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Physical Therapy
Weeks 2-3
• Passive ROM for elbow flexion and supination (with elbow at 90°)
• Assisted ROM for elbow extension and pronation (with elbow at 90°)
• Shoulder ROM as needed based on evaluation, avoiding excessive extension.
Week 4
• Active ROM elbow flexion and extension
Weeks 6-8
• Continue program as above
• May begin combined/composite motions (i.e. extension with pronation).
• If at 8 weeks post-op the patient has significant ROM deficits therapist may
consider more aggressive management, after consultation with referring
surgeon, to regain ROM.
Strengthening Program
Week 1 Sub-maximal pain free isometrics for triceps and shoulder musculature.
Week 2 Sub-maximal pain free biceps isometrics with forearm in neutral.
Week 3-4 Single plane active ROM elbow flexion, extension, supination, and
pronation.
Week 8 Progressive resisted exercise program is initiated for elbow flexion,
extension, supination, and pronation.
Initial Immobilization
• Posterior splint, elbow immobilization at 90° for 5-7 days with forearm in neutral
(Unless otherwise indicated by surgeon.)
Weeks 2-3
• Passive ROM for elbow flexion and supination (with elbow at 90°)
• Assisted ROM for elbow extension and pronation (with elbow at 90°)
• Shoulder ROM as needed based on evaluation, avoiding excessive extension.
Weeks 3-4
• Initiate active-assisted ROM elbow flexion
• Continue assisted extension and progress to passive extension ROM
Week 4
• Active ROM elbow flexion and extension
Distal Biceps Tendon Repair – Accelerated Rehabilitation Protocol
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All
rights reserved.
1
Weeks 6-8
• Continue progression as above
• May begin combined/composite motions (i.e. extension with pronation).
• If at 8 weeks post-op the patient has significant ROM deficits therapist may
consider more aggressive management, after consultation with referring
surgeon, to regain ROM.
Strengthening Program
Week 1 Sub-maximal pain free isometrics for triceps and shoulder musculature.
Week 2 Sub-maximal pain free biceps isometrics with forearm in neutral.
Week 3-4 Single plane active ROM elbow flexion, extension, supination, and
pronation.
Week 6 Progressive resisted exercise program is initiated for elbow flexion,
extension, supination, and pronation.
This protocol has been adopted from Brotzman & Wilk, which has been published in
Brotzman SB, Wilk KE, Clinical Orthopeadic Rehabilitation. Philadelphia, PA: Mosby
Inc; 2003:315-319. The Department of Rehabilitation Services at Brigham & Women’s
Hospital has accepted a modification of this protocol as our standard protocol for the
management of patients s/p ulnar collateral ligament reconstruction.
The intent of this protocol is to provide the clinician with a guideline of the post-
operative rehabilitation course of a patient that has undergone an ulnar collateral ligament
reconstruction without concomitant fracture. It is by no means intended to be a
substitute for one’s clinical decision making regarding the progression of a patient’s post-
operative course based on their physical exam/findings, individual progress, and/or the
presence of post-operative complications. If a clinician requires assistance in the
progression of a post-operative patient they should consult with the referring Surgeon.
Progression to the next phase based on Clinical Criteria and/or Time Frames as
Appropriate.
Goals:
• Protect healing tissue
• Decrease pain/inflammation
• Retard muscular atrophy
• Promote scar mobility
Week 1:
• Posterior splint (applied in the operating room) at 90 degrees
elbow flexion with forearm in neutral
• Range of Motion – Wrist active range of motion (AROM)
ext/flexion
• Elbow compression dressing: Apply 2-3 days after surgery
Exercises:
• Gripping exercises (AROM)
• Wrist AROM/PROM
Week 2:
• Brace – Application of hinged elbow brace set at 30-100 degrees
of open motion
Exercises:
• Initiate sub-maximal and pain free wrist isometrics
• Initiate sub-maximal and pain free elbow flexion/extension
isometrics
• Continue all exercises listed above
Edema/scar management:
• Scar massage/scar pads as needed
• Manage edema with light compression as needed
Week 3:
• Brace – Advance hinged elbow brace 15-110 degrees
(Gradually increase ROM 5 degrees extension/10 degrees
flexion per week)
Exercises:
• Continue all exercises listed above
Goals:
• Gradual increase in range of motion
• Promote healing of repaired tissue
• Regain and improve muscular strength
Week 4
• Brace – hinged elbow brace set 10-120 degrees
Exercises:
• Wrist curls, extensions, pronation, supination with light weight
(1-2#)
• Elbow extension/flexion AAROM/AROM
Week 6
• Brace – hinged elbow brace set 0-130 degrees.
