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
 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
 Facilitate tendon gliding without adherence
to adjacent tissues
 Rehabilitation Goals
 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
 Flexor Tendons

– Flexor digitorum
superficialis

– Flexor digitorum
profundus

– Flexor pollicis longus

 Significant Anatomy
 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
 Tendon Healing
 Phases of Healing
– Inflammatory Days 1-21
• Proliferation or cells on outer edge of tendon which
migrate into the tendon by day 7.
• Increased vascular proliferation in tendon occurs
• Day 9- repair is as strong as the original suturing
and continues to increase.
• Strength increases rapidly when tendon is stressed.
• Collagen synthesis begins and quantity of collagen
stabilizes by 3 weeks
 Tendon Healing
 Fibroplasia Phase Days 22-42
– Tensile strength increases
– Able to withstand AROM at 3-4 weeks

 Scar Maturation Days 43-84

– Collagen synthesis reaches its max after 4
weeks however; stays active.
– Active collagen synthesis allows us to
lengthen, weaken, or break adhesions over
time. We are able to create a more elongated
and better gliding scar.
– 5-6 weeks repair can withstand light resist.
– 7-9 weeks repair can withstand heavy resist
 Tendon Healing
 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- injury to vincula
• Gapping at repair site (poor repair; too much
stress on repair site)
• Double tendon injuries
• Patient Factors ie: age, health, scar formation,
motivation, socioeconomic factors
 Tendon Healing
 Controlled mobilization
programs
– tendons probably heal by a
combination of extrinsic and
intrinsic cellular activity- the more
intrinsic healing that occurs; the
less peritendinous adhesions

– Early Passive Mobilization

– Early Active Mobilization
 Tendon Repairs
 Primary repair within 24 hours
 Delayed primary repair
– Between 24 hours and 3 weeks
– Delayed by MD due to contamination
or loss of skin coverage
 Secondary repair
– More then 3 weeks after injury
• May be extensive scarring and
muscle contracture as well as
retraction of tendon ends, may require
tendon grafting
 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.
Flexor Tendon Suture Techniques
Approaches to Rehabilitation
 Immobilization

 Early passive
mobilization

 Early active
mobilization
Approaches to Rehabilitation
 Considerations in choice of
approach:
– Pt. compliance
– Surgeon preference
– Type of injury
– Location and zone of injury
– Strength of repair
Approaches to Rehabilitation
 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
 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
 Phase III: Late Stage
– Week 6-8
– Repair can withstand
resistance
– Continued scar
maturation
Factors Affecting Healing and
Rehab

 Patient Related Factors

– Age
• Decreased vinicula with ageing
– General health
• Lifestyles and dietary habits can adversely
affect healing.
– Cigarette smoker and coffee drinker= delayed
healing secondary to vasoconstrictive effect.
– Scar Formation rate/quality
– Patient Motivation
– Socioeconomic factors
Factors Affecting Healing and
Rehab
 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, each other and structures
lying within the carpal tunnel
• Zone III
– Tendons may adhere to adjacent tendons, lumbricals, 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
Factors Affecting Healing and
Rehab
 Injury and Surgery-related Factors (cont.)
– Type of Injury
• Crush or blunt injury
• Complete vs. 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
 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
Wound and Scar Care/Edema
Control
 Healing- 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
 Edema Control
– Overhead elevation
– Coban wrap at 1-2 weeks per MD
– Finger sock; 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
Wound and Scar Care/Edema
Control
 Scar care- 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
 Scar care- 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;
tendon ends may pull apart and scar will fill the gap.
– Active exercises
• Fisting
• Blocking
– Scar mobilization at 4-6 weeks
• Extractor
• Deep myofascial release
• Skin friction with active tendon glide
Approaches to Rehabilitation
 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
 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
 Immobilization
 Intermediate Stage- 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
 Late Stage: starting 4-6 weeks
– Splint is discontinued
• If flexor muscle-tendon shortening
becomes a problem- 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- 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
 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
 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
 Tendon Gliding
 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
 Zone 3-5 measure MP extension with wrist flexed
and extended
 Zone 2-3 measure PIP extension with MP flexed
and extended
 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
 Considerations
 Patient education on rupture capabilities
throughout stages is crucial
 When to increase amount of resistance and
functional use is not easy- there is no rules.
 Understanding of tendon healing and ability to
evaluate tendon function precisely is important for
progression through stages.
 Ruptures can occur even as late as 3 months.
 More adherent the tendon the safer it is to apply
resistance to glide.
 Smoothly gliding tendon resistance applied with
extreme caution
 Trigger finger may develop through excessive
repetitive gripping/squeezing- Therapist to
routinely palpate A1 pulley for triggering
Treating Adhesion Problems
 Restrictive adhesions are the most common
complication after immobilization of the repaired
flexor tendon
 Goal is to lengthen adhesion not break it!
 Treatment
– Dynamic extension splint
– Frequent blocking, putty scraping, sustained grip
activities
– NMES
– US with stretch or active tendon glide
– Massage
Early Passive Mobilization
 Produces superior results because early mobilization inhibits
restrictive adhesion formation, promotes intrinsic healing and
synovial diffusion.

