Muscle contracture

Short description: Permanent shortening of a muscle

A finger contracture caused by Dupuytren's contracture.

Muscle contractures can occur for many reasons, such as paralysis, muscular atrophy, and forms of muscular dystrophy. Fundamentally, the muscle and its tendons shorten, resulting in reduced flexibility.

Various interventions can slow, stop, or even reverse muscle contractures, ranging from physical therapy to surgery.

## Contents

* 1 Cause
* 1.1 Immobilization
* 1.2 Spasticity
* 1.3 Muscle imbalance
* 1.4 Low ATP reservoir in the muscle
* 1.5 Congenital myopathies
* 1.6 Ischemia
* 1.7 Adhesions and fibrosis
* 2 Treatment
* 2.1 Passive stretching
* 2.2 Splinting
* 2.3 Electrical stimulation
* 2.4 Surgery
* 3 References

## Cause

### Immobilization

Toe walking in an autistic individual

Joints are usually immobilized in a shortened position resulting in changes within the joint connective tissue, and the length of the muscle and associated tendon. Prolonged immobilization facilitates tissue proliferation which impinges on the joint space.[1] Maintaining a shortened position for a prolonged period of time leads to: fibrous adhesion formation, loss of sarcomeres, and a loss of tissue extensibility.[1]

For example, after a fracture when immobilization is done by casting the limb in plaster of paris, the muscle length shortens because the muscle is not used for a large span of time.

A common cause for having the ankle lose its flexibility in this manner is from having sheets tucked in at the foot of the bed when sleeping. The weight of the sheets keep the feet plantarflexed all night. By not tucking the sheets in at the foot of the bed, or by sleeping with the feet hanging off the bed when in the prone position, is part of correcting this imbalance.

Due to sensory issues, some autistic people prefer to toe walk instead of their feet making full contact with the ground. Chronic toe walking leads to muscle contracture due to the lack of calf muscles being adequately stretched. Once the muscle contracture has developed, the voluntary toe walking then becomes involuntary.[2] If someone has a disability that causes spasticity (such as cerebral palsy), they may walk on their toes involuntarily.

### Spasticity

If spasticity is left untreated, contractures can occur. A loss of muscle tone inhibition (hypertonia) causes a muscle to become hyperactive resulting in constant contraction, which reduces an individual’s control of the affected area. The joint will remain in a flexed state producing similar effects as listed in immobilization.

### Muscle imbalance

A muscle imbalance between an agonist and antagonist muscle can occur due to a neurological disorder, spinal cord injury, myopathy, and our lifestyle/postural habits.[1][3] One muscle may be normal while the other is atrophic or hypertrophic; alternately, one muscle may be hypertrophic while the other is atrophic.[3] A decrease in muscle tone leads to continuous disuse and eventually muscular atrophy. The constant contraction of the agonist muscle with minimal resistance can result in a contracture. Selective muscle hypertrophy may exacerbate contractures and postural instability.[3]

For example, in the case of partial paralysis (i.e. poliomyelitis) the loss of strength and muscle control tend to be greater in some muscles than in others, leading to an imbalance between the various muscle groups around specific joints. Case in point: when the muscles which dorsiflex (flex the foot upward) are less functional than the muscles which plantarflex (flex the foot downward) a contracture occurs, giving the foot a progressively downward angle and loss of flexibility.

### Low ATP reservoir in the muscle

In the metabolic myopathies of GSD-V (McArdle disease) and GSD-VII (Tarui disease), temporary muscle contractures develop in response to impending muscle damage associated with the ATP (energy) deficiency.[4] The muscle contracts and fails to relax again, becoming hard or stiff, the muscle may swell up, and although temporary, it is longer lasting and generally more painful than muscle cramps.[4][5] These contractures are different from cramps, because they are not elicited by the nerve, but by intrinsic mechanisms in the muscle itself and are silent on electromyography.[4] This type of transient contracture has also been called pseudomyotonia.[6][7]

In GSD-V and GSD-VII, a cramp or contracture is managed by cessation of the causal activity until pain resolves; however, repeated episodes can accumulate muscle damage (see below under fibrosis).[4] Unlike stretching of muscle cramps, stretching of a muscle in contracture should be avoided as it may cause further muscle damage by tearing muscle fibres (i.e. resist uncurling the fingers of a "clawed" hand).[4][5]

### Congenital myopathies

Some congenital myopathies, such as Bethlem myopathy and Ullrich congenital muscular dystrophy, cause muscle contractures to develop.[8] In these two myopathies, mutations in collagen VI and XII genes result in deficient or dysfunctional microfibrillar collagen in the extracellular matrix of muscle and other connective tissues.[8][9] The potential effects on muscle include progressive dystrophic changes, fibrosis and evidence for increased apoptosis. In Bethlem myopathy 1, contractures presenting in infancy may resolve by age 2 years, but reoccur as the disease progresses, typically by late of the first decade or early teens.[8]