• Brace may be discontinued at the end of week 6
Exercises:
• AROM 0-145 degrees without brace
• Progress elbow strengthening exercises as appropriate
• Initiate shoulder external rotation strengthening
• Progress shoulder program
Goals:
• Increase strength, power, and endurance
• Maintain full elbow ROM
• Gradually initiate sporting/functional/occupational activities
Week 9
Exercises:
• Initiate eccentric elbow flexion/extension
• Continue isotonic program; forearm & wrist
• Continue shoulder program (Throwers Ten Program if
appropriate)
• Manual resistance diagonal patterns
• Initiate plyometric exercise program if appropriate
Week 11
Exercises:
• Continue all exercises listed above
• Begin light sport/functional activities (i.e., golf, swimming, light
lifting, reaching) if appropriate
Goals:
• Continue to increase strength, power, and endurance of upper
extremity musculature.
• Gradual return to sport/functional/occupational activities
2
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
ZONE III – IV: Over the PIP joint to proximal phalanx
3
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
ZONE V: over the metacarpalphalangeal joint (MCP).
ZONE VI: over the metacarpal bone (MC).
4
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
ZONE VII: at the level of the dorsal retinaculum in the wrist.
EARLY ACTIVE MOTION PROTOCOL
WEEK SPLINT THER EX PRECAUTIONS OTHER
1-3 days Static or If EDC is repaired, No active *Choice of static vs.
post-op dynamic tenodesis from 40 ext to wrist dynamic splint is a
*
through splint : 10 ext. extension or clinical decision based on
week 3 Wrist 30 ext If wrist extensors are resistive severity of injury,
MPs at 0 repaired, tenodesis from activity with strength of repair,
40 ext to 20 ext. the hand. concomitant injuries and
If dynamic patient profile.
splint chosen, In both cases, allow See SOC for discussion
also fabricate active MP flexion to 30- on number of suture
static forearm 40 degrees of flexion strands and strength
based (via flexion block on (usually between 2 and
splint at night, splint) while the wrist is 4); issues are strength vs.
wrist at 30 ext, held in extension. bulk. Communication
MPs at 0, PIPs with MD is necessary to
free. If EDC is repaired, hook determine Rx plan.
fisting only.
If just wrist extensors
repaired, hook, full and
straight fisting
.
All exercises are 10
repetitions hourly.
Weeks 4-5 Progress MP flexion to Can begin light function
40-60 (week 4), 70-80 in the splint.
(week 5).
Can modify wrist to
neutral in night splint.
5
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
IMMEDIATE CONTROLLED ACTIVE MOTION (ICAM) PROTOCOL
ZONE IV – VII EXTENSOR TENDON REPAIR
This protocol has been modified from Howell JW. Merritt WH. Robinson SJ. Immediate
Controlled Active Motion Following Zone 4-7 Extensor Tendon Repair. J Hand Ther.
2005;18:182-190. April/June of 2005.
Splint Design
2 Components
1. Wrist splint 20-25 degrees of wrist extension
2. Yoke splint* with involved MP joint in 15-20 degrees of more extension
relative to the MP joints of the non-injured digits.
The yoke splint acts as a “dynamic assist” during finger extension to take
tension off the repair site.
6
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
ZONE VIII and MUSCLE BELLY REPAIR: below the level of the level of the
retinaculum to the musculotendinous juncture.
Protocol is similar to Zone V-VII. Rehab can progress sooner: AROM at 3 weeks,
AAROM at 4 weeks, PROM at 5 weeks, PREs at 6weeks. Splint according to anatomy
(i.e. what structures repaired) with static volar splint.
7
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
THUMB TI: over the IP joint
IMMOBILIZATION PROTOCOL
WEEK SPLINT THER EX PREC OTHER
1-3 days Splint IP joint at 0 None at this time No flexion of Issue 2nd splint for
post-op or slight IP joint. showers. May
through hyperextension also use
week 3 Remove splint McConnell tape to
Non-operative: daily for skin hold digit in place
8 weeks checks. during splint
continuously changes.
Operative: No gripping or
5-6 weeks pinching, even
continuously in splint.
5-6 weeks May remove Operative: AROM IP
splint for exercise, flexion in 20 degree
otherwise increments per week,
continue splint at modifying progression
all times for 2-4 if extensor lag develops.
more weeks. 10 repetitions/ hourly.
