––A contracture is a permanent or near-permanent shortening of a muscle, tendon, the skin or tissues immediately below the skin, or the tissues around a major joint causing a structural change and loss of movement. Contractures can develop most anywhere.
A contracture develops when normally elastic and stretchy tissues are replaced by abnormal dense, non-elastic, non-stretchy foreign tissues. Since this invasive and foreign fibrous tissue does not stretch as well as the tissue it replaced, the contracture prevents the tissue from stretching like before and alters normal movement. It is not terribly inaccurate to think of the contracture tissue being something like an internal contracture scar that cannot be seen but affects the body greatly anyway.
Contractures, because they shorten tissue, also change the way the invaded tissue looks:
- Nodules, lumps or cords appear where there were none previously.
- Twisting, curvature, or claw-like deformities can develop.
- Altered body symmetry, like a bent spine or a claw hand.
Contractures of the soft tissue of the body develop after the involved tissue has remained too tight for too long, allowing tissue changes to occur. These problems are long-term structural or orthopedic contractures of various short tissues, and should not be confused short-term contraction or voluntary use of muscles.
By the time the contracture can no longer be exercised away or stretched out the tissue must be released by orthopedic surgery.
Contracture of the hand and feet are fairly common, but from my experience not as common as contracture of the lower back due to the immobility of chronic sacroiliac and spinal osteoarthritis. Massive muscle contracture, reduced spinal range of motion and lower back pain are all present due to fibrous infiltration of the large deep lumbar and gluteal muscles. If contracture affects the neck after injury and torticollis develops, this can also lead to fibrous infiltration of the neck muscles so that full neck movement is impossible. This is the reason these spinal problems defy easy treatment; the muscles have undergone tissue change and cannot easily or quickly respond to any therapy thrown at the problem.
Contracture and muscle spasticity are not the same medical condition, although they can be related and can occur simultaneously. Contracture is a shortening and tightening due to fibrous tissue infiltrating soft tissue. Spasticity is a greater tone of muscle contraction that tends to be short term, but can worsen as it persists and develop into contracture.
Contracture can arise from common and extreme causes:
- Lack of use and prolonged immobility (confinement to bed because of illness or surgery, use of a splint, cast or support to immobilize the body, coma).
- Deep tissue or internal scarring after traumatic injury.
- Deep tissue damage as a result of 3rd degree burns.
- Nerve damage.
- Inability to move due to pain (sciatica, gout, shingles).
- Severe loss of blood supply or ischemia to a body part, in which tissue destruction occurs due to lack of oxygenation.
- Brain and nervous system disorders (spastic cerebral palsy or stroke).
- Inherited disorders (such as muscular dystrophy).
- Prolonged or chronic inflammation of one or more limbs (rheumatoid arthritis).
- Congenital diseases – Dupuytrens contracture (contracture of hand joints or contracture of fingers), Peyronie’s disease (affects tunica albuginea of penis), Ledderhose disease (affects plantar fascia of feet) – in which spontaneous contracture develop due to internal fibrous tissue like scars develop. These foreign structures cause pain, limited movement and loss of use of the involved body part. This is especially true of contracture of palmar fascia in Dupuytren’s contracture.
As a direct result of this shortening and tightness of different soft tissues of the body, muscles, tendons and ligaments that move a limb cannot bring that body part to a full range of motion. As a result, the patient might notice difficulty moving the hand or fingers or both, straightening or stretching the legs, walking, extending other parts of the body less than normal.
When joint or capsular contracture develops around a previously moveable articulation, the patient will exhibit limited range of motion, even though the muscles moving that body part are normal and healthy.
Most often contractures are painful, at least in the early developing stages as the tissue is shortening, only to become less painful as the condition stabilizes.
Most professional treatment of contracture is preventive in nature. Treatment is designed for patients who display early stages of muscle and connective tissue spasticity to prevent contractures from happening in the first place The usual course of treatment primarily consists of medical care, physical therapy and occupational therapy:
- Muscle relaxant, anti-inflammatory or pain medication.
- Botox (botulinium toxin) is sometimes injected into the muscles of cerebral palsy patients to weaken them as a strategy for postponing surgery.
- Stretching exercises.
- Mechanical devices (CPM or continuous passive motion machines) are very effective and popular to move a joint and related soft tissue through a comfortable range of motion, even if it is limited. The CPM is started 24-72 hours after injury or surgery when recovery and immobilization is known to be prolonged. It is frequently adjusted to the patient’s unique need, and as improvement occurs the settings are increased slowly for a greater range of movement. CPM are popular because they accelerate eventual recovery and reduce risk of complications.
- Moist heat applied to the affected joints and tissues.
- Muscle conditioning exercises that target the antagonist muscles of those that are spastic.
- Chiropractic adjustment or manipulation and related techniques are found helpful to improve motion of major joints and spinal problems when contracture is a component of injury.
- Massage therapy is often beneficial by restoring tissue length and increasing local circulation to joint structures, causing better elasticity.
- Professional yoga instruction can help prevent and restore joint mobility.
- Manipulation under anesthesia (MUA) of an affected joint might be helpful for severe contractures that do not respond to standard conservative care.
At-home treatment is an extension of the professional care in which the patient performs some variation of exercises and stretches, and perhaps uses orthopedic braces.
Ignoring or delaying appropriate contracture treatment may make it impossible or difficult restore or improve lost mobility. After prolonged bed confinement or post-surgical care it is important to advise your doctor about any unusual sense of restricted movement, muscle soreness, or feeling that the tissues of the trunk or limbs feel thicker or denser than previously.
Those under long-term hospital care, and those with neurological diseases like muscular dystrophy, cerebral palsy or stroke, should be monitored for development of contractures. Prompt treatment can provide the best possible recovery and outcome.
As with most things in life, the earlier and the more aggressively applied is the treatment for contracture, the better the eventual prognosis tends to be.
Lastly, a capsular contracture is the result of the immune system responding abnormally and excessively to foreign material being implanted in the body. It is most often encountered a medical complication of breast implants, cardiac pacemakers, penile prosthetics used for treatment of erectile dysfunction and artificial joint prosthetics (hips, knees or digits).
A capsular contraction forms when a capsule or membrane attempts to surround or isolate a foreign object surgically implanted in the body. This happens as the body’s best effort to protect itself from the foreign object. The protective capsule is made of dense and tightly woven fibers of collagen material. As the capsule naturally tightens around and presses on the foreign object it can be very painful and result in physical distortion and loss of normal use of that body part.
Occasionally surgery to correct capsular contracture will only cause a recurrence of another capsular contraction as the body continues to defend itself from more foreign implants. As implant surgery continues to improve and become more popular, less capsular contraction develops post-surgically. Better surgical techniques and improvement of prosthetic equipment have reduced the incidence of the capsular membrane:
- Better prosthetic placement within the area of involvement.
- Textured or polyurethane-coated implants.
- Limited manipulation or handling of the implants during surgery.
- Minimal contact of the implant with the skin prior to insertion.
- Heavy irrigation of implant site with antibiotic solutions.