Tendon contracture

Problems affecting the musculoskeletal system and connective tissues include tendon tightness or contracture, a condition in which the bundles of fibrous tissue connecting muscle to bone, which transmit muscle force to bones and joints, lose elasticity and firmness, limiting joint movement.

Epidemiology

In general, statistics on joint and tendon contractures are limited. According to some data, contractures develop in 30-54% of cases among patients with severe burns. The frequency of tendogenic contractures in cerebral palsy is estimated to be persistent36-42%.

The global prevalence of Dupuytren's contracture is 8.2%. Because of the significant number of cases in the male population of Northern Europe, it is called the Viking disease: in the Scandinavian countries the prevalence of this disease is 3.2-36%, in the UK - 8-30%, in Belgium -32%, in the Netherlands -22%. In the USA - no more than 4%, but this is about 15 million people.

Experts note that almost half of patients with Dupuytren's contracture also have Ledderhosen's contracture, which affects the tendons of the foot.

Achilles tendon injuries account for almost 50% of sports injuries. The thumb tendon is the most commonly injured tendon in hand injuries.

Causes of the tendon contractures

Contracture of the tendon or its synovial sheath is most commonly found in the wrist, hands, and feet. The main causes include the presence of post-traumatic scarring resulting from mechanical damage to the tendon (tear or rupture) or burn; deformation of articular and extra-articular structures of the musculoskeletal system, e.g. foot deformity in systemic diseases; prolonged immobility or immobilization of the limb; and certain diseases.

Thus, contracture can be a consequence of inflammation of tendons, their sheaths and/or synovial sheaths; occupational epicondylitis; various types of enthesopathies - pathological processes in the entheses (points of attachment of periarticular tendons to bones).

In cerebral palsy the muscles and tendons of the lower limbs may shorten over time, leading to the orthopedic complication of muscle spasticity and contractures. [1], [2] Multiple tendogenic contractures (tendo in Latin - tendo) and paresis of all limbs are characteristic of Charcot-Marie-Tooth disease (X-linked type I). [3], [4]

In addition, tendon retraction and flexion contracture are accompanied by congenital (due to genetic mutations) muscular dystrophies, which include Duchenne myodystrophy, [5] Emery-Dreyfus dystrophy and limb-girdle Erb-Roth dystrophy manifesting in adolescence.

A rare condition such as congenital poochyloderma (Rothmund-Thomson syndrome) with tendon contractures (often affecting the ankles and feet), myopathy, skin pigmentation abnormalities, and fibrotic lesions of the lung tissues may also develop at an early age.

Risk factors

Noted risk factors for tendon contractures include:

• Excessive physical exertion (often occupational) and injury. For more information see. - Occupational diseases of athletes;
• joint diseases of various etiologies;
• Insufficient limb muscle development or muscle tone disorder;
• Hereditary or acquired metabolic diseases;
• chronic liver disease;
• diabetes;
• prolonged alcohol consumption.

Tendon shortening is seen in patients with hand injuries and the development of acute compartment syndrome, a posttraumatic intrafascial hypertension syndrome. Which leads to flexion contracture of the hand and fingers.

Clinicians have observed that Dupuytren's contracture - contracture of the tendon in the palm of the hand, contracture of the palmar aponeurosis, or palmar fibromatosis - is more likely to develop in the presence of diabetes and epilepsy.

By the way, orthopedists say that women's addiction to high-heeled shoes puts them at risk for Achilles tendon contracture.

Pathogenesis

To date, the mechanism of tendon healing in case of tendon injuries and the pathogenesis of scar formation on them, which are considered to be one of the key etiologic factors of tendogenic contractures, are the most studied.

The basis of tendons is made up of fibers of extracellular matrix protein - fibrillar collagen type I (basic) and type III, which are combined into bundles (the main structural units of the tendon), each of which is covered by a layer of connective tissue - endotenon. The entire tendon is also surrounded by a thin connective tissue sheath - epitenon. Between the collagen bundles there are spindle-shaped cells - tenocytes and ovoid tenoblasts, i.e. Tendon fibroblasts.

After the first, inflammatory stage, a phase of increased vascularization begins - to nourish healing tissues, followed by the fibroplastic stage. Its essence lies in the migration from the epitenon to the site of damage of tenoblasts more active in the remodeling of the extracellular matrix - with increased production of type III collagen (capable of forming fast cross-links). The increase in type III collagen, as studies have shown, does not restore the original mechanical properties of the tissue, resulting in a thicker and stiffer, and often shorter, tendon, which causes contracture.

In enthesopathies, such as tendinitis or tendovaginitis, there are not only pathological changes in the structure of the collagen fibers of the enthesis, but also thickening of the tendon at the site of its fixation to the bone.

In Dupuytren's contracture, the layer of fibrous tissue underlying the skin of the palm and fingers is affected: at first it thickens, and over time it shrinks, causing the fingers to pull against the palm surface.

The mechanism of development of posttraumatic compartment syndrome is explained by the fact that the expansion of edematous tissue volume is limited by muscle fascia and bone surfaces, and this leads to increased pressure inside the fascial space. As a result, there is a local decrease in blood supply, causing ischemia of traumatized tissues, the reaction to which is the formation of a scar and muscle-tendon adhesions - with the development of contractures.

Symptoms of the tendon contractures

In addition to making it difficult or impossible to move joints normally, tendon contracture can cause symptoms such as pain and physical deformities such as bent fingers on the hand (if the contracture is flexion contracture).