 2 basic types of protocols

– Kleinert - Rubber band traction within DBS
– Duran and Houser- Passive exercise with DBS

 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

 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
Early Passive Mobilization
 Dynamic traction of Splint
– Rubber bands
– Elastic threads
– Sprints

 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.
– Indicated for delayed referral to
therapy > 1 week
– Passive mobilization by
therapist, pt and/or dynamic
flexion traction
– Passive flexion pushes tendon
proximally; limited active or
passive extension pulls the
tendon distally
– Begin active motion at 4 weeks
 Kleinert vs. Duran
 0-3 days post op  0-3 days post op
– DBS – DBS with velcro
– Remove compressive straps
dressings from
fingers and allow
passive flexion to
palm within DBS
– Rubber band on
involved digit
attached to volar
forearm
 Kleinert vs. Duran
 First 3 weeks  First 4 ½ weeks
 8 reps full passive flexion
 Patient encouraged to and extension of PIP joint
actively extend the finger  8 reps of full passive flexion
and allow elastic band to and extension of DIP joint
passively flex digit  8 reps of passive flexion and
 10x’s each hour 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
 Kleinert vs. Duran
 3-6 Weeks  4 ½ Weeks
 Continue with 1-4 ½ week
 DBS removed exercises
 Pt’s hand is maintained  10 reps of active flexion of
in a wrist band with wrist with digits flexed
rubber band traction followed by extension of
(full active extension of wrist and digits
IP and MCP joints  10 reps of composite
against rubber band active flexion and
with wrist in neutral extension MCP, PIP and
 Active digital flexion is DIP joints
still not permitted (bend/straighten)
 Exercises are performed
once every hour
throughout the day with
DBS worn b/w exercises
and at night
 Kleinert vs. Duran
 Change of protocol  5 ½ Weeks
at 6 weeks  DBS no longer used tx
plan changes:
– 12 reps of active flexion
of wrist with digits flexed,
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)
 Kleinert vs. Duran
 6 Weeks  6 Weeks
 Revisions:
 Wrist band removed – Passive extension of
wrist and digits is
and active flexion allowed
can commence and – Splinting: full
tendon gliding extension gutter or
exercises or extension resting pan
blocking may be initiated
– Active and passive
range of motion
exercises and
blocking exercises
are permitted on an
hourly basis
 Kleinert vs. Duran
 8-10 Weeks  8 Weeks
– Progressive – Progressive strength
strengthening is building may be
initiated starting with initiated
mild resistive exercises
followed by sustained
grip

 3 Months  10 Weeks
– Heavy resistive – Aggressive use of
exercises and return to hand with sports or
heavy labor activities heavy lifting is allowed
Early Active Mobilization
 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

