Flexion Deformity of the Knee: Difference between revisions
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== Definition/description == | == Definition/description == | ||
A flexion deformity of the knee is the inability to fully straighten the knee. A synonym for it is flexion contracture. Normal active range of motion (AROM) of the knee is 0° extension and 140° flexion. In people with a flexion deformity, AROM of one or both knees is reduced. It develops as a result of failure of knee flexors to lengthen in tandem with the bone, especially when there is inadequate physical therapy to provide active and passive mobilization of the affected joint.<ref name="1">Kwan MK, Treatment for flexion contracture of the knee during Ilizarov reconstruction of tibia with passive knee extension splint, 2004;59:39-41 (C)</ref> They often require extensive rehabilitation. <ref name="4">Suksathien R., A new static progressive splint for treatment of knee and elbow flexion contractures, 2010; 93 (7): 799-804 (C)</ref> In most cases, flexion deformities occur bilaterally. | A flexion deformity of the knee is the inability to fully straighten the knee. A synonym for it is flexion contracture. Normal active range of motion (AROM) of the knee is 0° extension and 140° flexion. In people with a flexion deformity, AROM of one or both knees is reduced. It develops as a result of failure of knee flexors to lengthen in tandem with the bone, especially when there is inadequate physical therapy to provide active and passive mobilization of the affected joint.<ref name="1">Kwan MK, Treatment for flexion contracture of the knee during Ilizarov reconstruction of tibia with passive knee extension splint, 2004;59:39-41 (C)</ref> They often require extensive rehabilitation. <ref name="4">Suksathien R., A new static progressive splint for treatment of knee and elbow flexion contractures, 2010; 93 (7): 799-804 (C)</ref> In most cases, flexion deformities occur bilaterally. | ||
== Epidemiology/etiology == | == Epidemiology/etiology == | ||
Flexion deformities can arise by different causes. Two types of flexion contracture of the knee can be distinguished: 1) contracture associated with joint destruction and [[Ankylosing Spondylitis|ankylosis]] and 2) contracture with joint anatomy and mobility are preserved.<ref name="2">damsin JP, TREATMENT OF SEVERE FLEXION DEFORMITY OF THE KNEE IN CHILDREN AND ADOLESCENTS USING THE ILIZAROV TECHNIQUE, 1995;77-B:140-4 (C)</ref> They can be caused by a piece of bone or other tissue getting in the way and blocking movement, knee replacement components in the wrong position or scar tissue restricting that cannot further straightening an extreme tightness in the hamstring muscles. Flexion deformities are common complications following trauma, inflammatory conditions, immobilization, burns and congenital deformities. <ref name="4" /><br>A few examples in which flexion contractures of the knee can occur are: burn scars, intra-articular fractures, [[Septic Arthritis|septic arthritis]], [[Juvenile Rheumatoid Arthritis|juvenile rheumatoid arthritis]], [[ | Flexion deformities can arise by different causes. Two types of flexion contracture of the knee can be distinguished: 1) contracture associated with joint destruction and [[Ankylosing Spondylitis|ankylosis]] and 2) contracture with joint anatomy and mobility are preserved.<ref name="2">damsin JP, TREATMENT OF SEVERE FLEXION DEFORMITY OF THE KNEE IN CHILDREN AND ADOLESCENTS USING THE ILIZAROV TECHNIQUE, 1995;77-B:140-4 (C)</ref> They can be caused by a piece of bone or other tissue getting in the way and blocking movement, knee replacement components in the wrong position or scar tissue restricting that cannot further straightening an extreme tightness in the hamstring muscles. Flexion deformities are common complications following trauma, inflammatory conditions, immobilization, burns and congenital deformities. <ref name="4" /><br>A few examples in which flexion contractures of the knee can occur are: burn scars, intra-articular fractures, [[Septic Arthritis|septic arthritis]], [[Juvenile Rheumatoid Arthritis|juvenile rheumatoid arthritis]], [[Cerebral Palsy Introduction|cerebral palsy]] and many others. <ref name="4" /><ref name="7">Klatt J. ,Guided Growth for Fixed Knee Flexion Deformity, 2008;28:626-631 (C)</ref><br> | ||
== Characteristics/clinical presentation == | == Characteristics/clinical presentation == | ||
Patients with flexion contractures often walk with a bent-knee gait. This provides increasing strain on the quadriceps and increasing strain contact forces in the patellofemoral joint. Walking distance is reduced and increased strain during bent-knee gait may lead to quadriceps weakness and | Patients with flexion contractures often walk with a bent-knee gait. This provides increasing strain on the quadriceps and increasing strain contact forces in the patellofemoral joint. Walking distance is reduced and increased strain during bent-knee gait may lead to quadriceps weakness and early onset of quadriceps fatigue. <ref name="6">Timothy L., Torque Measures of Common Therapies for the Treatment of Flexion Contractures 2010; 26:328-334 (D)</ref><ref name="7" /> Other symptoms of flexion contractures are [[Anterior knee pain|anterior knee pain]], a progressive crouch gait and limping while walking. They often lead to compensatory movements such as hip flexion deformity accompanied by lumbar lordosis. <ref name="7" /><br>Short-term and long-term changes can be distinguished. Early changes are shortening of stride gait, reduced popliteal angle and a flexed position of the knee at the initiation of the stand phase and throughout gait cycle. Changes which appear later are severe contracture of knee and hip and [[Patella alta|patella alta]].