Flexor Tendon Injuries

Restoring hand function after flexor tendon injuries continues to be one of the greatest challenges. Related stiffness, scarring and functional impairment persist on frustrating the most experienced hand surgeons and therapist.

Rehabilitation Goals
j Promote an opportune

environment for strong repair to support normal forces acting on the tendon in normal hand use
± Excessive stress in early healing may lead to rupture or attenuation
‡ Attenuation: tendons that are pulled apart with a gap filled with scar

Rehabilitation Goals j Facilitate tendon gliding without adherence to adjacent tissues .

Rehabilitation Goals j Facilitate tendon gliding without adherence to adjacent tissue ± Specific amplitude of excursion required to flex the digit completely and with power ‡ Active composite wrist and digital flexion required 9 cm of flexor excursion ± Adhesions to surrounding structures limit tendon function .

Significant Anatomy j Flexor Tendons ± Flexor digitorum superficialis ± Flexor digitorum profundus ± Flexor pollicis longus .

S2 Significant Anatomy j FDS ± Origin ‡ Humeroulnar head from the medial epicondyle and coronary process of the ulna ‡ Radial head arises from proximal shaft of radius ± Insertion ‡ Middle phalanx of each digit ± Innervation ‡ Solely median nerve ‡ FDS to small finger absent in 21% of population .

8/18/2006 .Slide 7 S2 Primary flexor of PIP joint Splits at proximal phalaynx level to insert into shaft of middle phalaynx Secondarily flexes MCP s and Wrist SHEENA.

S13 Tendon Healing j Phases of Healing ± Inflammatory Days 1-21 ‡ Proliferation or cells on outer edge of tendon which migrate into the tendon by day 7.repair is as strong as the original suturing and continues to increase. ‡ Increased vascular proliferation in tendon occurs ‡ Day 9. ‡ Collagen synthesis begins and quantity of collagen stabilizes by 3 weeks . ‡ Strength increases rapidly when tendon is stressed.

Slide 8 S13 Stressed tendons have fewer adhesions and better excursion Increasing place & holds. min AROM will increase strength Immobilized tendons lose glide by day 10 SHEENA. 8/18/2006 .

± Active collagen synthesis allows us to lengthen. stays active. ± 5-6 weeks repair can withstand light resist. We are able to create a more elongated and better gliding scar. ± 7-9 weeks repair can withstand heavy resist . weaken. or break adhesions over time.Tendon Healing j Fibroplasia Phase Days 22-42 ± Tensile strength increases ± Able to withstand AROM at 3-4 weeks j Scar Maturation Days 43-84 ± Collagen synthesis reaches its max after 4 weeks however.

health. motivation. socioeconomic factors ‡ ‡ ‡ ‡ ‡ ‡ ‡ . scar formation.injury to vincula Gapping at repair site (poor repair.Tendon Healing j Factors affecting adhesion formation: Pre-op condition of tendon Involvement of one or both tendons Location of injury Condition of surrounding structures Trauma from surgical procedures Tendon ischemia. too much stress on repair site) ‡ Double tendon injuries ‡ Patient Factors ie: age.

S14 Tendon Healing j Controlled mobilization programs ± tendons probably heal by a combination of extrinsic and intrinsic cellular activity. the less peritendinous adhesions ± Early Passive Mobilization ± Early Active Mobilization .the more intrinsic healing that occurs.

strength of healing tendon is proportional to the controlled stress applied SHEENA. 8/18/2006 .Slide 11 S14 Wolf s law.

may require tendon grafting j Primary tendon graft ‡ Unable to perform end to end repair so tendon in replaced with a graft from palm to fingertip. Treatment proceeds according to Zone II guidelines which follow only delay all exercises by 1-2 weeks. .Tendon Repairs j Primary repair within 24 hours j Delayed primary repair ± Between 24 hours and 3 weeks ± Delayed by MD due to contamination or loss of skin coverage j Secondary repair ± More then 3 weeks after injury ‡ May be extensive scarring and muscle contracture as well as retraction of tendon ends.

Flexor Tendon Suture Techniques .

