Brigham &amp Women's Hospital - Elbow &amp Hand Rehabilitation PT Protocols

Department of Rehabilitation Services
Physical Therapy
Distal Bicep Tendon Repair- Rehabilitation Protocol

The intent of this protocol is to provide the clinician with a guideline of the post-
operative rehabilitation course for a patient that has undergone a distal biceps tendon
repair. 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.
Initial Post operative Immobilization

• Posterior splint, elbow immobilization at 90° for 5-7 days with forearm in neutral
(Unless otherwise indicated by surgeon)
Hinged Elbow Brace

• Elbow placed in a hinged ROM brace at 5-7 days postoperative. Brace set
unlocked at 45° to full flexion.
• Gradually increase elbow ROM in brace (see below)
Hinged Brace Range of Motion Progression
(ROM progression may be adjusted base on Surgeon’s assessment of the surgical

repair.)
Week 2 45° to full elbow flexion

Week 8 Full ROM of elbow; discontinue brace if adequate motor control
Range of Motion Exercises (to above brace specifications)
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.
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 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
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.
• Progress shoulder strengthening program

o Weeks 12-14: May initiate light upper extremity weight training.
o Non-athletes initiate endurance program that simulates desired work
activities/requirements.
Formatted by Ethan Jerome, PT 04/06

rights reserved.
2
Physical Therapy
Distal Bicep Tendon Repair- Accelerated Rehabilitation

Protocol
operative rehabilitation course for a patient that has undergone a distal biceps tendon
repair. 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.
Initial Immobilization
• Posterior splint, elbow immobilization at 90° for 5-7 days with forearm in neutral
(Unless otherwise indicated by surgeon.)
Hinged Elbow Brace

• Elbow placed in a hinged ROM brace at 7 days postoperative. Brace unlocked at
30° degrees to full flexion.
• Gradually increase elbow ROM in brace (see below)
Brace Range of Motion Progression
(ROM progression may be adjusted base on Surgeon’s assessment of the surgical

repair.)
Week 3 Full extension to full flexion

Week 6 Discontinue brace if adequate motor control
Range of Motion Exercises
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
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.
• Progress shoulder strengthening program

o Weeks 12-14: May initiate light upper extremity weight training.
o Non-athletes initiate endurance program that simulates desired work
activities/requirements.
3 Months Post-op: Activity as tolerated is permitted.

6 Months Post-op: Full activity without restriction is allowed.

rights reserved.
2
Physical Therapy
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.
ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION

USING AUTOGENOUS GRAFT PROTOCOL:
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.
Phase I – Immediate Post Surgical Phase (Day 1-21):
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
ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING

AUTOGENOUS GRAFT PROTOCOL
1
• Sub-maximal shoulder isometrics (**no shoulder ER
isometrics to avoid force on repaired UCL)
• Sub-maximal pain-free biceps isometrics in neutral elbow
ROM
• Cryotherapy
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:
II. Intermediate Phase (Weeks 4-8):
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

2
• Progress shoulder isometrics to isotonics, emphasize rotator
cuff strengthening (Avoid resisted external rotation until 6th
week to minimize forces on repaired UCL)
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
III. Advanced Strengthening Phase (Weeks 9-13):
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:
• Begin light sport/functional activities (i.e., golf, swimming, light
lifting, reaching) if appropriate
IV. Return to Activity Phase (Weeks 14-26):
Goals:
• Continue to increase strength, power, and endurance of upper
extremity musculature.
• Gradual return to sport/functional/occupational activities

3
Week 14
Exercises:
• Athletes initiate interval throwing program (phase 1)
• Non-athletes initiate endurance program that simulates desired
work activities/requirements
• Continue strengthening program (shoulder, elbow, wrist, hand)
• Emphasis on overall UE flexibility program to maximize
ROM/muscle length
Weeks 22-26 (Time Frame may be adjusted based on Surgeon’s assessment

of surgical repair.)
Activities:
• Return to competitive throwing
• Return to full work capacity (lifting, pulling, reaching, pushing)