<ref name="8">Wheeless' Textbook of Orthopaedics (secondary)</ref><br>Knee flexion contractures have a lot of functional consequences such as weight-bearing activities and difficulties with bed or chair positioning. <ref name="3">steffen T., Low-Load, Prolonged Stretch in the Treatment of Knee Flexion Contractures in Nursing Home Residents, 1995; 75886-897.1 (A2)</ref><ref name="4" /> Normal daily activities become more difficult because more energy is required to perform them. | ||
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== Physical therapy management == | == Physical therapy management == | ||
Depending | Depending on etiology and severity of the deformity, different management programs are necessary. Treatment of knee flexion contractures include non-surgical and surgical methods. <ref name="4" /> In both cases, physiotherapy is necessary.<br>Conservative treatments include physical therapy, home exercise programs and home mechanical therapy. These are used to treat and minimize the occurrence of flexion contractures.<ref name="6" /> In some cases, such as with [[Cerebral_Palsy_Introduction|cerebral palsy]], spasticity management is also necessary. <ref name="7" /> | ||
Physical therapy consists of manual stretching exercise, prolonged stretch | Physical therapy consists of manual stretching exercise, prolonged stretch using a tilt table, sandbag weight over the distal femur, use of mechanical traction, passive range of motion exercise <ref name="3" /><ref name="4" /> and joint mobilization <ref name="4" /> The effectiveness of a given treatment to reduce flexion contractures is a function of the applied torque, as well as the duration and frequency of the treatment. <ref name="6" /> | ||
For patients who have failed standard conservative treatment for | For patients who have failed standard conservative treatment for two or more months, focused treatment protocols including physical therapy and the use of custom knee devices have been demonstrated to effectively treat flexion contractures. <ref name="6" /> | ||
Other treatment methods are an | Other treatment methods are an orthosis, casting and bracing.<ref name="2" /><ref name="4" /><ref name="7" /><br>Some types of splits have been marketed as another method of applying low stretching forces over prolonged periods. They provide a resistance to flexion, so the knee is at rest in maximum extension. The resistance can be inflated. They are easy to apply and mobile and comfortable for the patients. <ref name="1" /><br>In most of the cases splints and orthesis are used to prevent deformities or maintain range of motion after stretching but not for increasing motion. <ref name="4" /> | ||
In the more severe cases surgical treatment such as soft-tissue release, osteotomies (removing a part of the bone), femoral shortening, hamstring lengthening an rectus transfer can be necessary. <ref name="2" /><ref name="8" /> Hamstring lengthenining is helpful to relieve excessive contractures, especially when they have a significant effect on gait. Rectus transfer may be indicated to partially reduce the spasticity of the quadriceps, especially in patients with cerebral palsy. <ref name="5">Mauro C, Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy, 2008, 2(1): 37–43 (C)</ref><ref name="8" /><br> | In the more severe cases surgical treatment such as soft-tissue release, osteotomies (removing a part of the bone), femoral shortening, hamstring lengthening an rectus transfer can be necessary. <ref name="2" /><ref name="8" /> Hamstring lengthenining is helpful to relieve excessive contractures, especially when they have a significant effect on gait. Rectus transfer may be indicated to partially reduce the spasticity of the quadriceps, especially in patients with cerebral palsy. <ref name="5">Mauro C, Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy, 2008, 2(1): 37–43 (C)</ref><ref name="8" /><br> | ||
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Definition/description[edit | edit source]
A flexion deformity of the knee is the inability to fully straighten the knee. A synonym for it is flexion contracture. Normal active range of motion (AROM) of the knee is 0° extension and 140° flexion. In people with a flexion deformity, AROM of one or both knees is reduced. It develops as a result of failure of knee flexors to lengthen in tandem with the bone, especially when there is inadequate physical therapy to provide active and passive mobilization of the affected joint.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title They often require extensive rehabilitation. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In most cases, flexion deformities occur bilaterally.
