From the Guidelines
For a chronically contracted lower extremity at the knee, a hamstring tenotomy or lengthening procedure would provide improved range of motion. This surgical intervention targets the hamstring tendons (semitendinosus, semimembranosus, and biceps femoris) which, when contracted, limit knee extension. The procedure involves either complete release (tenotomy) or lengthening of these tendons to reduce their pull on the knee joint. In severe cases, additional procedures may include release of the posterior knee capsule or gastrocnemius recession if ankle equinus is contributing to the knee flexion contracture.
Key Considerations
- Post-operatively, patients require physical therapy for 6-12 weeks focusing on range of motion exercises, progressive strengthening, and gait training 1.
- Bracing may be necessary initially to maintain the correction.
- This intervention is effective because the hamstring muscles cross both the hip and knee joints, and when chronically shortened, they physically prevent full knee extension.
- Releasing or lengthening these tendons reduces this mechanical limitation, allowing for improved extension at the knee joint and subsequently improved gait and function.
Alternative Options
- Chemodenervation using Botulinum Toxin Type A may be considered to increase range of motion for patients with focal and/or symptomatically distressing lower limb spasticity 1.
- Ankle-foot orthoses and other splints should be considered in appropriate patients, and be customized to individual patients 1.
- Surgical interventions such as tendon repositioning to promote more functional joint mechanics may be considered in select patients 1.
Evidence-Based Recommendation
The most recent and highest quality study recommends surgical interventions such as tendon repositioning to promote more functional joint mechanics 1. However, the specific procedure of hamstring tenotomy or lengthening is not mentioned in this study. Nevertheless, based on the principles of reducing mechanical limitation and improving joint mechanics, hamstring tenotomy or lengthening procedure is still the most appropriate recommendation.
Additional Considerations
- Patients with paretic limbs and muscle spasticity are at high risk of developing contractures that restrict movement, cause pain, and adversely affect skin hygiene 1.
- Early treatment is key to preventing disabling complications, and positioning, passive stretching, and range-of-motion exercise may provide relief and should be done several times daily in persons with spasticity 1.
From the Research
Procedures for Improving Range of Motion
To improve range of motion in a chronically contracted lower extremity at the knee joint, several procedures can be considered:
- Hamstring release or tenotomy: This procedure involves releasing or cutting the hamstring tendons to reduce contracture and improve extension [ 2 ].
- Posterior capsular release: This procedure involves releasing the posterior capsule of the knee joint to improve extension and reduce contracture [ 3 ].
- Botulinum toxin injections: Injecting botulinum toxin into the hamstring muscles can help reduce spasticity and improve range of motion [ 4 , 3 ].
- Percutaneous hamstring tenotomy: This is a minimally invasive procedure that involves cutting the hamstring tendons to improve extension and reduce contracture [ 5 ].
Indications and Outcomes
These procedures are typically indicated for patients with severe flexion contractures that interfere with daily activities and quality of life. The outcomes of these procedures can vary depending on the individual patient and the severity of the contracture. However, studies have shown that these procedures can be effective in improving range of motion and reducing contracture [ 4 , 3 , 6 , 2 , 5 ].
Considerations
It's worth noting that each patient's situation is unique, and the best procedure for improving range of motion will depend on the individual's specific needs and circumstances. A thorough evaluation by a healthcare professional is necessary to determine the most appropriate course of treatment [ 4 , 3 , 6 , 2 , 5 ].