Approaches to Rehabilitation j Immobilization j Early passive mobilization j Early active mobilization .

Approaches to Rehabilitation j Considerations in choice of approach: ± ± ± ± ± Pt. compliance Surgeon preference Type of injury Location and zone of injury Strength of repair .

Approaches to Rehabilitation j Phases of all post-op tendon protocols ± Phase I ‡ Day 1 to Week 3-4 ‡ Tendon immobilized or mobilized in controlled way ‡ Includes inflammatory and fibroplasia phases of wound healing ‡ Repair is at its weakest .

Approaches to Rehabilitation j Phase II: Intermediate Phase ± Week 4 ± Increase stress on tendon ± Mobilize for the first time. or decrease protection during mobilization ± Includes scar maturation phases of wound healing .

Approaches to Rehabilitation j Phase III: Late Stage ± Week 6-8 ± Repair can withstand resistance ± Continued scar maturation .

± Cigarette smoker and coffee drinker= delayed healing secondary to vasoconstrictive effect. ± Scar Formation rate/quality ± Patient Motivation ± Socioeconomic factors .Factors Affecting Healing and Rehab j Patient Related Factors ± Age ‡ Decreased vinicula with ageing ± General health ‡ Lifestyles and dietary habits can adversely affect healing.

Factors Affecting Healing and Rehab j Injury and Surgery-related Factors ± Location of Injury ‡ Zone V ± Tendon may adhere to overlying skin and fascia. not usually a problem ‡ Zone IV ± Tendons may adhere to synovial sheaths. interossei and to overlying fascia and skin ‡ Zone II ± Adhesions likely between: ‡ FDP and FDS ‡ Tendon and Sheath ‡ Tendon and boney tissue ‡ Tendon and vascualr tissue ‡ Tendon and other soft tissue structures ‡ Zone I ± Possible adhesions to A4 or A5 pulley repair or attenuation of the repair ‡ Tendon only has a normal excursion of 5-7 mm in this zone. so small loss of excursion may be functionally limiting . each other and structures lying within the carpal tunnel ‡ Zone III ± Tendons may adhere to adjacent tendons. lumbricals.

partial laceration Infections Vascularity (integrity of vinicula) ± Sheath Integrity ± Surgical Technique ± Timing of Repair ‡ The longer the tendon repair is delayed the tendon can scar down to surrounding tissues.Factors Affecting Healing and Rehab j Injury and Surgery-related Factors (cont.) ± Type of Injury ‡ ‡ ‡ ‡ Crush or blunt injury Complete vs. .

Factors Affecting Healing and Rehab j Therapy related factors ± Timing ‡ Early stage is protective stage.repair is at its weakest ‡ Early mobilization protocol must begin therapy ASAP (24-48 hrs strengthens the repair) ‡ Immobilized tendon lose strength initially ± Technique ‡ *not every tendon injury can be treated with the identical protocol ± Expertise ‡ Therapist skill level .

S16 Wound and Scar Care/Edema Control j Healing. isotoner glove or digisleeve as edema stabilizers ± Increased edema = increased resistance to tendon glide and can have an effect on safety of performing early active motion exercises .sutured wound ± Adaptic and Kling wrap dressing ‡ Changed each visit ± Sutures removed 2-3 weeks ± Suture line debrided with scissors and forceps at 21 days post-op j Edema Control ± Overhead elevation ± Coban wrap at 1-2 weeks per MD ± Finger sock.

8/18/2006 .Slide 23 S16 More elevation the better! SHEENA.

internal ± Ultrasound can be used to soften scar at 8 weeks (10-12 weeks after tendon graft) ± Passive stretching into extension at 6-7 weeks ‡ If tendon is exposed to excessive stress during early stages.external ± 3-4 weeks initiate scar massage ± Instruct on desensitization when initiating scar massage via different textures ± Scar pad at 3-4 weeks to be worn up to 23 hours for the first 2 months. then at night up to 6 months ‡ CVS: curad scar therapy pads j Scar care.S17 Wound and Scar Care/Edema Control j Scar care. ± Active exercises ‡ Fisting ‡ Blocking ± Scar mobilization at 4-6 weeks ‡ Extractor ‡ Deep myofascial release ‡ Skin friction with active tendon glide . tendon ends may pull apart and scar will fill the gap.

