Definition

A joint contracture is a limitation in the passive range of motion of a joint. Changes in intra-articular structures (bone, cartilage, capsule) or extra-articular structures (muscles, tendons, skin) can prevent a joint from moving passively through its full range. A classification according to the tissue limiting the range of motion is proposed in Table 127.1 .

By this definition, regardless of the nature of the tissue alteration, if it results in joint motion limitation, the joint condition is called a joint contracture. For example, a muscle with adaptive shortening or fibrosis restricting joint motion is classified as “joint contracture—myogenic type.” It should not be referred to as a muscle contracture.

As another example, joint motion limited by conditions such as pain or spasticity qualifies as a joint contracture only if the limitation is demonstrated after the pain or the influence of the hyperactive upper motor neuron condition (increased tone, spasticity, co-contraction) has been removed. For example, when a person with a brain injury is treated for spasticity, the tone in the affected limbs will be reduced and an apparent flexion contracture may disappear. Conversely, some joint contractures may persist in these individuals despite treatment, as shown in Fig. 127.1 .

Persistent (A) wrist and (B) finger flexion contractures in a patient with a stroke and affected upper limb spasticity despite treatment with oral medications and botulinum toxin.

Photography: Claire de Lucovich.

Conventionally, a joint contracture is named according to the joint involved and the direction opposite the lack of range. For example, a knee flexion contracture defines a knee joint “stuck” in a certain amount of flexion, unable to fully extend, and an elbow extension contracture defines an elbow unable to fully flex. A contracture is the final common path of numerous conditions preventing movement of a joint through its full range of motion. Pain, trauma, immobility, weakness, and edema commonly contribute to reduced joint range of motion. The body’s natural reaction to a painful joint is to “splint” or immobilize it. Not moving the joint through its full range, with time, can cause structural changes to one or more intra-articular or extra-articular tissues, and a joint contracture can ensue. This can occur as quickly as one week after immobilization and may require specialized therapy after as few as four weeks. Joints traumatized by fracture or reconstructive surgery, such as anterior cruciate ligament repair that requires several weeks of immobilization, are susceptible to contractures. Joint contractures can happen as a consequence of the disease (e.g., prolonged immobility in bed; Fig. 127.2 ) or as part of the treatment (casting after fracture or prolonged use of a brace). Any joint can be affected. At the spine, affected vertebral amphiarthrodial and facet diarthrodial joints can limit the range at one or more segment(s).

Prolonged bed rest is a risk factor for contractures in multiple joints. (A) Common bed rest position placing patient at risk of developing contractures in multiple joints. (B) Plantar-flexion contracture due to prolonged bed rest in a patient with severe brain injury. (C) Elbow, wrist, and finger flexor contractures in same patient shown in (B).

Photography: Claire de Lucovich.

Neurologic conditions that increase muscle tone or cause weakness contribute to contractures because of unequal forces generated by opposing muscle groups. In upper motor neuron conditions, such as after a stroke or traumatic brain injury, excessive muscle tone prevents a joint from accessing portions of its normal range opposite the spastic muscle. Similarly, in lower motor neuron injuries, such as a plexopathy or peripheral nerve injury, the unopposed pull of spared muscles will limit joint motion toward the paralyzed muscle. The range of motion not accessed will eventually be lost, resulting in a joint contracture.

Both inflammatory and non-inflammatory arthritis can cause joint contracture. Osteoarthritis (OA) is the most common form of arthritis and the fastest growing chronic disease worldwide. As many as one third of patients with knee OA presenting for total knee replacement have a contracture in the affected knee. Of these, one third will also have a contracture of the opposite knee.

A number of other local conditions, such as joint infections, hemarthroses, and burns, will cause contractures. In addition, conditions affecting multiple systems, such as muscular dystrophy, diabetes, Parkinson, and Alzheimer diseases can limit mobility or initiation and put the patient at risk for contractures.

Data on incidence and prevalence of joint contractures are limited and often describe one specific joint. Nevertheless, these studies indicate a highly prevalent problem across diagnoses and age groups. At least one joint contracture was noted in 66% of persons after a spinal cord injury, between 16% and 84% of persons after an acquired brain injury, and about 50% of persons after a stroke. Thirty-six percent (36%) of cerebral palsy patients with upper limb involvement developed a contracture in the affected upper limb and 51% of children with an obstetric brachial plexus injury had a shoulder contracture. Twenty-two percent (22%) of institutionalized elderly individuals had a joint contracture, with as many as 56% of those who were unable to transfer independently.

Symptoms

Joint contractures develop insidiously and may progress asymptomatically. They are often painful only with attempts to move the joint through its full range beyond the restriction. Many daily activities do not require a joint to move through its entire range. Therefore, a contracture may develop unnoticed for extended periods until the joint restriction interferes with functional activity ( Table 127.2 ). In the outpatient setting, patients with hand and finger joint contractures might present with complaints of a weak or ineffective grasp. A patient with a knee flexion contracture may complain of a limp or of hip or low back pain. Individuals with a spinal cord injury were 2.5 times more likely to develop shoulder pain if a shoulder contracture was present and subjects with spinal muscular atrophy or congenital myopathy were over 8 times more likely to experience elbow pain if they had an elbow contracture.

Table 127.2

Range of Motion Required to Perform Select Activities of Daily Living Normally

Activity	Joint	Required Range
Sitting	Hip	91° of flexion
	Knee	90° of flexion
Walking	Hip	23° of flexion, 21° of extension
	Knee	60° of flexion
	Ankle	15° of dorsiflexion 20° of plantar flexion
Ascending stairs	Knee	94° of flexion
	Hip	67° of flexion
Eating (fork to mouth)	Shoulder	36° flexion, 23° abduction
	Elbow	103° of flexion
Combing hair	Shoulder	105° of abduction 90° external rotation
Perineal hygiene	Shoulder	90° of internal rotation
	Wrist	54° of flexion
Open a door with doorknob	Elbow	10° of pronation 77° of supination
	Wrist	32° of ulnar deviation
Open and close jar lid	Wrist	10° of radial deviation 36° of ulnar deviation

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