Epidemiology/etiology[edit | edit source]
Flexion deformities can arise by different causes. Two types of flexion contracture of the knee can be distinguished: 1) contracture associated with joint destruction and ankylosis and 2) contracture with joint anatomy and mobility are preserved.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title They can be caused by a piece of bone or other tissue getting in the way and blocking movement, knee replacement components in the wrong position or scar tissue restricting that cannot further straightening an extreme tightness in the hamstring muscles. Flexion deformities are common complications following trauma, inflammatory conditions, immobilization, burns and congenital deformities. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A few examples in which flexion contractures of the knee can occur are: burn scars, intra-articular fractures, septic arthritis, juvenile rheumatoid arthritis, cerebral palsy and many others. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Characteristics/clinical presentation[edit | edit source]
Patients with flexion contractures often walk with a bent-knee gait. This provides increasing strain on the quadriceps and increasing strain contact forces in the patellofemoral joint. Walking distance is reduced and increased strain during bent-knee gait may lead to quadriceps weakness and early onset of quadriceps fatigue. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Other symptoms of flexion contractures are anterior knee pain, a progressive crouch gait and limping while walking. They often lead to compensatory movements such as hip flexion deformity accompanied by lumbar lordosis. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Short-term and long-term changes can be distinguished. Early changes are shortening of stride gait, reduced popliteal angle and a flexed position of the knee at the initiation of the stand phase and throughout gait cycle. Changes which appear later are severe contracture of knee and hip and patella alta.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Knee flexion contractures have a lot of functional consequences such as weight-bearing activities and difficulties with bed or chair positioning. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Normal daily activities become more difficult because more energy is required to perform them.
Physical therapy management[edit | edit source]
Depending on etiology and severity of the deformity, different management programs are necessary. Treatment of knee flexion contractures include non-surgical and surgical methods. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In both cases, physiotherapy is necessary.
Conservative treatments include physical therapy, home exercise programs and home mechanical therapy. These are used to treat and minimize the occurrence of flexion contractures.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In some cases, such as with cerebral palsy, spasticity management is also necessary. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Physical therapy consists of manual stretching exercise, prolonged stretch using a tilt table, sandbag weight over the distal femur, use of mechanical traction, passive range of motion exercise Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and joint mobilization Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The effectiveness of a given treatment to reduce flexion contractures is a function of the applied torque, as well as the duration and frequency of the treatment. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
For patients who have failed standard conservative treatment for two or more months, focused treatment protocols including physical therapy and the use of custom knee devices have been demonstrated to effectively treat flexion contractures. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Other treatment methods are an orthosis, casting and bracing.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Some types of splits have been marketed as another method of applying low stretching forces over prolonged periods. They provide a resistance to flexion, so the knee is at rest in maximum extension. The resistance can be inflated. They are easy to apply and mobile and comfortable for the patients. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
In most of the cases splints and orthesis are used to prevent deformities or maintain range of motion after stretching but not for increasing motion. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
In the more severe cases surgical treatment such as soft-tissue release, osteotomies (removing a part of the bone), femoral shortening, hamstring lengthening an rectus transfer can be necessary. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Hamstring lengthenining is helpful to relieve excessive contractures, especially when they have a significant effect on gait. Rectus transfer may be indicated to partially reduce the spasticity of the quadriceps, especially in patients with cerebral palsy. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