Slide 24 S17 Initiate scar massage after sutures removed and holes closed The scar gaps weakens tendon and causes tendon to lengthen. Does not function well mechanically and increases adhesion formation SHEENA. 8/18/2006 .

Approaches to Rehabilitation j Immobilization ± Complete immobilization of tendon repair for 3-4 weeks ± Indicated for children < 10 years of age. or pt¶s that are unable to perform complex rehab protocols ‡ Cognitive deficits ‡ Unwilling patients ± Begin active and passive motions at 4 weeks .

Immobilization j Early Stage: 0 ± 3 or 4 weeks ± Splint ‡ Dorsal Forearm-based blocking splint/cast ± Wrist in 10-30 degrees of flexion ± MP joints in 40-60 degrees of flexion ± IP joints in full extension ‡ Worn 24 hours/day except for therapy visits 1-2 x/week ± Exercise ‡ AROM exercises to all uninvolved joints to prevent stiffness ‡ Therapist provides gentle protected PROM ± Adjacent joints are held in flexion while flexing and extending each joint ± Protected intrinsic stretch exercises ± Scar healing ‡ Cleaning of skin ‡ Massage once sutures are removed and incision is healed ± Assists with skin and tendon adhesions ‡ Elastomer or pressure dressings ± to flatten bulky scars .

starting at 3-4 weeks ± Splint ‡ Modified to bring wrist to neutral (0 degrees) ‡ Removed hourly for exercises ± Exercises ‡ Passive digit flexion and extension with wrist in 10 degrees of extension performed 10 x¶s ‡ Active differential tendon gliding 10 x¶s ‡ Tenodesis exercises increasing excursion attained (Cifdaldi Collins and Schwarze protocol) .Immobilization j Intermediate Stage.

nighttime extension splint may be fabricated and adjusted for continued improvements in extension ‡ If after 1 week improvement is noticed Dynamic or static progressive extension splint are introduced.Immobilization j Late Stage: starting 4-6 weeks ± Splint is discontinued ‡ If flexor muscle-tendon shortening becomes a problem.gentle tension initially ‡ PIP contractures may require serial casting in zone 2 injuries ± Exercises ‡ Blocking exercises for isolated FDP and FDS glide ± 10 repetitions 4-6 times/day ‡ Towel walking introduced after 1 week if active flexion not improved ‡ Sustained grip activities after 1 more week ‡ Heavy lifting not introduced until 10-12 weeks .

Tendon Gliding j Three ways of making a fist ± Hook ‡ Maximum differential glide b/w FDS and FDP ± Straight Fist ‡ Maximum FDS glide ± Full Fist ‡ Maximum FDP glide .

Tendon Gliding j Determine Tendon Gliding ± Compare active and passive flexion ± Measurements should be taken for DIP (block PIP in neutral) and PIP (block MP in neutral) ± If measurements are 10 degrees of each other assume tendon is gliding well ± If measurements are >15 degrees different (passive exceeds active) assume tendon is not gliding well and adhesions are restricting glide .

S18 Tendon Gliding j Determine if soft tissue is shortened or adherent ± Compare measurements of a joint¶s passive extension with adjacent joint first in flexion and then in extension ± Joints measured depends on site of injury j Zone 3-5 measure MP extension with wrist flexed and extended j Zone 2-3 measure PIP extension with MP flexed and extended j Zone 1-2 measure DIP extension with PIP flexed and extended ± If measurements are the same the loss is a joint problem ± If measurements are different the loss is due to adhesion or shortening of the tendon ‡ (MP extension improves when wrist is flexed) ‡ (PIP extension improves with MP¶s flexed) ‡ (DIP extension improves with PIP flexed) JOINT TIGHTNESS NOT ASSOCIATED WITH TENDON SHORTENING .

Slide 31 S18 Motion does not changed as adjacent joint positions are altered SHEENA. 8/18/2006 .

