How to manage leg pain due to contractures?

Management of Leg Pain Associated with Contractures

For leg pain associated with contractures, a comprehensive approach including physical therapy with daily stretching exercises, muscle relaxation strategies, proper positioning, and pharmacological management with gabapentin/pregabalin or NSAIDs is strongly recommended. 1

Physical Therapy Interventions

Stretching and Exercise

• Perform daily stretching exercises multiple times per day to maintain joint mobility and prevent worsening of contractures 1
• Structure exercise sessions with three essential phases:
  • Warm-up (5-10 minutes) with low-intensity repetitive exercises
  • Training with overload stimulus to increase joint range of motion
  • Cool-down (5 minutes) with static stretching 1
• Optimal timing: When pain and stiffness are minimal (e.g., before bedtime)
• Precede stretching with a warm shower or application of moist heat
• Follow with relaxation techniques before starting exercises 1
• Technique: Move slowly, extend range of motion to a comfortable point of slight resistance, hold stretch for 10-30 seconds 1

Positioning and Support

• Encourage optimal postural alignment at rest and during functional activities 2
• Avoid postures that promote prolonged positioning of joints at end range (e.g., full hip, knee or ankle flexion while sitting) 2
• Support the affected limb when at rest using pillows or furniture to take weight off the limb 2
• Ensure even distribution of weight in sitting, transfers, standing, and walking to normalize movement patterns 2

Pharmacological Management

First-line Options

• Topical NSAIDs: First pharmacological treatment of choice for pain relief (Grade A recommendation) 1
• Oral NSAIDs (e.g., ibuprofen): For short-term pain relief, with caution regarding GI side effects 1, 3
  • Ibuprofen has demonstrated effectiveness in controlling pain and inflammation in joint conditions 3
  • Typically administered at doses up to 2400mg daily 3

Second-line Options

• Gabapentin: Start at 300mg daily, gradually increase as needed 1
• Pregabalin: Start at 75mg twice daily 1
• Tizanidine: Particularly effective for chronic spasticity with improvements in pain without loss of motor strength 1
• Cyclobenzaprine: For short-term use (up to 2-3 weeks) as an adjunct to rest and physical therapy 1

Orthoses and Assistive Devices

• Knee braces: Patellofemoral knee orthoses for knee contractures; tibiofemoral knee braces when contractures affect ambulation and joint stability 1
• Kinesiotaping: Conditionally recommended for knee contractures 1
• Proper positioning aids: Use supportive devices and implement regular position changes every 2 hours 1
• Power mobility features: Consider tilt, recline, and elevating leg rests to allow position changes and weight shifting 1

Other Interventions

Electrical Stimulation

• Neuromuscular electrical stimulation (NMES) may provide short-term increases in motor strength and control 1
• Helps prevent fiber atrophy and disuse muscle atrophy in immobile individuals 1

Advanced Interventions

• Botulinum toxin injections: Consider for focal dystonia and spasticity-related contractures 1
• Surgical interventions: Consider when other treatments have been insufficiently effective (Grade D recommendation) 1

Prevention of Complications

• Regular skin assessments using objective risk scales
• Minimize friction and pressure on the skin
• Provide adequate support surfaces
• Implement regular position changes
• Maintain good skin hygiene 1

Important Cautions

• Avoid splinting as first approach as it may prevent restoration of normal movement and function 2
• Potential problems with splinting include:
  • Increased attention and focus to the area, potentially exacerbating symptoms
  • Increased accessory muscle use
  • Use of compensatory movement strategies
  • Immobilization leading to muscle deconditioning
  • Learned non-use
  • Increased pain 2
• Serial casting for fixed functional dystonia has been associated with worsening symptoms 2

The evidence for passive movements alone is very low quality and does not clearly demonstrate effectiveness for treating contractures 4, 5. Instead, focus on active strategies that promote normal movement patterns and functional use of the affected limb 2, 1.