A contracture is a joint that can no longer move through its full range, held bent or straight because the tissue around it has tightened. It is less a disease of its own than a result of something else: a stretch of not moving, a burn scar, a stroke, a nerve condition, or a hand disorder. What caused it shapes what can be done, and many contractures improve with steady stretching and splinting rather than an operation.
What Happens Inside a Joint That Gets Stuck
Doctors describe how far a joint moves as its range of motion, and a contracture is a loss of that range. The tightening can sit in the muscle, the tendon, the ligaments, or the joint capsule, the sleeve of tissue that wraps a joint.1International Center for Limb Lengthening. Contractures Skin scarring, such as after a burn, can also pull a joint into a fixed position.2PM&R KnowledgeNow. Contractures
In daily life, the joint resists when you try to straighten it, even gently. It often isn’t painful at rest but hurts when pushed. Knees, elbows, ankles, fingers and hips are common spots, and the limb tends to settle into the same bent position again and again. Ordinary morning stiffness loosens as you move around, but a contracture does not.
When a joint is kept still, the collagen fibres in its capsule form extra cross-links that make the tissue stiffer.3PubMed Central. Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments The fibres also become disorganised instead of lying in neat lines.4PubMed Central. Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments The capsule also loses molecules that hold water, which may let even more cross-links form.5PubMed Central. Noninflammatory Joint Contractures Arising from Immobility: Animal Models to Future Treatments In animal studies the body tries to rebuild the capsule in the first weeks, but that effort fades as the contracture becomes long-standing.6PubMed Central. Temporal gene expression profiling of the rat knee joint capsule during immobilization-induced joint contractures Tissue is still changeable early on, so early movement matters most.
The longer it lasts, the harder the tissue is to stretch back.
Common Causes of Contractures
Staying in intensive care for two weeks or more can set the stage for contractures.7Assiut Scientific Nursing Journal. Effect of Early Activity Exercises and Proper Positioning on Occurrence of Joint Contractures Among Critically Ill Patients About one in three people with long intensive care stays develop joint contractures.8PubMed Central. Continuous passive motion for prevention of ankle contracture and muscle loss in mechanically ventilated ICU patients A stay of 8 weeks or more carried roughly seven times the odds of a contracture compared with 2 to 3 weeks.9PubMed Central. Joint contracture following prolonged stay in the intensive care unit
Nerve and brain conditions are another major cause. In the year after a severely disabling stroke, about 6 in 10 people developed a contracture.10PubMed. The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke In children with cerebral palsy, tight muscles and uneven muscle pull make contractures common as they grow, especially without ongoing care.11PubMed. The musculoskeletal management of children with cerebral palsy
Deep burns can heal with thick scars that shrink and pull joints.12PubMed. Biological Principles of Scar and Contracture Cells that pull a wound closed normally disappear once healing ends, but in thick scars they linger and keep contracting.13Burns & Trauma. Current progress in understanding the molecular pathogenesis of burn scar contracture
Everyday situations count too. A cast or brace worn for weeks after a fracture can do it, as can arthritis that makes someone avoid moving a joint. So can being bedbound in a care home or at home, or a nerve injury that weakens one side of a joint.
The same person often has some joints affected and others spared. Contractures form in joints that sit in a habitual position, so someone lying curled on one side often loses straightening in the hips and knees first. Muscles that cross two joints, such as the calf and hamstrings, shorten easily when held slack, which is why ankles tend to point downward and knees stay bent in people who rest in bed. A weaker or paralysed side is at higher risk than the stronger side, because the stronger side keeps moving through daily activity.
The Main Types of Contracture
Dupuytren’s contracture is a hand condition in which cords form under the palm skin and slowly pull fingers down toward the palm. A signalling chemical in the hand tissue drives scar-forming cells to multiply and lay down collagen.14PubMed Central. Dupuytren’s Contracture: A Review of the Literature It mostly affects the ring and little fingers and is more common in men over 50.