 Active contraction of the injured

flexor muscle within strict
precautions
– Pulling the tendon proximally should
produce better glide
 Early Active Mobilization
 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 active extension, and
active flexion to 30 degrees at PIP, 5-10 degrees at DIP.
4th week= 80-90 degrees active flexion at PIP, 50-60 degrees at
DIP,
 Early Active Mobilization
 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. (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- tendon gliding, heavier
hand use at 8 weeks and 12
weeks full function
 Active-hold/place-hold
mobilization
 By Strickland/Cannon
– “active-hold”
– “passive-place active mobilization”
• Digits are passively placed in flexion and
patient attempts to maintain flexion for
gentle muscle contraction
Active-hold; Passive-place
 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. 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
Active-hold; Passive-place
 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; Passive-place
 Late Stage (starting at 7 or 8 weeks)
– Splint discontinued
– Exercise
• PRE’s,
• ADL’s- gradually no restrictions at 14
weeks
• FPL is moved more aggressively with
theraputty (7 weeks)
 Tenolysis
 Surgical procedure to excise adhesions that limit flexor
tendon glide
 Original diagnosis
– Repair
– Graft
– Incomplete laceration
– Crush
– Fractures
– Healed infections
 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, occupational
needs, and individual desires of patient
 Tenolysis
 After surgery
– New adhesions will form
– Begin active motion a.s.a.p.
– 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
 Tenolysis Rehabilitation
 Daily treatment for first 7-10 days
 Post-Op eval
– Wound assessment
– Pain
– Edema
– AROM
– PROM- caution! Tendon is weak and vulnerable to rupture
– Sensory testing
 Edema Control
– Elevation
– Gentle coban wrap
– CPM with hourly active exercise
 Pain Control
– TENS
– Medication
 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
 Phase I (week 1)
– Achieve/maintain A/PROM achieved in
surgery
– Decrease pain
– Control edema
 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
 Phase III (Weeks 4-6)
– AROM equivalent or greater than achieved in surgery
– Increased hand strength
– Eliminate residual edema
 Phase IV (weeks 7 onward)
– Return to work (8-12 wks post-op)
– Work hardening
– Job simulation
– Maximize strength
References
 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. (October 25-26 2002) course. Elbow,
Wrist & Hand Injuries: Surgical and Therapeutic Management
 Hunter; Mackin & Callahan (2002). Rehabilitation of the Hand and Upper Extremity. St. Louis,
MO; Mosby, Inc.
 McGrouther, D.A.; Colditz, J.C.& Harris, J.M. (2001) Interactive Hand; Primal Pictures
 Roholt, P.K. (2001) Clinical Specialty Education: Hands on Tendon Trauma course: Flexor &
Extensor Tendon Injuries
 Steinberg, D.R. (1997) Flexor Tendon Lacerations in the Hand retrieved November 30, 2002 from
the World Wide Web. http://www.uphs.upenn.edu/ortho/oj/1997/oj10sp97p5.html
 Schneider, R.M.; (Sept 17-18, 2005) An Introduction to Hand Therapy course.
 Sethi, S; (December 4, 2002) Flexor Tendon Injuries presentation for Seton Hall University School
of Graduate Medical Education: Advanced Hand Seminar
 Skolnik, D.; (Fall Semester 2002) Advanced Hand Seminar; Seton Hall University: School of
Graduate Medical Education, South Orange, NJ
 The Hand Rehabilitation Center of Indiana (2001). Diagnosis and Treatment Manual for
Physicians and Therapist: Upper Extremity Rehabilitation; Fourth Edidtion.
 Orthoteers; Flexor Tendon Injuries of the Hand retrieved Novermber 30, 2002 from the World Wide
Web. http://orthoteers.co.uk/Nrujp~ij33lm/Orthhandtendoninj.htm
 Wehebe’, M. & Hunter, J.M.; (1985) Flexor Tendon Gliding in The Hand; Part I. In vivo excursions.
The Journal of Hand Surgery, 10A, No. 4, 570-579.