Understanding of tendon healing and ability to evaluate tendon function precisely is important for progression through stages.Therapist to routinely palpate A1 pulley for triggering .Considerations j Patient education on rupture capabilities j j j j j j throughout stages is crucial When to increase amount of resistance and functional use is not easy.there is no rules. Smoothly gliding tendon resistance applied with extreme caution Trigger finger may develop through excessive repetitive gripping/squeezing. More adherent the tendon the safer it is to apply resistance to glide. Ruptures can occur even as late as 3 months.

sustained grip activities ± NMES ± US with stretch or active tendon glide ± Massage . putty scraping.Treating Adhesion Problems j Restrictive adhesions are the most common complication after immobilization of the repaired flexor tendon j Goal is to lengthen adhesion not break it! j Treatment ± Dynamic extension splint ± Frequent blocking.

S19 Early Passive Mobilization j Produces superior results because early mobilization inhibits restrictive adhesion formation.Passive exercise with DBS j Forearm based Dorsal blocking splint (DBS) applied at surgery ± Wrist and MP joints blocked in flexion ‡ Places tendons on slack ± IP joints are left free ‡ And may extend to neutral within the splint j Thermoplastic splint 1-2 weeks ± Passive flexion of fingers does not allow extension beyond limits of the splint ± Dynamic traction maintains fingers in flexion to further relax the tendon & prevents active flexion .Rubber band traction within DBS ± Duran and Houser. promotes intrinsic healing and synovial diffusion. j 2 basic types of protocols ± Kleinert .

8/18/2006 .Slide 34 S19 Benefits to early controlled motion: Enhances tensiel strength of repaired tendon by increasing blood flow and moves tendon away from adherent structures so they don t get stuck. Glide repaired tendons away from adjacent damaged areas Reduce or elongate peritendinous adhesions SHEENA.

Early Passive Mobilization j Dynamic traction of Splint ± Rubber bands ± Elastic threads ± Sprints j Traction applied to fingernail ± Placing a suture through the nail in surgery ± Gluing to fingernail ‡ ‡ ‡ ‡ ‡ Dress hook Velcro Soft leather Moleskin Rubber band .

Early Passive Mobilization ± Passively mobilize tendon repair within first 24 hours to 1 week. limited active or passive extension pulls the tendon distally ± Begin active motion at 4 weeks . pt and/or dynamic flexion traction ± Passive flexion pushes tendon proximally. ± Indicated for delayed referral to therapy > 1 week ± Passive mobilization by therapist.

Kleinert vs. Duran j 0-3 days post op ± DBS ± Remove compressive dressings from fingers and allow passive flexion to palm within DBS ± Rubber band on involved digit attached to volar forearm j 0-3 days post op ± DBS with velcro straps .

Kleinert vs. Duran j First 3 weeks j Patient encouraged to j First 4 ½ weeks j 8 reps full passive flexion j j actively extend the finger and allow elastic band to passively flex digit j 10x¶s each hour j j and extension of PIP joint 8 reps of full passive flexion and extension of DIP joint 8 reps of passive flexion and extension of in a composite manner to MCP. PIP and DIP joints Do passive motions to the uninvolved digits to prevent stiffness Remove velcro straps for the above exercises on hourly basis .

Duran j 3-6 Weeks j DBS removed j Pt¶s hand is maintained j 4 ½ Weeks j Continue with 1-4 ½ week in a wrist band with rubber band traction (full active extension of IP and MCP joints against rubber band with wrist in neutral j Active digital flexion is still not permitted exercises j 10 reps of active flexion of wrist with digits flexed followed by extension of wrist and digits j 10 reps of composite active flexion and extension MCP.Kleinert vs. PIP and DIP joints (bend/straighten) j Exercises are performed once every hour throughout the day with DBS worn b/w exercises and at night .

Kleinert vs. followed with active extension of wrist and digits ± 12 reps of composite active digital flexion and extension ± 12 reps of blocking exercises for PIP joint (5 sec hold) ± 12 reps of blocking exercises for DIP joint (5 sec hold) . Duran j Change of protocol at 6 weeks j 5 ½ Weeks j DBS no longer used tx plan changes: ± 12 reps of active flexion of wrist with digits flexed.