Non-operative: No
ROM at this time.
Gradually wean Operative: May start
8weeks from splint during AAROM if needed,
day. provided no extensor
lag.
Continue splint at
night. Non-operative: Initiate
AROM IP flexion in 20
degree increments
Operative: PROM and
10-12 weeks D/C splint PREs (light gripping
and pinching)
Non-operative:
AAROM, progress to
PROM, PREs as
tolerated
8
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
THUMB TII: over the proximal phalanx of the thumb
IMMOBILIZATION PROTOCOL
WEEK SPLINT THER EX PRECAUTIONS OTHER
Week 1 Hand based No active
static splint motion at this
(short time.
opponens) MP
and IP at 0
degrees, thumb
in radial
abduction.
Week 3 Initiate AROM The problems
flexion at each of tendon-to-
joint; progress bone adherence
in 25-30 degree may become an
increments each issue in this
week. zone.
Week 4 -5 AAROM Light
flexion, isolated prehension
and combined ADL out of
joint splint
Week 6 Begin to wean Moderate
from splint. prehension
ADL out of
Dynamic splint
flexion
splinting PRN.
Week 8 D/C splint PREs Full function
9
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
THUMB T III: over the metacarpophalangeal joint (MP)
THUMB T IV: over metacarpal bone
10
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
THUMB T V: level of the retinaculum of the wrist
REFERENCES
Evans, R. Clinical management of extensor tendon injuries. In: Hunter JM, Macklin
EJ,Callahan AD,Skirven TM,Schneider LH,Osterman AL, eds. Rehabilitation of the hand
and upper extremity St. Louis, Missouri; 2002:542-579.
Authors: Reviewers:
Joanne Bosch, PT Gayle Lang, OT
9/07 Reg Wilcox, PT
Maura Walsh, OT
11
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL
(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
The intent of this protocol is to provide the clinician with a guideline for the post-operative
BRIGHAM AND WOMEN’S HOSPITAL rehabilitation course of a patient that has undergone a flexor tendon repair. It is by no means
A Teaching Affiliate of Harvard Medical School intended to be a substitute for one’s clinical decision-making regarding the progression of a
75 Francis St. Boston, Massachusetts 02115 patient’s post-operative course based on their exam findings, individual progress, and/or presence
of post-operative complications. If a clinician requires assistance in the progression of a post-
Department of Rehabilitation Services operative patient, they should consult with the referring surgeon.
Physical Therapy
Zone 1, FDP Flexor Tendon Repair Protocol
Week Splint Therapeutic Exercise Precautions Other
0-3 weeks Forearm based dorsal block splint Home exercise program: No active DIP
with wrist at 30 degrees of flexion, 1. Passive DIP flexion to 75 degrees flexion of involved
MP’s at 30 degrees of flexion and 2. Passive composite digit flexion digits.
IP’s fully extended. 3. Passive modified hook fist (MP’s
extended only to 30 degrees). No active wrist
Separate finger splint of repaired 4. Block MP in full flexion and actively flexion.
digits holding DIP in 45 degrees of extend PIP, keeping repaired digit in DIP
flexion (taped onto finger splint. No passive finger
proximal to DIP crease). 5. Use distal strap to hold unaffected digits extension, except as
in extension against splint. Place/hold noted above.
This positions the FDP tendon repaired finger in PIP flexion (tp glide
repair proximal to the skin FDS only).
incision, and counteracts the effect 6. Passive (or gravity assisted) wrist
of the oblique retinacular ligament. flexion, followed by active wrist
extension to limits of splint. .
Note: Splint is the same, with or
without a suture button (tendon Therapist performs with patient in clinic:
repaired to tendon or repaired to 1. Passive wrist extension with fingers
bone). flexed (splinted removed)
2. Passive wrist flexion with passive hook
fisting to prevent intrinsic tightness
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 1
BRIGHAM AND WOMEN’S HOSPITAL
A Teaching Affiliate of Harvard Medical School
75 Francis St. Boston, Massachusetts 02115
Discard DIP flexion splint. Continue with all previous exercises. No resistive exercise.
(Patient may perform all exercises at
home).
weeks Convert splint to hand based Active tendon gliding in all three fist Ensure smooth Light prehensile
dorsal block splint. positions. gliding tendons, activities OK in
minimal tension therapy.
Gentle DIP flexion blocking exercises during ROM.
for FDP gliding.