### Ischemia

Following trauma (such as fractures, crush injuries, burns and arterial injuries), ischemia (restriction of blood flow) leads to the death of muscle tissue (necrosis) and can cause contracture, such as Volkmann's contracture.[10]

### Adhesions and fibrosis

Adhesions bind two separate tissues or organs together with fibrotic scar tissue, joining muscle fibres to facia, ligaments, or joints. Fibrosis occurs within the same organ, the fibrotic scar tissue within skeletal muscle known as myofibrosis, limits muscle contractibility and stiffens muscles.[11][12][13]

Muscle injury (such as a large burn or surgery) can cause muscle contractures as internal scar tissue (adhesions and fibrosis) develops. Repetitive muscle injuries (e.g. sports injuries, major muscle strains) and micro-injuries (e.g. overuse injuries, minor muscle strains) can also cause this. Adhesions and fibrosis are made of dense fibrous tissue, which are strong and supportive, helping to prevent the injury or micro-injury from reoccurring. However, the fibrotic scar tissue causes the muscle tissue to become stuck together which restricts movement, causing pain, weakness, and limited joint mobility.[13][14][15][16]

## Treatment

### Passive stretching

Typically performed by physical therapists, passive stretching is a more beneficial preventative measure and tool to maintain available range of motion (ROM) rather than used as a treatment.[17] It is very important to continually move the limb throughout its full range at a specific velocity but a passive stretch can’t be maintained for the period of time required for optimal benefit.

A 2017 Cochrane review found that stretching does not provide any short-term pain relief.[18]

### Splinting

A contracture corrective device (CCD) is a dynamic splint that provides a continuous stretch with a continuous force and operates based on the principles of creep.[1] It is the most advantageous splint but more research is required. Splints are used in long term treatments and must be removed in order to stretch the antagonist muscle to maintain range of motion (passive stretching).

### Electrical stimulation

Electrical stimulation improves passive range of motion but only temporarily.[1] Once the treatment is withdrawn, all benefits are reduced. It can play a critical role in muscle atrophy prevention.

### Surgery

Surgery is a solution to muscle shortening but other complications may arise. Following muscle lengthening surgery, force production and ROM is usually reduced due to the shift in sarcomere locations between a muscle's maximal and minimal length.[1] In adjunct with surgery, refractory muscle contracture can also be treated with Botulinum toxins A and B; however, the effectiveness of the toxin is slowly lost over time, and most patients need a single treatment to correct muscle contracture over the first few weeks after surgery.[19] Shortening of the surgically lengthened muscle can re-occur.

