Contractures do occur when the soft tissues cannot accommodate changes in bone length. To treat contractures effectively, one needs to identify the potential problem muscles. In tibial lengthening, for example, the problem muscles are the gastrocnemius and toe flexors. As a result, patients can develop knee flexion, ankle plantar flexion, and toe flexion contractures.
In the femur, both rectus femoris and hamstring muscles resist lengthening. This can result in a fixed flexion deformity of the knee and a deficit in flexion range of motion. Despite these problems, the following specific protocols and modalities at HillsClinic are followed to prevent and treat contractures :-
Passive stretching and soft tissue mobilization: Patients are given pain medications 30 minutes before receiving therapy.
A muscle is prepared for stretching by applying moist heat for 15 minutes before activity. The antagonist muscle are activated before stretching the agonist muscle. This way muscle is thereby relaxed by means of reflexive inhibition.
The skin over the pin site is immobilized with tight gauze to help reducing pain during range of motion exercises
In general, biarticular muscles (muscles that work on two joints) are stretched 20 to 30 times per session and uniarticular
muscles (muscles that work on one joint) are stretched 10 to 15 times per session.
When stretching a biarticular muscle, the aim is to obtain maximum stretch in the direction opposite that of the muscle action at both proximal and distal joints and hold each stretch for 20 to 30 seconds. Some examples of biarticular muscle stretch include rectus femoris stretch with the hip in full extension and knee flexion and ankle dorsiflexion with knee extension to stretch the gastrocnemius muscle.
Positioning: Optimal maximal positions vary based on the body parts that are affected. For example, patients who are undergoing tibial lengthening are positioned with the knee extended straight and the ankle flexed up. Knee extension along with hip abduction is a desirable position for patients who are undergoing femoral lengthening.
Splints: Custom designed splints help to keep the soft tissues (muscles and tendons) stretched properly. Using a splint to place a muscle under tension for as many hours as possible helps to prevent contractures by obtaining plastic response in the connective tissue.
Dynamic splinting: In certain situations, special dynamic splints are used. These are different from static splints because they include a spring-like or elastic mechanism to produce elongation of the tissues through a low load prolonged duration stretch. Dynamic splints work most effectively in treating knee flexion contractures.
Such splints work only in optimal positions and that their tension should always be increased gradually. These types of splints are also often used for the toes.
In addition to joint stiffness, patients may experience muscle weakness. This is caused by lack of use (because the patient cannot walk normally). Pain can also inhibit muscle function, adding to weakness. We use the following modalities to help in the management of muscle weakness:-
Electrical stimulation: Electrical stimulation is used as an adjunct to a strengthening program and to augment voluntary muscle contraction. To accomplish this, a muscle stimulator machine is applied to the surface of the limb (thigh, for example) and a low level electrical signal stimulates the underlying muscle to contract.
Hydrotherapy (water therapy): Hydrotherapy helps patients avoid significant muscle weakness, especially when both legs are being lengthened. It promotes active range of motion. The natural buoyancy allows simulated weight bearing. The higher the level of the water (chest deep versus waist deep, for example), the more "weightless" one feels. Hydrotherapy also helps in keeping pin sites clean.
Progressive weight bearing: Programs of progressive weight bearing are important during all phases of limb lengthening rehabilitation.
During the lengthening phase, patients at HillsClinic are encouraged to perform weight bearing as prescribed. Some patients may experience pain from increased weight bearing, and the increased weight bearing can cause undue stress on the pins or wires.
Weight bearing is even more critical during the consolidation phase. We encourage that the patient should progress from two crutches to one and then to none. He or she should also perform closed chain exercises. (Closed chain exercises are defined as
resistive exercises with which the load is applied through the feet; some examples of closed chain exercises are leg press, stair climber, and bicycle). Many patients who have been following the HillsClinic protocols of physiotherapy from the very start can walk without assistive devices and have no limp during the latter part of the consolidation phase.
Nerve injury is not common and occurs primarily in patients who are undergoing tibial lengthening. It happens when certain nerves do not stretch enough to accommodate the bone lengthening. Peroneal nerve symptoms during tibial lengthening are caused by referred pain in the dorsum of the foot. This pain may present initially as hyperesthesia (increased sensitivity) and then as hypoesthesia (reduced sensitivity). Weaknesses in the muscles that control toe and foot action are sometimes observed.
Pain medications usually do not help. Referred pain in the top of the foot is increased with knee extension and is relieved by flexing the knee. When signs of peroneal nerve irritation occur, the use of a dynamic knee extension splint is discontinued and knee extension exercises are reduced. A patient who may be developing this condition should notify the doctor as soon as possible. In most cases, reducing the rate of lengthening reduces the symptoms of nerve.
In cases in which our patients do not respond to rate reduction, then peroneal nerve decompression surgery is done. This is a small procedure that involves a small incision. When indicated, nerve decompression prevents permanent nerve injury and allows the nerve to recover. This, in turn, allows the lengthening to continue.
Physical and occupational therapists play a critical role in limb lengthening. A successful functional outcome depends on the quality and amount of therapy a patient receives. Success also depends on the involvement of the family members and caregivers. At HillsClinic Physical therapists encourages families and care providers to attend the physical therapy sessions. There, they can learn the optimal positions for stretching and the passive stretching exercises. With team effort, limb lengthening rehabilitation can be successful.