Kleinert vs. Duran
j 6 Weeks j Wrist band removed j 6 Weeks j Revisions:
± Passive extension of wrist and digits is allowed ± Splinting: full extension gutter or extension resting pan may be initiated ± Active and passive range of motion exercises and blocking exercises are permitted on an hourly basis

and active flexion can commence and tendon gliding exercises or blocking

Kleinert vs. Duran
j 8-10 Weeks ± Progressive strengthening is initiated starting with mild resistive exercises followed by sustained grip j 8 Weeks ± Progressive strength building may be initiated

j 3 Months ± Heavy resistive exercises and return to heavy labor activities

j 10 Weeks ± Aggressive use of hand with sports or heavy lifting is allowed

Early Active Mobilization
j Key Points
± Actively mobilize the tendon within first 24 hrs to 3 days post-op ± Only appropriate if both therapist and surgeon possess skill and experience in tendon management, communicate closely with one another and suture utilized is adequate in strength. ± Indicated for physically and cognitively competent patients ± Most aggressive approach

j Active contraction of the injured

flexor muscle within strict precautions

± Pulling the tendon proximally should produce better glide

5-10 degrees at DIP. . and active flexion to 30 degrees at PIP. full active extension. 50-60 degrees at DIP. 4th week= 80-90 degrees active flexion at PIP.Early Active Mobilization j Early Stage: 0-4 or 6 weeks ± Postoperative cast ‡ ‡ ‡ ‡ ‡ Wrist in 20 degrees flexion MP joints at 89-90 degree of flexion IP joints in full extension Extends 2 cm beyond fingertips to prevent use of hand Radial plaster wing wraps proximal to the thumb around wrist to prevent migration distally ± Exercises ‡ Zone 2 initiated 48 hrs post surgery ‡ Zone 3 initiated 24hrs post surgery ‡ Full passive flexion. active flexion and active extension ± All digits 2 repetitions every 4 hours Goal 1st week= full passive flexion.

(full fist within first 2 weeks of repair) ‡ 3 weeks post discontinuation of splints is when flexion contractures are addressed with finger based dynamic extension splints ± Exercise ‡ Protective passive IP extension w/ MCP in flexion ‡ 6 weeks. heavier hand use at 8 weeks and 12 weeks full function .tendon gliding.Early Active Mobilization j Intermediate Stage: 4-6 weeks ± Splint ‡ Discontinued at 4 weeks if tendon glide is poor ‡ Discontinued 5 weeks for most patients ‡ Discontinued 6 weeks for patients with unusually good tendon gliding.

Active-hold/place-hold mobilization j By Strickland/Cannon ± ³active-hold´ ± ³passive-place active mobilization´ ‡ Digits are passively placed in flexion and patient attempts to maintain flexion for gentle muscle contraction .

Active-hold. Full digit flexion and IP extension are allowed with MP extension limited to 60 degrees. ‡ Utilized for distal FPL repairs (zone T1) allowing IP extension to only 25 degrees to prevent deformation and problems with glide deep to the A2 pulley ± Exercise ‡ Hourly 15 repetitions of PROM to PIP and DIP joints and the entire digit in DBS ‡ 25 repetitions of place ±hold digit flexion in the tenodesis splint . Passive-place j 0-4 weeks ± 2 splints are utilized ‡ Dorsal blocking splint w/20 degrees of flexion & MP joints at 50 degrees ‡ Exercise splint with hinged wrist. allowing full wrist flexion with extension limited to 30 degrees.

Passive-place j Intermediate Stage (4 weeks to 7-8 weeks) ± Discontinue tenodesis splint. DBS worn except for tenodesis exercises ± Exercises ‡ Tenodesis exercises 25x every 2 hrs ‡ Active flexion and extension 25 repetitions avoiding simultaneous wrist and digit extension ‡ Week 5 or 6.blocking and hook fist added .Active-hold.

Active-hold.gradually no restrictions at 14 weeks ‡ FPL is moved more aggressively with theraputty (7 weeks) . Passive-place j Late Stage (starting at 7 or 8 weeks) ± Splint discontinued ± Exercise ‡ PRE¶s. ‡ ADL¶s.