## References

1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Farmer, S.E; M. James (2001). "Contractures in orthopaedic and neurological conditions: a review of causes and treatment". Disability and Rehabilitation 23 (13): 549–558. doi:10.1080/09638280010029930. PMID 11451189.
2. ↑ Valagussa, Giulio; Balatti, Valeria; Trentin, Luca; Piscitelli, Daniele; Yamagata, Momoko; Grossi, Enzo (2020-08-20). "Relationship between tip-toe behavior and soleus - gastrocnemius muscle lengths in individuals with autism spectrum disorders". Journal of Orthopaedics 21: 444–448. doi:10.1016/j.jor.2020.08.013. ISSN 0972-978X. PMID 32982098.
3. ↑ 3.0 3.1 3.2 Kornegay, Joe N.; Childers, Martin K.; Bogan, Daniel J.; Bogan, Janet R.; Nghiem, Peter; Wang, Jiahui; Fan, Zheng; Howard, James F. et al. (February 2012). "The Paradox of Muscle Hypertrophy in Muscular Dystrophy". Physical Medicine and Rehabilitation Clinics of North America 23 (1): 149–xii. doi:10.1016/j.pmr.2011.11.014. ISSN 1047-9651. PMID 22239881.
4. ↑ 4.0 4.1 4.2 4.3 4.4 Lucia, Alejandro; Martinuzzi, Andrea; Nogales-Gadea, Gisela; Quinlivan, Ros; Reason, Stacey; International Association for Muscle Glycogen Storage Disease study group (December 2021). "Clinical practice guidelines for glycogen storage disease V & VII (McArdle disease and Tarui disease) from an international study group". Neuromuscular Disorders 31 (12): 1296–1310. doi:10.1016/j.nmd.2021.10.006. ISSN 1873-2364. PMID 34848128. https://pubmed.ncbi.nlm.nih.gov/34848128/.
5. ↑ 5.0 5.1 "IAMGSD | Medical emergencies" (in en). https://www.iamgsd.org/medical-emergencies.
6. ↑ Bhai, Salman (September 2021). "Neuromuscular Notes: Diagnosing Metabolic Myopathies" (in en). https://practicalneurology.com/articles/2021-sept/neuromuscular-notes-diagnosing-metabolic-myopathies.
7. ↑ Chen, Y.; Hagen, M.; Lawandy, M.; Do, J.Y. (2017-03-09). "Congenital and Acquired Myotonia" (in en-US). https://now.aapmr.org/congenital-and-acquired-myotonia/.
8. ↑ 8.0 8.1 8.2 Bönnemann, Carsten G. (2011-06-21). "The collagen VI-related myopathies: muscle meets its matrix". Nature Reviews. Neurology 7 (7): 379–390. doi:10.1038/nrneurol.2011.81. ISSN 1759-4758. PMID 21691338.
9. ↑ Hicks, Debbie; Farsani, Golara Torabi; Laval, Steven; Collins, James; Sarkozy, Anna; Martoni, Elena; Shah, Ashoke; Zou, Yaqun et al. (2014-05-01). "Mutations in the collagen XII gene define a new form of extracellular matrix-related myopathy". Human Molecular Genetics 23 (9): 2353–2363. doi:10.1093/hmg/ddt637. ISSN 1460-2083. PMID 24334769. https://pubmed.ncbi.nlm.nih.gov/24334769/.
10. ↑ Mirza, Taaha M.; Taqi, Muhammad (2023), "Volkmann Contracture", StatPearls (Treasure Island (FL): StatPearls Publishing), PMID 32491686, http://www.ncbi.nlm.nih.gov/books/NBK557754/, retrieved 2023-05-07
11. ↑ Massage, Walnut Creek (2014-10-02). "Adhesions vs. Fibrosis • Loosen Up Bodywork" (in en-US). https://loosenupbodywork.com/2014/10/injuries/adhesions-vs-fibrosis/.
12. ↑ Nelson, Fred R. T.; Blauvelt, Carolyn Taliaferro (2015-01-01), Nelson, Fred R. T.; Blauvelt, Carolyn Taliaferro, eds., "2 - Musculoskeletal Diseases and Related Terms" (in en), A Manual of Orthopaedic Terminology (Eighth Edition) (Philadelphia: W.B. Saunders): pp. 43–104, ISBN 978-0-323-22158-0, https://www.sciencedirect.com/science/article/pii/B9780323221580000020, retrieved 2023-05-07
13. ↑ 13.0 13.1 Lieber, Richard L.; Ward, Samuel R. (2013-08-01). "Cellular Mechanisms of Tissue Fibrosis. 4. Structural and functional consequences of skeletal muscle fibrosis". American Journal of Physiology. Cell Physiology 305 (3): C241–C252. doi:10.1152/ajpcell.00173.2013. ISSN 0363-6143. PMID 23761627.
14. ↑ Nemoto, F. (January 1980). "[Pathogenesis of quadriceps contracture in children and adolescence (author's transl)"]. Nihon Seikeigeka Gakkai Zasshi 54 (1): 15–31. ISSN 0021-5325. PMID 7381269. https://pubmed.ncbi.nlm.nih.gov/7381269/.
15. ↑ Bugden, Krista (2018-11-30). "Muscle Adhesions: What Are They & How Do I Treat Them? | Sidekick Blog" (in en-US). https://blog.sidekicktool.com/muscle-adhesions-are-they-getting-in-the-way-of-your-athletic-performance/, https://blog.sidekicktool.com/muscle-adhesions-are-they-getting-in-the-way-of-your-athletic-performance/.
16. ↑ Taylor, J.; Tangner, C. H. (2007). "Acquired muscle contractures in the dog and cat. A review of the literature and case report". Veterinary and Comparative Orthopaedics and Traumatology: V.C.O.T 20 (2): 79–85. doi:10.1160/vcot-06-01-0007. ISSN 0932-0814. PMID 17546206. https://pubmed.ncbi.nlm.nih.gov/17546206/.
17. ↑ Worland, R., Arredondo, J., Angles, F., Lopez-Jimenez, F., & Jessup, D. (1998). Home continuous passive motion machine versus professional physical therapy following total knee replacement. Journal of Arthroplasty, 784-787, doi:10.1016/S0883-5403(98)90031-6
18. ↑ Harvey, Lisa A; Katalinic, Owen M; Herbert, Robert D; Moseley, Anne M; Lannin, Natasha A; Schurr, Karl (2017-01-09). "Stretch for the treatment and prevention of contractures". Cochrane Database of Systematic Reviews 1 (2): CD007455. doi:10.1002/14651858.cd007455.pub3. ISSN 1465-1858. PMID 28146605.
19. ↑ Sanchez-Sotelo, Joaquin (2018-01-01), Morrey, Bernard F.; Sanchez-Sotelo, Joaquin; Morrey, Mark E., eds., "56 - Elbow Stiffness: Rehabilitation After Surgical Contracture Release" (in en), Morrey's the Elbow and its Disorders (Fifth Edition) (Philadelphia: Elsevier): pp. 552–556, ISBN 978-0-323-34169-1, https://www.sciencedirect.com/science/article/pii/B9780323341691000565, retrieved 2023-05-06