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BRIGHAM AND WOMEN’S HOSPITAL
A Teaching Affiliate of Harvard Medical School
75 Francis St. Boston, Massachusetts 02115

Physical Therapy
PRIMARY EXTENSOR TENDON REPAIR PROTOCOL

(EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU)
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 an extensor tendon repair.
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 exam findings,
individual progress, and/or 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.
ZONE I: Over the distal phalangeal joint (DIP)-Mallet deformity

ZONE II: Over the middle phalanx
WEEK SPLINT THER EX PRECAUTIONS OTHER
1-6 DIP at 0-15 A-AAROM of Daily skin checks If swan-neck
hyperextension MP and PIP. while maintaining deformity develops,
(HE). Splint worn DIP in HE 10-15. splint PIP at 30-45
continuously. flexion via dorsal
No active DIP block splint.
Provide 2 splints, 1 motion.
for showering. Casting is an option,
and may have better
outcomes via
constant
circumferential
positioning.
6-8 Remove splint for AROM of DIP flex/ext, If extensor lag
weeks exercise, otherwise 10 reps hourly. develops > 10
splint is worn degrees, resume
continuously. Start at 10 degrees continuous
flexion, progress in 10-20 splinting (no ROM)
degree increments per for 1- 2 weeks and
week, if no extensor lag reassess.
develops.
>8 weeks Gradually wean Can introduce AAROM Prehension and
from splint during as needed. coordination exercise
day.Continue splint should supplement
at night. ROM program.
10-12 D/C splint PROM/PREs
weeks
1
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of
Rehabilitation Services. All rights reserved.
ZONE III: Over the proximal interphalangeal joint (PIP)-Boutonniere deformity
ZONE IV: Over the proximal phalanx *
IMMOBILIZATION PROTOCOL
1-6 weeks Volar digit static ROM may be No forceful Serial cast may be
splint, PIP at initiated anytime flexion. chosen if there is a
absolute 0 during week 3 to 6, PIP joint flexion
degrees, or serial depending upon No gripping. contracture, if there
cast healing. is a closed injury,
Splint remains or if the patient is
Initiate AROM PIP on continuously unable to adhere to
Lateral bands flex to 30 degrees. If between ROM splinting program.
Repaired: include no extensor lag sessions.
DIP at 0 degrees. develops, progress in Timing of initiating
10-20 degree AROM is
If the lateral increments each determined based
bands are not week. 10 repetitions on severity of
repaired the DIP hourly. laceration, strength
is left free. of repair, and
If lateral bands are patient profile.
repaired, begin
gliding at week 3,
and at week 1 if
lateral bands not
injured.
6-8 weeks Gradually wean AAROM or dynamic Light function
from splint during flexion splinting may out of splint.**
day. be initiated, as well
as combined flexion
Continue splint at of the wrist and
night. digits.
10-12 weeks D/C splint PROM/PREs
* Because of the broad tendon-bone interface in zone IV and resultant scar adhesions,
you may want to consider the short arc motion protocol. See next page.
** Light functional activities are manipulating activities no greater than 1-3 lbs. (i.e.
turning pages, eating, folding light laundry, tying a shoe, buttoning, typing)
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ZONE III – IV: Over the PIP joint to proximal phalanx
SHORT ARC MOTION (SAM) PROTOCOL