Tenolysis j Surgical procedure to excise adhesions that limit flexor tendon glide j Original diagnosis ± ± ± ± ± ± Repair Graft Incomplete laceration Crush Fractures Healed infections j Indications ± Unable to achieve full gliding limiting range of motion ± Progress plateaus ± Flexor tendon intact ± Passive flexion markedly exceeds active flexion ± Restriction of passive motion into extension ± Limitation of active motion relative to age. and individual desires of patient . occupational needs.

± Controlled stress to ensure that new adhesions are long & elastic to allow tendon glide ± Initiate therapy within 12 hours ± Tendon rupture is still a risk .p.Tenolysis j After surgery ± New adhesions will form ± Begin active motion a.a.s.

Tenolysis Rehabilitation j Daily treatment for first 7-10 days j Post-Op eval ± Wound assessment ± Pain ± Edema ± AROM ± PROM.caution! Tendon is weak and vulnerable to rupture ± Sensory testing j Edema Control ± Elevation ± Gentle coban wrap ± CPM with hourly active exercise j Pain Control ± TENS ± Medication j Splinting ± If patient had good extension but limited flexion pre-op ‡ Dorsal resting splint for 2 weeks with wrist at 30 degrees of flexion and MP. IP joints in balance flexion ± If transverse carpal ligament was released wrist in 10-20 degrees of extension for the first 2-3 weeks .

Tenolysis Rehabilitation j Phase I (week 1) ± Achieve/maintain A/PROM achieved in surgery ± Decrease pain ± Control edema j Phase II (week 2-3) ± Facilitate wound healing ± Promote scar mobility ± Maintain AROM ± Continue edema control ± Encourage functional hand use of involved hand in light ADL¶s .

Tenolysis Rehabilitation j Phase III (Weeks 4-6) ± AROM equivalent or greater than achieved in surgery ± Increased hand strength ± Eliminate residual edema j Phase IV (weeks 7 onward) ± Return to work (8-12 wks post-op) ± Work hardening ± Job simulation ± Maximize strength .

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St. D. 2002 from the World Wide Web. (2001) Interactive Hand. 2002 from the World Wide Web. http://www. Part I. Wrist & Hand Injuries: Surgical and Therapeutic Management Hunter. P. Mackin & Callahan (2002). (Sept 17-18. J. Mosby. (1985) Flexor Tendon Gliding in The Hand. Rehabilitation of the Hand and Upper Extremity. D. Fourth Edidtion. Primal Pictures Roholt. South Orange. 10A. D.A.. R. S. No. 2002) Flexor Tendon Injuries presentation for Seton Hall University School of Graduate Medical Education: Advanced Hand Seminar Skolnik.M. McGrouther. (October 25-26 2002) course. (1997) Flexor Tendon Lacerations in the Hand retrieved November 30. Inc. In vivo excursions. Elbow.M.References j j j j j j j j j j j j Hand Rehabilitation Foundation (March 18-21 2006) Surgery and Rehabilitation of the Hand Conference Concurrent Sessions: Flexor Tendon Management Hospital for Special Surgery Rehabilitation Department.htm Wehebe¶. Seton Hall University: School of Graduate Medical Education.. NJ The Hand Rehabilitation Center of Indiana (2001). Diagnosis and Treatment Manual for Physicians and Therapist: Upper Extremity Rehabilitation.. J. Orthoteers. M. 4.M.html Schneider. http://orthoteers. & Hunter. (December 4. 2005) An Introduction to Hand Therapy course. Colditz. MO. J. (Fall Semester 2002) Advanced Hand Seminar.R.co. Louis. .C. Sethi.upenn.& Harris. The Journal of Hand Surgery..uk/Nrujp~ij33lm/Orthhandtendoninj. 570-579.uphs.K.edu/ortho/oj/1997/oj10sp97p5. Flexor Tendon Injuries of the Hand retrieved Novermber 30. (2001) Clinical Specialty Education: Hands on Tendon Trauma course: Flexor & Extensor Tendon Injuries Steinberg.

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