* v
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Diseases of joints (M00–M19, 711–719)

Inflammatory|

| Infectious|

* Septic arthritis
* Tuberculosis arthritis
* Reactive arthritis (indirectly)

|

Noninfectious|

* Seronegative spondyloarthropathy
* Reactive arthritis
* Psoriatic arthritis
* Ankylosing spondylitis

* Juvenile idiopathic arthritis

* Rheumatoid arthritis
* Palindromic rheumatism
* Adult-onset Still's disease
* Felty's syndrome

* Crystal arthropathy
* Gout
* Chondrocalcinosis

Noninflammatory|

* Osteoarthritis
* Heberden's node
* Bouchard's nodes

General|

* Arthritis
* Monoarthritis
* Oligoarthritis
* Polyarthritis

Symptoms|

* Arthralgia
* Joint stiffness

Other|

* Bleeding
* Osteophyte
* villonodular synovitis
* Pigmented villonodular synovitis

* v
* t
* e

Soft tissue disorders

Capsular joint|

| Synoviopathy|

* Synovitis/Tenosynovitis
* Calcific tendinitis
* Stenosing tenosynovitis
* Trigger finger
* De Quervain syndrome
* Transient synovitis
* Ganglion cyst

* osteochondromatosis
* Synovial osteochondromatosis
* Plica syndrome

* villonodular synovitis
* Giant-cell tumor of the tendon sheath

|

Bursopathy|

* Bursitis
* Olecranon
* Prepatellar
* Trochanteric
* Subacromial
* Achilles
* Retrocalcaneal
* Ischial
* Iliopsoas
* Synovial cyst
* Baker's cyst
* Calcific bursitis

Noncapsular joint|

| Symptoms|

* Ligamentous laxity
* Hypermobility

|

Enthesopathy/Enthesitis/Tendinopathy|

| upper limb|

* Adhesive capsulitis of shoulder
* Impingement syndrome
* Rotator cuff tear
* Golfer's elbow
* Tennis elbow

|

lower limb|

* Iliotibial band syndrome
* Patellar tendinitis
* Achilles tendinitis
* Calcaneal spur
* Metatarsalgia
* Bone spur

other/general:|

* Tendinitis/Tendinosis

Nonjoint|

| Fasciopathy|

* Fasciitis: Plantar
* Nodular
* Necrotizing
* Eosinophilic

|

Fibromatosis/contracture|

* Dupuytren's contracture
* Plantar fibromatosis
* Aggressive fibromatosis
* Knuckle pads

* v
* t
* e

Trauma

Principles|

* Polytrauma
* Major trauma
* Traumatology
* Triage
* Resuscitation
* Trauma triad of death

Assessment|

| Clinical prediction rules|

* Revised Trauma Score
* Injury Severity Score
* Abbreviated Injury Scale
* NACA score

|

Investigations|

* Diagnostic peritoneal lavage
* Focused assessment with sonography for trauma

Management|

| Principles|

* Advanced trauma life support
* Trauma surgery
* Trauma center
* Trauma team
* Damage control surgery
* Early appropriate care

|

Procedures|

* Resuscitative thoracotomy

Pathophysiology|

| Injury|

* MSK
* Bone fracture
* Joint dislocation
* Degloving
* Soft tissue injury
* Resp
* Flail chest
* Pneumothorax
* Hemothorax
* Diaphragmatic rupture
* Pulmonary contusion
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* Cardiac tamponade
* GI
* Blunt kidney trauma
* Ruptured spleen
* Neuro
* Penetrating head injury
* Traumatic brain injury
* Intracranial hemorrhage

|

Mechanism|

* Blast injury
* Blunt trauma
* Burn
* Penetrating trauma
* Crush injury
* Stab wound
* Ballistic trauma
* Electrocution

Region|

* Abdominal trauma
* Chest trauma
* Facial trauma
* Head injury
* Spinal cord injury

Demographic|

* Geriatric trauma
* Pediatric trauma

Complications|

* Posttraumatic stress disorder
* Wound healing
* Acute lung injury
* Crush syndrome
* Rhabdomyolysis
* Compartment syndrome
* Contracture
* Volkmann's contracture
* Fat embolism
* Chronic traumatic encephalopathy

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