Week 1 Digit volar Remove PIP joint Patient is instructed
immobilization splint: immobilization splint must be in technique of controlled
PIP and DIP at 0 hourly for 10-20 reps positione motion
degrees. of AROM PIP and d at 0 with minimal active
Splint worn at all times DIP motion in both degrees tension.
except during template 1 & 2 in
exercise. splints. immobili
zation
Two volar static Wrist is held in 30 splint to
exercise splints: flexion, MP at 0. prevent
template 1 If lateral bands are extensor
PIP 30 flex, DIP 20 flex repaired, limit DIP lag.
flexion to 30-35 in
template 2 template 2. If not
PIP 0, DIP free injured, fully flex and
extend DIP.
Week 2 If no extensor lag: If an extensor lag If rupture is suspected,
Progress develops, flexion refer patient to MD for
template 1 to increments should be assessment.
PIP 40-50, DIP 30-40 more modest and
exercise should focus
on extension.
Week 3 If no extensor lag:
Progress
template 1 to
PIP 50-60, DIP 40-50
Week 4 If no extensor lag: If PIP is stiff, splint
Progress intermittently into
template 1 to flexion, but continue
PIP 70-80, DIP 50-60 static extension splinting
into week 5 or 6.
Week 5 Begin splint weaning. Composite flexion Initiate light functional
and gentle PREs. activities out of splint.
Week 6 D/C splint. Splint at PROM & PREs,
night only PRN. reverse putty scraping
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ZONE V: over the metacarpalphalangeal joint (MCP).
ZONE VI: over the metacarpal bone (MC).
CONTROLLED PASSIVE MOTION

1-3 days Forearm based AROM flexion: isolated Full fisting May consider
post-op dynamic digital joint and tendon gliding may option of total
through extension splint (hook and straight fist). place too much immobilization if
week 3 Wrist 25-30 Passive extension via stress on the necessary.
degrees ext, MP at elastic recoil of the repair. Assess
0, PIPs free dynamic splint. on a case-by-
10-20 reps hourly. case basis.
Fabricate static
forearm based Begin active MP flexion
Splint at night, to 30-40 degrees (via
wrist at 30-40 ext, flexion block on dynamic
MPs at 0, PIPs splint).
free. Progress MP flexion as
tolerated.
Perform wrist and digit
PROM in extension and
tenodesis out of splint 10
repetitions hourly.
Come out of splint Progress MP flexion to No resistance Volar static digital
4-6 for exercise 40-60 (week 4), 70-80 until 6-8 weeks IP extension splints
weeks (week 5). can be made to
Initiate full fisting facilitate MP
if not already done. excursion by
Composite wrist and immobilizing IP
finger flexion. joint (splint placed
Active digital extension in slings). Allows
exercises out of splint. greater pull-through
at MP joint.
D/C splint. AAROM, PREs, heat and May initiate
6 weeks stretch, reverse putty NMES, therapeutic
Dynamic flexion scraping heating via
splinting PRN. ultrasound if
needed.
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ZONE VII: at the level of the dorsal retinaculum in the wrist.
EARLY ACTIVE MOTION PROTOCOL
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.
Begin AROM of wrist:

isolated, and combined
with 50% finger flexion.
Week 6 Wrist splint, Combined wrist and Gradually progress to
gradually wean finger flex (full fist) moderate activity out of
to protection the splint.
only AAROM in flexion
Week 8 D/C splint PREs OK for resistive activities
5
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.
*Please refer to the article regarding the yoke splint fabrication.
WEEK SPLINT THER EX PRECAUTION OTHER

S
Phase I: Both wrist and AROM digit motion, Vigor of Edema control
Week 0-3 yoke splint at including full fisting exercise is
all times. monitored to Scar management
prevent
inflammatory Goal: Full AROM digits
response. prior to progressing to
Phase II.
No resistive
activity.
Phase II: Yoke splint at Initiate AROM wrist Goal: Full wrist AROM
Week 4-5 all times. with digits relaxed. prior to removing wrist
splint for light activities.
Yoke and wrist If no extensor lag,
splint during progress to composite
mod-heavy wrist flexion with
activities. fisting & composite
wrist and digits ext.
Phase III: D/C wrist splint Goal: Full composite
Week 6-7 Yoke splint or wrist and digit motion
buddy strap prior to removing yoke
worn during splint for activities and
activity, wean D/C from therapy.
as tolerated.
6
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
THUMB TI: over the IP joint
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
THUMB TII: over the proximal phalanx of the thumb
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
THUMB T III: over the metacarpophalangeal joint (MP)
THUMB T IV: over metacarpal bone
CONTROLLED PASSIVE MOTION PROTOCOL

