Definition

A joint contracture is a limitation in the passive range of motion of a joint. Changes in articular structures (bone, cartilage, capsule) or nonarticular 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 126.1.

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 such, joint motion limited by 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 (increased tone, spasticity, co-contraction) has been removed. For example, when a person with a spinal cord injury is treated for spasticity, the tone in the lower extremities will be reduced and an apparent chronic ankle plantar flexion contracture may disappear.

Conventionally, a joint contracture is named according to the joint involved and the direction opposite the lack of range. Some examples: a knee flexion contracture lacks full extension; an elbow extension contracture lacks full flexion; and an ankle plantar flexion contracture lacks dorsiflexion.

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 articular or nonarticular tissues, and a joint contracture can ensue [1]. Joints traumatized by fracture or reconstructive surgery, such as anterior cruciate ligament repair or arthroplasty, are susceptible to contractures [2]. Joint contractures can happen as a consequence of the disease (prolonged immobility in bed in intensive care units; Fig. 126.1) 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 segments.

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, spasticity and excessive muscle tone prevent a joint from accessing portions of its normal range [3]. Similarly, in lower motor neuron injuries, such as a plexopathy or peripheral nerve injury, the unopposed muscle pull will limit joint motion toward the paralyzed muscle. The range of motion not accessed will eventually be lost, resulting in a joint contracture.

A number of other local conditions, such as arthritis, joint infections, and burns, will cause contractures [4]. In addition, conditions affecting multiple systems, such as muscular dystrophy, diabetes, and 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 [4]. Nevertheless, these studies indicate a common problem. At least one joint contracture was noted in 7% to 51% of persons after a spinal cord injury [5–7]. Between 16% and 81% of persons with an acquired brain injury developed a joint contracture [3,8,9], and 51% of children who had an obstetric brachial plexus injury were found to have a shoulder contracture [10]. In institutionalized elderly, one study reported that 71% of those who were immobile had a joint contracture, whereas none of the mobile patients had a joint contracture [11].

Symptoms

Joint contractures develop insidiously and may progress asymptomatically. They are 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 126.2). 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 [17] or of hip or low back pain. Nearly half of tetraplegic spinal cord injury patients with a shoulder contracture experienced shoulder pain [18]. Subjects with spinal muscular atrophy or congenital myopathy were more than eight times more likely to experience elbow pain if they had an elbow contracture [19].