Volkmann’s contracture follows compartment syndrome, a dangerous pressure build-up in a limb that cuts off blood flow, most often after a forearm or elbow fracture or a tight cast.15PubMed Central. Refinements in the Treatment of Volkmann Ischemic Contracture of the Forearm: A Thematic Review Muscle dies and is replaced by scar, often with nerve damage too.16PubMed. Nerve Lesions in Volkmann Ischemic Contracture The deep finger-bending muscles of the forearm are most at risk, leaving a clawed hand.17PubMed Central. Refinements in the Treatment of Volkmann Ischemic Contracture of the Forearm: A Thematic Review It can rarely start before birth, appearing in a newborn.18Journal of Neonatology. Ischemic Volkmann Contracture From Intrauterine Compartment Syndrome
Severe pain out of proportion after a fracture or tight cast is a warning sign. Pain on moving the fingers, numbness, or a pale limb need same-day care, and quick treatment can prevent the lasting contracture.
Some contractures are present at birth. Arthrogryposis is a label for at least 400 conditions in which a baby is born with several stiff joints.19Journal of the Pediatric Orthopaedic Society of North America. The Orthopaedic Management of Arthrogryposis Multiplex Congenita The common thread is that the baby moved too little in the womb.20Journal of the Pediatric Orthopaedic Society of North America. The Orthopaedic Management of Arthrogryposis Multiplex Congenita Reduced movement can come from the baby’s own nerves or muscles or from outside limits such as crowding in the womb.21PubMed Central. Diagnosing Arthrogryposis Multiplex Congenita: A Review
A burn scar contracture shows up as tight, shiny, thickened skin over a joint such as the elbow, armpit or neck, and stretching the joint makes the scar look pale or pulled. Burns over the front of a joint, where skin must stretch when it straightens, are especially likely to cause a fixed bend.
How Doctors Diagnose a Contracture
The doctor compares the joint’s size and resting position with the other side.22PM&R KnowledgeNow. Contractures They check the skin for scars or thickening that could be pulling the joint.23PM&R KnowledgeNow. Contractures Then a hinged ruler measures the joint’s angle so progress can be tracked.24PM&R KnowledgeNow. Contractures
Muscle tightness from nerve damage, called spasticity, gets worse the faster a limb is moved. Stretching slowly and then quickly helps separate true contracture from it.25PM&R KnowledgeNow. Contractures Resistance to slow stretching mostly reflects stiff muscle itself.26PubMed Central. Neuro-musculoskeletal simulation of instrumented contracture and spasticity assessment in children with cerebral palsy Some rating scales mix the two up, while others are designed to tell them apart.27PubMed. The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it
The difference shapes treatment. Overactive, tight muscles from nerve damage may ease with medicines that relax muscle, while a fixed contracture needs stretching, casting or surgery. Many people have both at once, so both get treated.
It helps to tell the doctor when the stiffness started and whether it is getting worse. Mention what tasks it now blocks, like dressing or washing, and any pain, falls or skin breakdown in the area.
How to Prevent Contractures
Early activity exercises and proper positioning are used in intensive care to cut contracture risk.28Assiut Scientific Nursing Journal. Effect of Early Activity Exercises and Proper Positioning on Occurrence of Joint Contractures Among Critically Ill Patients Machines that gently move a joint are being used for the ankles of people on ventilators.29PubMed Central. Continuous passive motion for prevention of ankle contracture and muscle loss in mechanically ventilated ICU patients If someone you love is in hospital, ask the care team whether physical therapy can begin while they are still there.
For a bedbound relative at home, the routine is simple. Move each major joint through its range several times a day and change position every couple of hours. Keep feet supported so ankles don’t drop, and use splints at night if a therapist prescribes them.
Range-of-motion movements work best when done carefully. Support the limb on both sides of the joint and move it slowly to the point of mild stretch, never forcing it past resistance or pain. Take each joint through its full movement in both directions, including the shoulders, elbows, wrists, fingers, hips, knees and ankles. Hold a gentle stretch briefly at the end rather than bouncing, because slow steady pull is what lengthens tissue. A physical or occupational therapist should demonstrate on the actual person first, especially after a stroke, fracture or surgery, when some movements need care.
For children with cerebral palsy, prevention is lifelong, combining therapy, braces and medicine. Growth spurts are when tightness often worsens, and regular check-ups catch losses early.
