Following repair, the physician must decide which of two protocols is appropriate for the patient with primary goals of protecting the tendon and avoiding rupture. With some exception, the controlled motion protocol is used for patients who have had 2 or 4 strand repairs or _____. The early active motion protocol is often used for 6-strand repair. The 6-strand repair is stronger, but bulkier. Early motion allows for active contraction of the repaired flexor, pulling the tendon proximally to produce a better glide. STUDIES
Weeks
1-3
Splinting
Immediately post-operatively the patient is placed in dressings and a plaster splint that protects the wrist in 20-30 degrees of flexion with the MP joints flexed. Within the first week and ideally during the first 1-2 days, the patient should be fitted with a fiberglass dorsal block splint (DBS) that places the wrist in 20-30 degrees of volar flexion, the MP joints in 50-70 degrees of flexion, and allows for full extension of the IP joints. Often foam block is attached to the splint at the level of P1 to further block the MP joints into flexion, allowing the IP joints additional room to extend.
A
“Post-op Flexor Tendon Brace” (PFT) may be fitted to facilitate full passive
flexion of the IP joints and to relax the tendon, preventing inadvertent active
flexion. Some insurance companies will
not pay for a pre-fabricated device such as this, so rubber band traction using
nylon and a safety pin is used.
Typically, no rubber band traction is used with Zone 5 injuries. Whether all of the fingers or those adjacent
to the injured fingers are included in the rubber band traction is physician dependent.
It is often more comfortable for the patient to have all of the fingers
included with the exception of the index. Often the physician will provide
traction to all digits for young children and those patients who appear
over-aggressive.
The
patient is followed in therapy weekly to ensure that the DBS is fitting
appropriately and that full IP extension is allowed. If the patient is unable to fully extend the
IP joints into the block due to MP position, addition MP block foam may be
considered. If pain or weakness appears
to be the cause, the therapist can consider several options. The rubber bands can be placed on top of the
roller bar at night or the proximal safety pin can be moved distally for those
fitted with rubber bands only. The DBS
can be cut back to the PIP joint level or buddy splinting can also be
tried. If the lack of extension appears
to be due to the excessive resistance of the rubber bands, the patient may be
instructed to manually release the tension of the band during active
extension.
1. The first therapy visit
should include a detailed education session to explain the importance of hourly
exercise and potential ways of causing tendon rupture. The patient should not remove the DBS, but
can be removed by the therapist only for refitting of the block, for wound
care, and for scar care as needed. It is
helpful for the patient to be made aware of the length of time the DBS will be
necessary, what types of activity will be allowed when the block is removed,
and when they can expect to return to full activities.
2. Hourly home exercise should
include: 50 repetitions of active IP extension to the limits of the DBS, 5-10
repetitions of isolated passive flexion to the PIP and DIP joints, followed by
composite passive flexion to each digit.
If the PFT or rubber band traction does not allow for these motions to
occur, it may be removed for exercise.
3. Edema reduction should be
initiated by elevation and/or in combination with finger compression socks or
coban, assuming adequate integrity of the vascular structures.
4. TENS can be used for pain
control. It is often helpful to first
try the median and ulnar nerve distributions.
5. ROM exercises to facilitate
end range shoulder motion, elbow flexion/extension, and forearm
supination/pronation exercises should begin immediately.
6. During the first week of
treatment, the therapist and patient should give attention to the inflammatory
process that is naturally occurring following injury and decrease the
aggressiveness of exercise as needed.
1. The patient should be instructed in place and hold exercises. This is done by passively placing the digits into flexion and allowing the patient to actively hold the digits with minimal to moderate effort.
2. Upon suture removal, scar massage should be initiated. The patient can be instructed to perform massage daily depending on the location of the scar. The patient must not need to forcefully passively extend the fingers or remove the block to perform massage. In these cases, the therapist can perform massage until the DBS is removed.
Week 4
1. The DBS may be discontinued and the PFT reapplied with the wrist in neutral. Some physicians may prefer to discontinue the PFT and continue the DBS. If the patient’s motion is good to excellent at this point, this may indicate weak or minimal scarring of the tendon and the DBS and PFT should be worn for another 1-2 weeks.
2. If the DBS is discontinued, the patient should be instructed to block the MP joints into flexion using the unaffected hand while performing IP extension. The degree of MP flexion can gradually be decreased over the next week. Add Wehbe-Hunter tendon gliding exercises as described in the patient handout section. The Patient can also begin isolated glides of the FDS tendons. The PFT may be removed several times per day to perform mid-range wrist flexion and extension.