Week 1 Forearm based splint, Initiate AROM No active Choices for
static or dynamic, flexion in 20 extension. exercise and
thumb MP joint at 0 degree increments splinting are based
(not HE) and slight per week. No gripping or on MD preference,
abduction, wrist at 30 pinching, even strength of repair,
ext. PROM extension in splint. potential for
(either via dynamic scarring, and
If dynamic splint traction, or self- patient.
chosen, also fabricate PROM to static splint
static forearm based limit).
splint at night, wrist at
30 ext, MP at 0
Week Increase AROM
2-4 flexion arc
as tolerated.
Place and hold

extension may be
initiated at 3 weeks.
Week 4 AROM in extension
Week Initiate dynamic flexion Full AROM flexion,
5-6 splinting PRN. isolated and
combined
Week D/C splint PREs
6-8
10
THUMB T V: level of the retinaculum of the wrist
Dynamic As above Dense adhesions

Week 1 extension may limit EPL
splinting as excursions at the
described in retinacular level.
Zones III and Proper wrist and
IV. thumb positioning
are crucial.
Week 3 May initiate
AAROM flexion
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.
Newport M, Tucket R. New Perspectives on Extensor Tendon Repair and Implications

for Rehabilitation. Journal of Hand Therapy. April/June 2005;175-181.
Howell J, Merrit W, Robinson S. Immediate Controlled Active Motion Following Zone

4-7 Extensor Tendon Repair. Journal of Hand Therapy. April/June 2005;182-189.
Authors: Reviewers:
Joanne Bosch, PT Gayle Lang, OT
9/07 Reg Wilcox, PT
Maura Walsh, OT
11
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

Physical Therapy
Zone 1, FDP Flexor Tendon Repair Protocol
Week Splint Therapeutic Exercise Precautions Other

3 weeks Bring wrist to neutral in Add place/hold fisting in all three fist No functional use of
dorsal blocking splint. positions, using minimal tension. hand.
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.
5 weeks Discontinue splint. Light prehensile

activities OK at
May use static progressive home.
splints to regain DIP
extension if needed
6 weeks Gentle passive DIP extension exercises May initiate
if needed NMES, therapeutic
heating via
ultrasound if
needed.
8 weeks Resistive exercise; progress gradually.
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.
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.
Reminders: Severe edema increases tendon drag and likelihood of

rupture.
Therefore, wait until 48-72 hours post-op prior to initiating ROM.
Tensile strength of tendons decreases from days 5 to 15.
Place/hold digital flexion with wrist extended in hook, straight and

full fist positions.
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07)

Physical Therapy Zones 2-5 Flexor tendon repair Protocol
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.
Avoid muscle co-

contraction by patient
during place hold
exercises.
Week 4 Convert splint to hand based Initiate active, non-resistive digital flexion Light prehensile
dorsal block splint. and extension in all three fist positions activities OK in
with wrist extended. therapy.
Week 5 Discharge splint. Add gentle blocking exercises for DIP/PIP Light prehensile
flexion if needed. activities OK at
home.
Week 6 May initiate dynamic PIP May initiate NMES,
extension splinting if therapeutic heating
needed. via ultrasound if
needed.
Week 8 Gradually add resistive exercise to home Functional use of
program. hand, but consider
strength, motion and
sensory demands of
task.
Reminder: Zone 5 injuries: Need to pay special attention to differential digit tendon glide (differentiating FDS and FDP
tendons from one finger to another at the wrist level.)
Copyright © 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07)
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)
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.
Tendon tensile strength decreases from

days 5 to 15 post-op.
Place/hold thumb flexion with wrist

extended.