Avoid resistance until
weeks 7-8.
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 2
The intent of this protocol is to provide the clinician with a guideline for the post-operative
rehabilitation course of a patient that has undergone a flexor tendon repair. It is by no means
BRIGHAM AND WOMEN’S HOSPITAL intended to be a substitute for one’s clinical decision-making regarding the progression of a
A Teaching Affiliate of Harvard Medical School patient’s post-operative course based on their exam findings, individual progress, and/or presence
75 Francis St. Boston, Massachusetts 02115 of post-operative complications. If a clinician requires assistance in the progression of a post-
operative patient, they should consult with the referring surgeon.
Department of Rehabilitation Services
Physical Therapy Zones 2-5 Flexor tendon repair Protocol
Timeline Splint Therapeutic Exercise Precautions Other
Week Dorsal Blocking Home exercise program: No active Wound
0-3 Splint 1. Passive composite full fist flexion of care
a. Wrist 2. Passive DIP extension maintaining MCP and PIP in flexion involved digits
neutral 3. Block MCP in full flexion and actively extend IP’s unless cleared Edema
b. MCP’s 50° 4. Passive DIP flexion and active extension for early active control
flexion 5. Passive PIP flexion and active extension motion (EAM).
c. IP’s in full 6. Isolated FDS glide of unaffected fingers Scar
extension 7. Passive (or gravity assisted) wrist flexion, followed by active No passive massage
extension to splint limits. wrist extension.
Reminder: If FDP Note: If
of MF, RF, or SF Therapist performs with patient in clinic: No passive pulley
repaired, must 1. Remove splint: passive wrist extension with fingers flexed. finger was
include all three 2. Passive wrist flexion with passive hook fisting to prevent extension, repaired,
digits in splint. intrinsic tightness except as noted may need
above. pulley
Early Active Motion Protocol: ring
No functional fabricated.
*If cleared by MD and suture of adequate strength (four strand core use of involved
repair with epitendinous suture augmentation). hand.
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07)
BRIGHAM AND WOMEN’S HOSPITAL
A Teaching Affiliate of Harvard Medical School
75 Francis St. Boston, Massachusetts 02115
Week 3 May initiate serial static PIP Add place/hold if not yet done via EAM. Same as week 1-3
extension splints at night if 1. Place/hold for hook, full and straight fist
needed. with wrist extended. Place/hold exercises
2. Place hold for isolated FDS glide of should be done with
involved digits. gentle tension only.
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07)
The intent of this protocol is to provide the clinician with a guideline for the post-operative
BRIGHAM AND WOMEN’S HOSPITAL rehabilitation course of a patient that has undergone a FPL Repair. It is by no means intended
A Teaching Affiliate of Harvard Medical School to be a substitute for one’s clinical decision-making regarding the progression of a patient’s
75 Francis St. Boston, Massachusetts 02115 post-operative course based on their exam findings, individual progress, and/or presence of
post-operative complications. If a clinician requires assistance in the progression of a post-
Department of Rehabilitation Services operative patient, they should consult with the referring surgeon.
Physical Therapy
Flexor Pollicis Longus (FPL) Repair Protocol (all zones)
Timeline Splint Therapeutic Exercise Precautions Other
0-3 1. Dorsal Blocking splint Home exercise program: No active Wound care
weeks a. Wrist at neutral 1. Passive composite thumb thumb flexion
b. Thumb CMC flexed flexion/active extension to limits unless cleared Edema control
and abducted under of splint. for early active
second metacarpal 2. Passive IP flexion/active extension motion (EAM). Scar massage
c. Thumb MP in full to limit of splint.
extension. 3. Gravity assisted wrist flexion/ No passive May need pulley ring if
active extension to limit of splint. wrist extension. pulley repair.
Zone I only: 4. Tendon gliding exercises for digits
2-5. No passive
2. Separate dorsal gutter Early Active Motion Protocol: thumb
thumb IP splint blocking IP extension.
in 30 degrees flexion, to be *If cleared by MD and suture of adequate
worn with above splint. strength (four strand core repair with No functional
epitendinous suture augmentation). use of the
involved hand.
Reminders: Severe edema increases
tendon drag and likelihood of rupture.
Therefore, wait until 48-72 hours post-op
prior to initiating ROM.
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 1
BRIGHAM AND WOMEN’S HOSPITAL
A Teaching Affiliate of Harvard Medical School
75 Francis St. Boston, Massachusetts 02115
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 2