3. The patient may also begin gentle protected passive extension to the IP joints if active extension is limited. It is helpful to hold the MP joint down with the long finger, while extending the IP gently with the thumb and index finger.
4. Scar care should be continue including massage and the addition of silicone sleeves or gel sheeting if its use was difficult for the first few weeks.
Week 5
1. Continue with PFT and/or DBS
if easy motion indicates weak or minimal scarring. Discontinue PFT and/or DBS if the patient has
limited motion.
2. Continue tendon gliding
exercises, wrist ROM if DBS has been discontinued, FDS isolated glides, and
protected passive extension.
3. Gentle non-resistive
blocking exercises can be initiated to facilitate FDS/FDP glide. The therapist should ensure that the patient
isn’t over-aggressive in attempts to flex the DIP, as this may apply excessive
stress to the newly repaired tendon.
1. The PFT and/or DBS should be discontinued if not already done.
2. If extrinsic flexor tendon
tightness is observed, the therapist should consult the physician to begin
gentle static progressive and/or dynamic splinting. In severe cases, this can be initiated as
early as 4 or 5 weeks with the wrist flexed.
The patient is not allowed to flex against dynamic bands.
3. Add isolated blocking exercises to facilitate FDS and FDP gliding exercises with a graded level of aggressiveness with pull-through. If decreased glide is noted, gently increase aggressiveness of the exercise. If the tendons are gliding easily, only light effort is appropriate, decreasing potential for rupture.
4. Gentle passive stretching can begin for control of contractures. This may include ____
5. NMES can be initiated to facilitate FDS and/or FDP pull-through if the physician feels the repair is strong enough and is unsatisfied with the current AROM.
6. The patient can begin light functional ADL.
1. Splinting continues as needed to correct extrinsic flexor tendon tightness or joint contracture. A joint jack can be used for single finger PIP contractures of less than 30 degrees. If the contracture is greater than 30 degrees, the patient will need an outrigger than flexes the MP joints and extends the IP joints.
2. Home exercise continues as described in week 6 with the addition of light grip and wrist strengthening. This can include the use of theraputty or sponges and the use of theraband or light weights for wrist strengthening.
Weeks 8-12
At this point, the patient can progress strengthening exercises as indicated with progression to work conditioning and simulation as appropriate.
12 weeks
Grip and pinch strength testing should not be performed until 12 weeks post-op to prevent rupture. The patient has no restrictions at 12 weeks and may return to full functional activities if allowed by the physician.
Early Active Motion Program for Zones 1-5
Weeks 1-3
Splinting
Immediately post-operatively the patient is placed in dressings and a plaster splint that protects the wrist in 20-30 degrees of flexion with the MP joints flexed. Within the first week and ideally during the first 1-2 days, the patient should be fitted with a fiberglass dorsal block splint (DBS) that places the wrist in 20-30 degrees of volar flexion, the MP joints in 50-70 degrees of flexion, and allows for full extension of the IP joints. Often foam block is attached to the splint at the level of P1 to further block the MP joints into flexion, allowing the IP joints additional room to extend.
A
“Post-op Flexor Tendon Brace” (PFT) may be fitted to facilitate full passive
flexion of the IP joints and to relax the tendon, preventing inadvertent active
flexion. Some insurance companies will
not pay for a pre-fabricated device such as this, so rubber band traction using
nylon and a safety pin is used.
Typically, no rubber band traction is used with Zone 5 injuries. Whether all of the fingers or those adjacent
to the injured fingers are included in the rubber band traction is physician
dependent. It is often more comfortable
for the patient to have all of the fingers included with the exception of the
index. Often the physician will provide traction to all digits for young
children and those patients who appear over-aggressive.
The
patient is followed in therapy weekly to ensure that the DBS is fitting
appropriately and that full IP extension is allowed. If the patient is unable to fully extend the
IP joints into the block due to MP position, addition MP block foam may be
considered. If pain or weakness appears
to be the cause, the therapist can consider several options. The rubber bands can be placed on top of the
roller bar at night or the proximal safety pin can be moved distally for those
fitted with rubber bands only. The DBS
can be cut back to the PIP joint level or buddy splinting can also be
tried. If the lack of extension appears
to be due to the excessive resistance of the rubber bands, the patient may be
instructed to manually release the tension of the band during active
extension.