Physical Therapy
Flexor Pollicis Longus (FPL) Repair Protocol (all zones)
3 weeks Continue with all previous exercises. Continue
with all
Under therapist supervision in clinic: previous
precautions.
Add place/hold for thumb flexion with
wrist passive extended (if not already Avoid co-
done via EAM). Gentle muscle contraction
contraction only. during
place/hold
exercises
4 weeks Convert splint to hand-based. Initiate active, non-resistive thumb flexion Light prehensile
with wrist extended. activities OK in
therapy.
5 weeks Discontinue splint Add gentle blocking exercises for thumb Light prehensile
IP flexion. activities OK at home.
6 weeks May initiate dynamic IP May add putty scraping if needed.

extension splinting if needed. May initiate NMES,
therapeutic heating via
ultrasound if needed
8 weeks Gradually add resistive exercise to home Gradually allow

program. resistive use of
involved thumb in
ADLs.

Brigham &amp Women's Hospital - Elbow &amp Hand Rehabilitation PT Protocols

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Brigham &amp Women's Hospital - Elbow &amp Hand Rehabilitation PT Protocols

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Department of Rehabilitation Services

Distal Bicep Tendon Repair- Rehabilitation Protocol

Initial Post operative Immobilization

Hinged Elbow Brace

Hinged Brace Range of Motion Progression

(ROM progression may be adjusted base on Surgeon’s assessment of the surgical

Week 2 45° to full elbow flexion

Range of Motion Exercises (to above brace specifications)

Distal Biceps Tendon Repair – Accelerated Rehabilitation Protocol

• Progress shoulder strengthening program

Formatted by Ethan Jerome, PT 04/06

Distal Biceps Tendon Repair – Accelerated Rehabilitation Protocol

Distal Bicep Tendon Repair- Accelerated Rehabilitation

Hinged Elbow Brace

Brace Range of Motion Progression

(ROM progression may be adjusted base on Surgeon’s assessment of the surgical

Week 3 Full extension to full flexion

Range of Motion Exercises

• Progress shoulder strengthening program

3 Months Post-op: Activity as tolerated is permitted.

Formatted by Ethan Jerome, PT 04/06

Distal Biceps Tendon Repair – Accelerated Rehabilitation Protocol

ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION

Phase I – Immediate Post Surgical Phase (Day 1-21):

ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING

II. Intermediate Phase (Weeks 4-8):

ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING

III. Advanced Strengthening Phase (Weeks 9-13):

IV. Return to Activity Phase (Weeks 14-26):

ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING

Weeks 22-26 (Time Frame may be adjusted based on Surgeon’s assessment

Formatted by Ethan Jerome, PT 04/06

ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING

Department of Rehabilitation Services

PRIMARY EXTENSOR TENDON REPAIR PROTOCOL

ZONE I: Over the distal phalangeal joint (DIP)-Mallet deformity

SHORT ARC MOTION (SAM) PROTOCOL

CONTROLLED PASSIVE MOTION

Begin AROM of wrist:

*Please refer to the article regarding the yoke splint fabrication.

WEEK SPLINT THER EX PRECAUTION OTHER

CONTROLLED PASSIVE MOTION PROTOCOL

Place and hold

Dynamic As above Dense adhesions

Newport M, Tucket R. New Perspectives on Extensor Tendon Repair and Implications

Howell J, Merrit W, Robinson S. Immediate Controlled Active Motion Following Zone

Department of Rehabilitation Services

Week Splint Therapeutic Exercise Precautions Other

5 weeks Discontinue splint. Light prehensile

8 weeks Resistive exercise; progress gradually.

Reminders: Severe edema increases tendon drag and likelihood of

Tensile strength of tendons decreases from days 5 to 15.

Place/hold digital flexion with wrist extended in hook, straight and

Department of Rehabilitation Services

Timeline Splint Therapeutic Exercise Precautions Other

Avoid muscle co-

Tendon tensile strength decreases from

Place/hold thumb flexion with wrist

Department of Rehabilitation Services

6 weeks May initiate dynamic IP May add putty scraping if needed.

8 weeks Gradually add resistive exercise to home Gradually allow

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