For example, Ledderhose tendon contracture (etiologically related to plantar fibromatosis) does not begin to manifest itself immediately, but after fibrous nodules in the medial part of the plantar fascia begin to proliferate with the formation of pulls, making the surface of the sole bumpy. Then there are difficulties in extending the toes (they are in a bent position), pain in the foot and ankle joint, skin tightness, paresthesia, and persistent changes in gait. [6]

The first signs of tendogenic contracture of the feet in muscular dystrophies appear at different times and in different ways. For example, in Duchenne myodystrophy, children have a late onset of independent walking, walking on tiptoe - without reaching the floor with the heel; running and jumping are sometimes impossible, and falls are frequent.

Achilles tendon contracture restricts the dorsiflexion of the ankle joint to a neutral or stance position (defined as equinus), and there is also a valgus (external) deviation of the hindfoot with more pronounced dorsiflexion. Congenital Achilles tendon contracture also leads to tiptoeing, and the characteristic gait pattern is increased plantar flexion of the ankle and knee at the end of the stride, but decreased flexion of both knees at the initial swing. [7]

Contracture of the tendons of the hand in cases of stenosing or nodular tenosynovitis (tenovaginitis), called snapping finger syndrome, is accompanied by a clicking sensation when flexing and extending the finger, discomfort or pain when moving the fingers, stiffness of the fingers (especially in the morning) and difficulty in movement. More than one finger may be affected at a time and both hands may be involved. [8]

If the process affects only the tendons of the extensor and withdrawor muscles of the thumb, it has its own name, de Quervain's disease or syndrome, in which movements of the thumb are difficult and cause pain.

Almost all domestic and foreign orthopedists associate tendon contracture on the palm with slowly progressive Dupuytren's contracture, in which one or more small tubercles (nodules) may appear on the palm, then the skin on the palm thickens and becomes lumpy, and the subcutaneous tissues tighten, pulling the fingers (more often the little and ring fingers) to the palm so that they cannot be straightened. This contracture can occur in both hands, although one hand is usually more severely affected.

Complications and consequences

The main complications and consequences of tendon contracture are: limitation of range of motion and function of a certain part of the body, discomfort and pain, as well as physical deformities, e.g. Bent fingers, incorrect position of feet and legs, etc. Disability cannot be ruled out.

Diagnostics of the tendon contractures

Diagnosis begins with recording the patient's complaints, history taking and examination with determination of active range of motion (goniometry) and examination of tendon reflexes.

General and biochemical blood tests, rheumatoid factor, C-reactive protein, muscle enzyme levels (creatine phosphokinase, etc.) are taken.

Instrumental diagnostics are performed: x-rays or CT scans of the joints, ultrasound of tendons and muscles, needle electromyography.

The task of differential diagnosis is to rule out muscle contracture and spasticity, congenital joint contracture (arthrogryposis), and, in elderly patients, joint contractures in various types of dementia.

Treatment of the tendon contractures

Treatment of tendogenic contractures can be conservative and surgical: it all depends on their severity and duration.

When pain and inflammation are present, the main medications are non-steroidal anti-inflammatory drugs: Ibuprofen, Naproxen (Nalgesin) and others.

In most cases, hydrocortisone injections near or into the tendon sheath have a positive effect. But in diabetic patients, steroid injections tend to be less effective.

Injections into the contracture area of Collalysin (Clostridiopeptidase A, Xiaflex) containing the enzyme collagenase, as well as Lidase or Longidase - with the enzyme hyaluronidase, which breaks down glycosaminoglycans, may be prescribed. These drugs are not used in pregnancy and cancer; side effects may be generalized weakness, headache and dizziness, chills and fever, pain and redness of the skin at the injection site (which is given in the same place - once a month). There is also a risk of an autoimmune reaction to these enzymes.

In the initial stages of Dupuytren's contracture or Ledderhosen's contracture, Contratubex gel can be applied externally, massage and stretching exercises should also be performed, which can slow down its progression; in later stages, injections of the above mentioned drugs can be used.

Splinting with an orthosis is used to relax the tendon and fix it in a stretched position.

In tendon contractures of the fingers of the hand caused by scar formation, gradual stretching of tendon tissues by external fixation with compression-distraction devices (similar to the Elizarov apparatus) is used. After their removal, physical therapy and physiotherapeutic treatment: electrophoresis or ultraphonophoresis with hydrocortisone, pulsed magnetic therapy, etc. Are prescribed.

Surgical treatment is required to restore full range of motion - if stretching the tendon with exercise therapy and physical therapy does not help prevent the contracture from worsening. During surgery, called a tenotomy, the thickened tendon is separated through an incision; the tendon scar may also be excised. A tendon transfer or arthrodesis is used to improve ankle function.

The most common surgeries for contractures in children with cerebral palsy are tenotomy and tendon grafting or lengthening (which is recommended between the ages of 6-10 years).

Treatment of tendogenic contractures of the foot due to compartment syndrome depends on the severity. In mild cases, splinting is sufficient; in severe cases, treatment is surgical: decompression fasciotomy, lengthening of the musculotendinous structures or tenotomy.

There is no evidence that herbal treatment will help to get rid of tendon contracture or at least reduce it. Nevertheless, there is advice to make compresses and rub fingers, palms and feet with alcohol tinctures from the seeds of the common muzzlewort (Echinops ritro) with the addition of horseradish root (grated), but such folk remedies are used exclusively for inflammatory joint diseases, plexitis, osteochondrosis and sciatica.

Prevention

Prevention of tendogenic contractures due to tendon tear/rupture or burn is prevention of injury and burns. By the way, if an injury occurs, one way to prevent contractures is to wear a bandage (orthosis) for several hours every day or even while sleeping - to passively stretch the tendon, keeping it loose. This applies to burns as well.

Forecast

According to experts, most contractures can be reversed if detected before the joint is fully immobilized. But the prognosis can be poor if left untreated, as such contractures can lead to foot or hand deformities, paralysis and sensory neuropathy.