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Contracture: Conservative Management of Joint Contractures

Clinical guide · Reviewed by Robyn Midgley, Hand & Upper Extremity Therapist

Most joint contractures can be improved without surgery — if the right approach is matched to the type of contracture and started before the tissue becomes fixed.

A contracture is a loss of joint range of motion caused by shortening or stiffening of the soft tissues around a joint — muscle, tendon, joint capsule, skin or fascia. In the hand, contractures are a common and challenging complication of injury, surgery, arthritis and neurological conditions. Conservative (non-surgical) management is generally attempted first, and the choice of approach depends on the type of contracture (arthrogenic, myogenic or soft-tissue), its severity and duration, and the underlying cause.

Stretching and exercise

Passive stretching is widely prescribed, but the evidence for it is nuanced. A Cochrane review of stretch interventions for neurological contractures found that stretching applied for less than 30 minutes a day over less than three months does not produce clinically meaningful change. Active exercise and functional activities performed with the tissue in a lengthened position often produce better outcomes than passive stretching alone.

Orthotic devices

Static splints hold a joint's position and can slow contracture progression. Dynamic orthoses apply gentle elastic traction; static-progressive orthoses use inelastic components adjusted incrementally to hold the joint at end range for prolonged periods. The key variable across all of them is total end-range time — the cumulative time the tissue spends at its maximum tolerable length.

Serial casting

Serial casting uses circumferential casts, usually plaster of Paris, to hold a contracted joint at its maximum comfortable range for extended periods, changing the cast every few days to progressively reposition the joint. Pioneered by Paul Brand for leprosy-related contractures, it has since been applied to post-traumatic, post-surgical, arthritic and neurological contractures. For the hand it suits PIP joint flexion contractures particularly well; unless there is a bony block or dislocation, it can succeed even with established fixed deformities where other orthoses have failed. Read more in our guide to therapeutic casting.

Casting motion to mobilise stiffness (CMMS)

CMMS, developed by Judy Colditz, takes a different approach to the contracted and poorly-patterned hand. Rather than positioning the stiff joint at end range, it immobilises the proximal joints in a therapeutic position while the patient performs active motion at the distal joints. This addresses both the structural and the neuromotor components of stiffness at once — valuable when a contracture coexists with a maladaptive movement pattern, which is common after prolonged immobilisation.

Botulinum toxin

For contractures driven by spasticity — after stroke, cerebral palsy or traumatic brain injury — botulinum toxin can temporarily reduce muscle overactivity, opening a therapeutic window in which stretching and casting work better. One randomised trial combining serial casting, botulinum toxin, splinting and motor training achieved a mean 26-degree improvement in passive ankle dorsiflexion, sustained at eight weeks.

Electrical stimulation

Electrical stimulation can temporarily improve passive range of motion and help prevent muscle atrophy during immobilisation, though the benefits tend to diminish once treatment stops. It is generally an adjunct rather than a standalone treatment.

This article is educational and does not replace individual clinical assessment. Treatment should be guided by a qualified clinician.