1. The first therapy visit
should include a detailed education session to explain the importance of hourly
exercise and potential ways of causing tendon rupture. The patient should not remove the DBS, but
can be removed by the therapist only for refitting of the block, for wound
care, and for scar care as needed. It is
helpful for the patient to be made aware of the length of time the DBS will be
necessary, what types of activity will be allowed when the block is removed,
and when they can expect to return to full activities.
2. Hourly home exercise should
include: 50 repetitions of active IP extension to the limits of the DBS, 5-10
repetitions of isolated passive flexion to the PIP and DIP joints, followed by
composite passive flexion to each digit.
If the PFT or rubber band traction does not allow for these motions to
occur, it may be removed for exercise.
3. Begin passive place and
active hold exercises 2-5 repetitions per hour.
4. One physician who
consistently uses the 6 strand repair allows the patient to begin gentle active
composite flexion 2-5 repetitions every 1-2 hours. If extension of the IP joints is limited, he also allows
active assisted extension to be added.
5. Edema reduction should be initiated by
elevation and/or in combination with finger compression socks or coban,
assuming adequate integrity of the vascular structures.
6. TENS can be used for pain
control. It is often helpful to first
try the median and ulnar nerve distributions.
7. Shoulder ROM in all planes, elbow
flexion/extension, and forearm supination/pronation exercises should begin
immediately.
8. During the first week of
treatment, the therapist and patient should give attention to the inflammatory
process that is naturally occurring following injury and decrease the
aggressiveness of exercise as needed.
1. Splinting stays the same as
in weeks 1-3, with the exception of zone 5.
These patients may be splinted more toward neutral at weeks 2-3.
2. The patient may begin active
composite flexion exercises.
3. Scar care should be
initiated with massage during therapy and outside of therapy if massage can be
done without removal of the DBS.
1. For zone 1-4 injuries, some physicians may discontinue the DBS and reapply the PFT in neutral. For zone 5, the DBS may be discontinued and changed to a hand-based anti-claw splint if the ulnar nerve is involved and/or an opponens splint if the median nerve is involved.
2. If the DBS is discontinued, the patient should be instructed to block the MP joints into flexion using the unaffected hand while performing IP extension. The degree of MP flexion can gradually be decreased over the next week. Add Wehbe-Hunter tendon gliding exercises as described in the patient handout section. The Patient can also begin isolated glides of the FDS tendons. The PFT may be removed several times per day to perform mid-range wrist flexion and extension.
3. The patient may also begin gentle protected passive extension to the IP joints if active extension is limited. It is helpful to hold the MP joint down with the long finger, while extending the IP gently with the thumb and index finger.
4. Scar care should be continue including massage and the addition of silicone sleeves or gel sheeting if its use was difficult for the first few weeks.
1. AROM can be progressed. Gentle non-resistive blocking exercises can begin to facilitate FDS/FDP glide.
1. The DBS and/or PFT can be discontinued if it hasn’t already been done. Dr. Tsai typically does not discontinue the DBS until 8 weeks, regardless of the zone of injury.
2. If extrinsic flexor tendon tightness is
observed, the therapist should consult the physician to begin gentle static
progressive and/or dynamic splinting. In
severe cases, this can be initiated as early as 4 or 5 weeks with the wrist
flexed. The patient should not flex
against the bands.
3. Add isolated blocking exercises to facilitate FDS and FDP gliding exercises with a graded level of aggressiveness with pull-through. If decreased glide is noted, gently increase aggressiveness of the exercise. If the tendons are gliding easily, only light effort is appropriate, decreasing potential for rupture.
4. Gentle passive stretching can begin for control of contractures. This may include ____
5. NMES can be initiated to facilitate FDS and/or FDP pull-through if the physician feels the repair is strong enough and is unsatisfied with the current AROM.
6. The patient can begin light functional ADL.
1. Splinting continues as needed to correct extrinsic flexor tendon tightness or joint contracture. A joint jack can be used for single finger PIP contractures of less than 30 degrees. If the contracture is greater than 30 degrees, the patient will need an outrigger than flexes the MP joints and extends the IP joints.
3. Home exercise continues as described in week 6 with the addition of light grip and wrist strengthening. This can include the use of theraputty or sponges and the use of theraband or light weights for wrist strengthening.
Weeks 8-12
At this point, the patient can progress strengthening exercises as indicated with progression to work conditioning and simulation as appropriate.
12 weeks
Grip and pinch strength testing should not be performed until 12 weeks post-op to prevent rupture. The patient has no restrictions at 12 weeks and may return to full functional activities if allowed by the physician.