Non-Surgical Treatment for Contractures
Serial casting means a series of casts, each set a little straighter, to stretch tissue slowly. Casts are usually changed about weekly, and progress is measured in degrees at each change. Mild discomfort is normal, but numbness or colour change needs checking. A program of casting, botulinum toxin, splinting and training gained about 26 degrees of ankle movement, still held 8 weeks later.30PubMed. Effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training for contracture management: a randomized controlled trial In babies with nerve injuries at the elbow, casting helped, but tightness often came back.31PubMed. Serial casting for elbow flexion contractures in neonatal brachial plexus palsy So keep stretching and splinting after the casts come off. Low steady force for long periods suits casts and splints better than a few hard pulls, which can cause pain or tear tissue.
Spring-loaded splints and splints you tighten in steps worked about equally for stiff elbows, so the choice comes down to comfort and the advice of your surgeon or therapist.32PubMed Central. REVIEW OF ARTICULATED ELBOW ORTHOTICS FOR JOINT STIFFNESS REHABILITATION For stiff finger joints, gains grew steadily with weeks of splint wear.33PubMed. The Long-term relationship between duration of treatment and contracture resolution using dynamic orthotic devices for the stiff proximal interphalangeal joint: a prospective cohort study Bending gains peaked around 12 weeks, while straightening kept slowly improving past 17 weeks.34PubMed. The Long-term relationship between duration of treatment and contracture resolution using dynamic orthotic devices for the stiff proximal interphalangeal joint: a prospective cohort study
Botulinum toxin temporarily weakens overactive muscle, which helps in conditions like cerebral palsy.35PubMed. Botulinum Toxin Injections in Musculoskeletal Disorders It works only when paired with regular therapy and splinting or casting.36PubMed Central. Botulinum toxin type A for the training of muscle contractures secondary to acute spinal cord injury in a young cat The usual timeline is months, not days.
Injections for Dupuytren’s Contracture
An enzyme injected into the cord breaks down collagen.37PubMed. Injectable Collagenase Clostridium Histolyticum for Dupuytren’s Contracture About 64% of injected cords met the treatment goal versus about 7% with a dummy injection.38PubMed. Injectable Collagenase Clostridium Histolyticum for Dupuytren’s Contracture Average finger movement rose from about 44 to 81 degrees.39PubMed. Injectable Collagenase Clostridium Histolyticum for Dupuytren’s Contracture Often several injections a month apart are needed.40PubMed Central. Collagenase Dupuytren Contracture: Achieving Single Treatment Success with a Hand Therapist-Based Protocol
The injection is given in the clinic. A day or so later the doctor stretches the finger to snap the weakened cord, and a night splint and hand therapy follow. Bruising and swelling are common afterwards.
Injections work on a distinct cord that can be felt in the palm, so they are not suitable for every pattern of Dupuytren’s. Treatment is usually considered once the finger bend begins to interfere with using the hand, such as difficulty putting on gloves, washing the face or putting the hand in a pocket, rather than at the first small lump. A hand specialist decides whether injection, needle release or surgery is best, based on which joints are bent and how far.
When Surgery Is Needed
Surgery is considered for fixed contractures that hurt function and haven’t improved with therapy.41PM&R KnowledgeNow. Contractures Options include releasing tight muscle, lengthening or cutting a tendon, releasing the joint capsule, or replacing the joint.42PM&R KnowledgeNow. Contractures Surgeons may combine steps, such as capsule release plus injections for a knee stuck bent after replacement.43PubMed. Treatment with posterior capsular release, botulinum toxin injection, hamstring tenotomy, and peroneal nerve decompression improves flexion contracture after total knee arthroplasty: minimum 2-year follow-up Therapy starts soon after surgery to keep the gained range, and splints are often worn for weeks. Good questions for the surgeon: which tissue is tight, how much movement is realistic, and what rehab will be required.
Living With a Contracture
Contractures can cause pain and make moving, transfers, daily tasks, work and hygiene harder.44PM&R KnowledgeNow. Contractures After severe stroke, people with fewer abilities had more complications such as contractures, falls and pain.45PubMed. The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke Burn survivors with contractures describe effects on finances, social roles and accepting their changed body.46PubMed Central. Lived Experiences of Adult Burn Survivors with Post-Burn Contractures
A bent elbow or clenched hand can make dressing, washing under the arm or cutting nails slow and awkward. A knee or hip stuck bent changes the way a person walks or transfers from bed to chair, which can raise the risk of falls. Skin folds, such as the palm of a clenched hand, are harder to keep clean.
Occupational therapists can suggest tools for dressing and eating. Support groups can help with the emotional side.