.^[124]^[125] Multidisciplinary involvement extends to physiotherapists who oversee mobility and balance training, pain management specialists who employ modalities like transcutaneous electrical nerve stimulation to alleviate therapy-related discomfort, and psychological support providers who offer coping strategies for the emotional challenges of prolonged recovery.^[126]^[127] Participation in these structured programs has been associated with Functional Independence Measure (FIM) score improvements of 20-30 points, reflecting enhanced performance in self-care, mobility, and social cognition domains.^[128]^[129] Following surgical options for contracture release, rehabilitation initiates promptly to maximize functional recovery.^[17]

Prevention

Strategies in At-Risk Populations

In at-risk populations such as post-stroke patients, early mobilization through passive range-of-motion (ROM) exercises is a key strategy to help maintain joint mobility and prevent contracture development.^[130] These exercises involve gentle, therapist-assisted movements across full joint ranges to maintain muscle length and joint mobility, particularly in the upper and lower extremities affected by hemiplegia.^[130] For burn patients, anti-contracture positioning helps minimize scar tension and promotes tissue elongation during the acute healing phase.^[131] Proper positioning plays a critical role in intensive care settings for immobilized individuals. For post-stroke patients in particular, positioning the hemiplegic shoulder in maximum external rotation for 30 minutes daily while supine or seated reduces the risk of subluxation and subsequent contracture.^[130] In burn care, positioning affected joints in an anti-deformity alignment—such as extension for the elbow or knee—immediately post-injury minimizes scar tension and promotes tissue elongation.^[131] For children with cerebral palsy, splinting protocols initiated at diagnosis target spastic muscles to prevent progressive contractures, often using rigid or semi-rigid orthoses worn during rest to apply low-load prolonged stretch. These include ankle-foot orthoses to maintain dorsiflexion or hand splints to support neutral wrist and thumb positions, typically for 4-6 hours daily.^[132] Evidence from randomized trials supports that such early orthotic interventions improve joint range and reduce contracture incidence without adverse effects on function.^[133] Clinical guidelines emphasize these multimodal strategies, with studies showing prevention of plantar flexion contractures among immobilized patients through consistent positioning.^[134]

Post-Treatment Prevention

Maintenance therapy plays a crucial role in preventing the recurrence of contractures after initial treatment. Home exercise programs, typically involving stretching and range-of-motion activities tailored to the affected joint, are recommended to sustain therapeutic gains. Such consistent adherence helps maintain joint mobility and reduces the likelihood of tissue shortening over time.^[135] Regular monitoring is essential to detect early signs of contracture relapse following treatment. Patients should attend follow-up appointments every 3-6 months, where healthcare providers use goniometry to measure joint range of motion and identify any progressive shortening.^[136]^[137] Goniometry provides a reliable, quantitative assessment of joint angles, allowing for timely adjustments to the rehabilitation plan if deviations from baseline are observed. This proactive approach integrates briefly with ongoing rehabilitation efforts to ensure long-term joint health. Lifestyle modifications further support post-treatment prevention by minimizing mechanical stress on the treated areas. Weight management is particularly important, as excess body weight increases load on weight-bearing joints like the knees and hips, potentially exacerbating tissue strain and promoting contracture recurrence.^[138] Similarly, ergonomic adjustments in daily activities—such as using supportive seating, proper workstation setup, and avoiding repetitive postures—help reduce ongoing strain and preserve treatment outcomes.^[139] In cases involving surgical intervention for contractures, night splinting is a standard preventive measure. Patients are typically advised to wear a static extension splint at night for 6-12 months postoperatively to maintain joint alignment and counteract scarring tendencies.^[140]

