to end of week 6

At 3¹₂ weeks gentle active flexion exercises are begun. Prior to the commencement of active exercise, the patient must first ‘warm up’ with passive flexion exercises. Active flexion is only begun if the patient is able to passively flex both IP joints to near-normal flexion range with ease. The last few degrees of passive flexion can sometimes be restricted by dense scarring or residual oedema.

As a tendon glides, it meets a certain degree of normal resistance from surrounding tissues. This is referred to as ‘drag’. Following injury and surgery, this resistance is significantly increased due to swelling, sutures and healing scar. The newly repaired tendon must not, therefore, be subjected to the added stress of overcoming joint stiffness when active movement is commenced.

Every 2 h the hand is removed from the splint and rested comfortably on the table in neutral wrist extension. From their flexed position, the MCP joints are actively extended to within 20 or 30 degrees of full extension and gently supported.

This more extended MCP joint position will help accommodate extrinsic finger flexion.

With the wrist in neutral and the MCP joints supported in 20 to 30 degrees of flexion, the patient is asked to actively extend the IP joints to their maximum range as they have been doing in the Figure 3.13. Patients who heal with dense scarring

often have an increased propensity toward PIP flexion deformity. This can be managed with a sling that applies negligible extension force to the digit. Where necessary, the sling is used during sleep. During the day, the sling is removed hourly to perform passive IP joint flexion exercises.

splint. When maximum IP joint extension range is reached, the patient is then asked to actively flex both IP joints simultaneously with minimal effort (Fig. 3.14). This position is gently held for several seconds before the exercise is repeated. Five to ten repetitions are performed. These early attempts may yield 30 or 40 degrees of PIP joint flexion and 20 or 30 degrees DIP flexion. From the 4th week onward, the MCP joints can be increasingly extended during IP joint flexion exercises to better facilitate flexor tendon pull-through.

Patients who demonstrate marked active flexion range are considered at greater risk of rupture due to minimal scar formation. These patients are protected for a longer period. This means that the commencement of active movement is delayed by another week and protective splinting is continued for 1 to 2 weeks longer. When active movement is then initiated, it can be done so with the less-stressful tenodesis manoeuvre described below.

Resisted use of the hand will also be delayed by several weeks.

Tenodesis manoeuvre

If active flexion range is minimal or where the risk of rupture is considered greater, the patient should be shown ‘place and hold’ exercises as it takes less force to maintain an already flexed finger in the flexed position than it does to actively bring the finger into flexion from the extended position. This manoeuvre involves passively flexing the fingers, allowing the wrist to extend to 40 to 45 degrees and then removing the passive support and asking the patient to maintain the flexed finger position with minimal active muscle-tendon tension (Fig. 3.15(a)). Savage (1988) has shown that this position produces the least tension on the repaired tendon during active movement. This position is held for 3 to 5 seconds. The wrist is then brought

Figure 3.14. Gentle combined active IP joint flexion (i.e. both IP joints simultaneously) is practised second-hourly with 5–10 repetitions at each session.

Active range of motion is usually still quite limited at this early stage. Patients who demonstrate significant active range with ease are ‘held back’ because they tend to be at greater risk of rupture due to minimal scar formation.

Figure 3.15. (a) The first part of the ‘tenodesis manoeuvre’ involves passively flexing the fingers and allowing the wrist to assume a position of 45 degrees extension. Passive support is then removed and the patient is asked to maintain the flexed position with minimal active muscle-tendon tension. (b) The wrist is then brought forward into flexion while the fingers gently extend.

(a)

(b)

Flexor tendons 37

forward into flexion while the fingers gently extend, i.e. the tenodesis effect. This manoeuvre is repeated 5 to 10 times second hourly (Fig. 3.15(b)).

The patient may find it helpful to perform their active exercises in both of the described ways.

Weeks 6 to 8

The splint is discarded at the end of the 6th postoperative week unless the nature of the scar indicates that extended protection is necessary. The hand can be used for light daily functional activities that are minimally resistive. The light (sustained) squeezing of a soft bath sponge in warm water is a suitable exercise at this stage.

Patients whose work does not involve heavy manual activity usually return to work at this stage.

Residual flexion deformity of the PIP joint is addressed with a neoprene fingerstall (Fig. 3.16). If adhesions are affecting tendon glide, the use of an MCP joint blocking splint will facilitate pull-through of the extrinsic flexors (Fig. 3.17).

During activity, the injured finger can be buddy-taped to an adjacent finger with Microfoam tape if limitation of active flexion range makes gripping objects difficult. Small handles such as cutlery or razor can be temporarily built up with insulation tubing (i.e. Bradflex). Light-grade exercise putty can be added to the programme by the 7th week.

Putty squeezing should be carried out in a slow and sustained manner and the patient should take care not to over-exercise. Three or four short sessions (5 min) each day are sufficient as the patient should also be engaging the hand in regular activity (Fig. 3.18).

Repair in Zones III, IV and V is often accom-panied by tethering of the tendon to skin and surrounding tissues and some shortening of the muscle-tendon unit. This can be addressed with serial volar splints which exert a gentle corrective extension force and are worn at night and inter-mittently throughout the day. Occasionally soft tissue tightness is quite marked. This may warrant the use of a dynamic outrigger. Regardless of the splinting method used, the tension applied should be low and the correction should be gradual to avoid rupturing the repair. The patient should feel a gentle stretching sensation that is not painful.

Week 8 onwards

Gentle resistance is added to active flexion exer-cises and activity can be upgraded. Stabilized exercises are continued; however, they need not be

Figure 3.16. Unresolved flexion deformities of the PIP joint are managed with a neoprene fingerstall from the 6th week onward.

Figure 3.17. An MCP joint blocking splint will facilitate pull-through of the extrinsic flexor tendons.

Figure 3.18. Light-grade exercise putty is added to the programme by the 7th week.

repeated as frequently. Return of function is more of a priority at this stage in rehabilitation and patients are encouraged to perform domestic or mechanical tasks as part of their therapy pro-gramme if they have not yet returned to work.

Patients whose work is heavily resistive do not return to work in their normal capacity until the end of the 12th week. This period is extended for a further 2 weeks where scar formation has been minimal.

Note: Many patients make steady gains in active flexion range during the first 3 to 4 postoperative months. Patients who heal with dense scar fre-quently show slower progress. Final range of active motion may not be achieved for some months following cessation of formal therapy.

Patients are therefore encouraged to persevere with their exercise/activity programme.