Hesperian Health Guides

Prevention and Early Management of Contractures

Contractures can often be prevented by (1) positioning, and (2) range-of-motion exercises.


If a child is likely to develop contractures or has begun to develop them, try to position her to stretch the affected joints. Look for ways to do this during day-to-day activities: lying, sitting, being carried, playing, studying, bathing, and moving about.

During a severe illness (such as acute polio), or a recent spinal cord injury, contractures can develop quickly. Therefore, early preventive positioning is very important:

child sleeps correctly with a pillow put a pillow between legs to hold knees apart. child sleeps correctly with a pillow
Lying and sleeping straight helps prevent contractures. Also use pillows for side- lying to keep a good position.
child sleeps incorrectly
Lying and sleeping with the legs in a twisted or bent position causes contractures.

DVC Ch8 Page 81-4.png
Letting feet hang over edge helps prevent ankle contractures. DVC Ch8 Page 81-5.png
Lying part of the time face down helps stretch hips backward. A pillow here helps stretch knees. A foot board helps to prevent ankle contractures.
DVC Ch8 Page 81-6.png
The foot support can be leaned forward a little so that the child can stretch his feet by pushing against it. (Be sure to pad it.)

child in a wheelchair with legs straight out Support feet at right angles.
If knee contractures might develop, keep the knees straight as much as possible.
a child lies down with a leg separator
leg separator if needed
a child eats at a table standing on a frame
A child who spends most of the time sitting should spend part of the day lying or standing (on a frame if necessary). This will help prevent contractures of the hips and knees.

a child eats at a table with unsupported feet
a child eats at a table with a foot lift
foot lifts
a child eats at a table with a foot lift
a child eats using child-sized furniture
Figure out ways to help the child stay in contracture-preventing positions child-sized furniture
For a child with spasticity whose legs press together or cross, look for ways to sit, lie, or carry him with his legs separated. Here are a few examples: See more examples of ways to prevent ‘knock-knee’ contractures.
a child using a special seat
a child sitting with his legs separated by a log
a child sitting with a pot between his legs
a child is held with separated legs

For more ideas about special seating and positioning, see Chapter 65.

DVC Ch8 Page 82-1.png

Exercises to prevent contractures

Just as cats, dogs, and many other animals stretch their bodies after they wake up, children often enjoy stretching their limbs and testing their strength. This is one of the purposes of play.

Daily stretching keeps the joints able to move smoothly and freely through their full range of motion.

a woman helps a child move his arm up and down
Range-of-motion exercises for the shoulder.

Unfortunately, some children, because of illness, paralysis or weakness, are not able to stretch all parts of their bodies easily during their play and daily activities. If some part of their body is not regularly stretched or moved through its full range, contractures may develop.

To maintain full, easy movement of their joints and limbs, these children therefore need daily exercises that move the affected parts of their bodies through their full range of motion.
Range-of-motion exercises for each body joint are discussed in Chapter 42.

woman talks to and helps a child with range of motion exercise

Bend your foot as far as you can. I'll help you.
Have the child move the part as far as she can without help. Then help her to move it the rest of the way.

As much as possible, the child herself should try to move the affected part through its range of motion. Often the limb will be too weak and help is needed. But be sure the child moves it as much as she can herself.

Where there is muscle imbalance, strengthening the weaker muscles can help prevent contractures. Examples of muscle strengthening exercises are found:

As much as possible, try to make exercises fun.

A child whose feet tend to bend inward like this, may benefit from exercises that bend them outward, like this. Walking on boards in a V-shape may provide similar stretching and be more fun. But going with father on the V-shaped paths to the bean fields may be even more fun—and it stretches his ankles more, because it is a long way.
child with feet bent inward exercising to bend feet outward DVC Ch8 Page 82-6.png
DVC Ch8 Page 82-7.png

FOUR WAYS TO APPROACH STRETCHING EXERCISES: To prevent (or help correct) contractures, exercises can be done in 4 different ways, depending on the needs and ability of the child. These 4 ways, shown on the next page, progress from exercises where the child depends completely on help, to exercises that she does on her own as a part of everyday activity.

DVC Ch8 Page 83-1.png

Four Ways to do Exercises that Stretch a Tight Heel Cord

1. Someone else moves the limb. 2. The child does his own exercises, but without using the muscles in the affected part.
DVC Ch8 Page 83-2.png DVC Ch8 Page 83-3.png (This may help to prevent a contracture but will not help much to correct it.) Here the child does his own stretching with some help from his mother.

DVC Ch8 Page 83-4.png
Often necessary— but not much fun.
Keep heels down. DVC Ch8 Page 83-5.png Leaning against a wall stretches the feet more than standing upright does. DVC Ch8 Page 83-6.png If the child is strong enough, bending the knees or touching the toes is a good way to stretch the muscles that cause a tight heel cord. DVC Ch8 Page 83-7.png
CAUTION! When doing these exercises, carefully check to see that the foot is not dislocating to the side. If so, you should use Method 1, being careful to hold the foot in such a way that it does not ‘cave in’ to the side.
DVC Ch8 Page 83-8.png
3. The child does the exercise—using muscles of the affected part.
If the child has some strength to raise his foot, have him raise it as far as he can. Then help him to raise it as far as it will stretch.
Developing the muscles that lift the foot may help prevent contracture.
woman talks to and helps child exercise
Now pull your foot up. I'll help.
If the child has enough strength to raise his foot against resistance, he should do so. But be sure that the foot comes all the way up.
DVC Ch8 Page 83-10.png
sand bag tied to foot
DVC Ch8 Page 83-11.png
piece of old car or bicycle tire inner tube
4. The child does the exercise—during normal daily activities.
Figure out ways or aids so that the child can take part in ordinary activities that stretch muscles and prevent contractures.
DVC Ch8 Page 83-12.png
standing and walking uphill to stretch heel cords
DVC Ch8 Page 83-13.png
picking vegetables
DVC Ch8 Page 83-14.png
chest band that hooks over crutch top
strong wire
DVC Ch8 Page 83-15.png
DVC Ch8 Page 83-16.png
sewing on a machine can exercise foot and combat contractures. bar that permits child to squat and bend ankles

This page was updated:21 Nov 2019