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Joint Capsulotomy - an overview | ScienceDirect Topics
Joint capsulotomy is defined as a surgical procedure that involves the incision of the joint capsule to release contractures and facilitate the correction ...
[110]
Z-Plasty - StatPearls - NCBI Bookshelf
Jul 5, 2023 · Z-plasty is a common reconstructive surgical technique used for scar revision and contracture release. It involves the transposition of two opposing triangular ...Introduction · Anatomy and Physiology · Equipment · Technique or Treatment
[111]
Surgical treatment algorithms for post-burn contractures - PMC
Mar 14, 2017 · Deep partial-thickness and full-thickness burns that are not treated with early excision and grafting can be disabling, as these deep ...
[112]
Outcome of arthrodesis for severe recurrent proximal ... - PubMed
Oct 7, 2020 · We report long-term outcomes of proximal interphalangeal joint arthrodesis for treatment of severe recurrent joint contractures secondary to Dupuytren's ...
[113]
Analysis of Long-Term Outcomes Following Surgical Contracture ...
Apr 26, 2021 · Our clinical outcome data showed most patients are able to comfortably complete ADLs, have minimal pain, and are highly satisfied with their ...
[114]
Burn scar contracture release surgery effectively improves functional ...
Mar 28, 2025 · Burn scar contracture release surgery effectively improves functional range of motion, disability and quality of life: A pre/post cohort study ...
[115]
Surgical treatment of joint burn scar contracture: a 10-year single ...
However, a recent systematic review revealed that it is unclear which surgical technique is the most effective to resolve joint burn scar contracture (13). ...
[116]
The Impact of Spasticity and Contractures on Dependency and ...
This regional center provides multidisciplinary rehabilitation, including integrated spasticity management, for patients with highly complex neurological ...
[117]
Intrinsic contracture of the hand: diagnosis and management
Intrinsic contracture of the hand may result from trauma, spasticity, ischemia, rheumatologic disorders, or iatrogenic causes.
[118]
Inpatient occupational therapists hand-splinting practice for clients ...
To reduce spasticity, to correct contractures and thus increase range of motion (ROM) were the commonly used splinting goals. These were the goals that were ...<|control11|><|separator|>
[119]
[PDF] The HELP Guide To Burn Contractures In Developing Countries
What is a burn contracture scar? A burn contracture is an area of skin that has undergone excessive scarring as a result of healing from a deep burn injury.
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OUTCOME OF PHYSICAL THERAPY AND SPLINTING IN HAND ...
The splint was maintained continuously for 6–7 weeks and after 6–7 weeks until 3 month splints were used only during the night. At patients who had burn ...Missing: intensive | Show results with:intensive
[121]
ICF-based multidisciplinary rehabilitation program for complex ...
Dec 1, 2020 · The multidisciplinary treatment concept involved physical therapists, occupational therapists, psychologists, neurologists, nuclear medicine, ...
[122]
Pain Rehabilitation - an overview | ScienceDirect Topics
Pain rehabilitation is defined as a comprehensive approach to managing chronic pain that focuses on normalizing function and improving quality of life ...
[123]
Inpatient rehabilitation outcomes in primary and revision total knee ...
Functional Independence Measure (FIM) scores improved from admission to discharge for the TKAP (81.6 to 110.5) and TKAR (74.4 to 101.4) groups (p = 0.015). TKAP ...
[124]
Full article: Minimal clinically important difference of the functional ...
Improvements of 22 and 21 points at the total and motor FIM were identified as indicators of minimal clinical change in those admitted to a rehabilitation ...Missing: contracture | Show results with:contracture
[125]
Stretch for the treatment and prevention of contractures - PMC
Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective.
[126]
Guidelines for Adult Stroke Rehabilitation and Recovery
The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.
[127]
Prevention and Treatment of Burn Scar Contracture - NIH
Jan 19, 2024 · This review sought to identify techniques used for prevention and correction of burn contractures published in the literature since 2000 and to ...
[128]
Clinical practice recommendations for positioning of the burn patient
The body area affected by the burn should be positioned opposite the direction of potential burn scar contracture.
[129]
Splint: the efficacy of orthotic management in rest to prevent equinus ...
Mar 26, 2012 · Splint: the efficacy of orthotic management in rest to prevent equinus in children with cerebral palsy, a randomised controlled trial. Josina ...
[130]
Protocol for a multicentre randomised controlled trial of upper limb ...
May 27, 2016 · The primary goal of wearing rigid WHO for all children with CP is to prevent the development of muscle stiffness, maintain the integrity of soft ...
[131]
Preventing Heel Pressure Ulcers and Plantar Flexion Contractures ...
Aug 6, 2025 · Application of the heel protectors led to a 50% reduction in prevalence of abnormal heel position. No patients developed plantar flexion ...
[132]
[PDF] VA DoD CPG for Management of Stroke Rehabilitation
This CPG provides clinical practice recommendations for the care of patients ... • 2021 AHA/ASA Guidelines for the Prevention of Stroke in Patients with Stroke ...
[133]
FREQUENCY AND MODALITY OF EXERCISE ON PAIN AND ...
Feb 3, 2025 · Stretching training was found to be effective in reducing knee pain only when performed three times a week, and improved functional independence when done two ...
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None
### Summary on Prevention of Contractures After Treatment
[135]
Goniometry - Physiopedia
Goniometry refers to the measurement of angles, which in rehabilitation settings refers to the measurement of angles in each plane at the joints of the body.Category:Goniometry · Ankle (Subtalar) Eversion · Shoulder Flexion · Elbow FlexionMissing: contractures | Show results with:contractures
[136]
Dupuytren Contracture Treatment & Management
Sep 25, 2023 · However, 50% of patients experienced recurrence of nodules 1 to 3 years after their last injection, and those with mild MCP contractures (< 15º) ...
[137]
Influencing factors of flexion contracture among patients with knee ...
Sep 1, 2025 · Joint deformities can occur at any stage of KOA, with common causes including mechanical factors, osteoporosis, and obesity. Among them, flexion ...
[138]
Ergonomic and prophylactic interventions for lower body work ...
Jun 4, 2025 · Ergonomic workplace interventions include altering heights of monitors, desks, chairs, and armrests, as well as chairs with proper back support ...
[139]
Night-time splinting after fasciectomy or dermo ... - PubMed Central
The routine addition of night-time splinting for all patients after fasciectomy or dermofasciectomy is not recommended except where extension deficits reoccur.
[140]
[PDF] The Effects of Splinting on Functional Independence for Adults with ...
Conclusion and Relevance: Night splinting is effective and improves ROM post-surgery and decreases Dupuytren's contracture recurrence for individuals with ...