REVIEW OF LITERATURE

HAND REHABILITATION FOLLOWING FLEXOR

TENDON INJURIES
Abey P Rajan
2nd year MPT
Dept. Of Orthopedic Physiotherapy
 CONTENTS
 INTRODUCTION

 RELEVANT CLINICAL ANATOMY

 TENDON NUTRITION

 BASIC CONCEPTS OF TENDON HEALING

 POSTOPERATIVE MANAGEMENT (Protocols)

 EVIDENCE BASED REHABILITATION

 SPECIAL CASES

 SUMMARY
 INTRODUCTION
 Tendons connect muscle to bone and form a musculo- tendinous unit whose

primary function is to transmit tensile loads generated by muscles to move and stabilize
joints.

 Injuries to the flexor tendons of the hand are common

and result mainly from lacerations by knives or glass,

road accidents, severe crushing injuries etc..

 RELEVANT CLINICAL ANATOMY

 The flexor tendons of the hand, which arise from the flexor muscles in the
forearm, enable the movement and bending of the fingers. Flexor tendons
are smooth, thick flexible strings of fibrous tissue running through
lubricated tunnels or compartments (flexor tendon sheaths).
 Flexor tendon system consists of intrinsic and extrinsic components
Extrinsics:
FDP: flexing the DIP joint
FDS: Flexing the PIP Joint
FPL: Flexing the IP joint of the thumb
Intrinsics:
Lumbricals: Flex the MCP joints and Extend the
IP joints

 Fibro-Osseous Sheath
 Extent: Ant to MCPJ to the distal phalanges

 Allows smooth gliding of the tendon- Reduce friction

 Facilitates nutrition to the tendon by Synovial diffusion

 Pulley system

 Synovial sheath is reinforced by a system of fibrous pulleys

Pulley System Of Hand

 Annular pulley-5
 Cruciate pulley-3

What is the use of pulleys in hand?

A4
A3
A2
Avoids bowstringing!

A2-pulley rupture during a stress test in the biomechanical

laboratory.
Note the increased distance between the flexor tendons and the bone.
The A3-pulley is unharmed (Schoffl, laboratory study, Germany)
 TENDON NUTRITION

 2 Sources
1. Vincula system
2. Synovial Diffusion

• Vincula system- Slender tendinous band

blood supply to the flexor tendon
 Vincula Brevis and Vincula longus

• V1 and V2- Supplies to FDS

• V3 and V4 – Supplies FDP
Vincula System
Flexor Zones Of Hand

 Flexor tendon injuries have been classified into zones by Verdan

1960.

Zone 1- Tip of the finger to FDS tendon

Zone 2- Noman’s land- FDS tendon to dist. Palm crease

Zone 3 - Lumbrical origin

Zone 4 - over carpal tunnel

Zone 5 - Muscle-tendon junction (Volar aspect)

 BASIC CONCEPTS OF TENDON HEALING
2 forms:

 Intrinsic healing : occurs between the tendon ends only. Relies on synovial diffusion,
does not result in movement restriction of the tendon.

 Extrinsic healing: Depends on the formation of adhesion between tendon and the
surrounding tissues. Occurs by proliferation of fibroblast from peripheral epitenon;
adhesions occur because of this process and limit tendon gliding within the synovial
sheath.
Intrinsic Tendon healing occurs in 3 Phases:
i. Exudative or inflammatory phase
ii. Proliferative or fibroplasia phase
iii. Remodelling or maturation phase

 Inflammatory phase (0-5 days)

 Start immediately after injury
 In 3-5 days the tensile strength of the repaired tendon diminishes because of softening of
the tendon ends
 Softening does not occur in the tendon ends in case of early mobilization

Later softening ends leads to

scarring
 Proliferative phase(5-28days):

 Fibroblast migrate to the wound area and start production of tropocollagen approx. 5
days after the injury. Type 3 collagen

 Remodelling phase(>28 days):

 Collagen in the repair site remodels and continues to strengthen- Type 3 replaced to
type 1.
EFFECT OF MOTION ON TENDON HEALING
 Laboratory experiments proved the beneficial effect of early mobilization

 Mason and Allen in 1941 stated in their study that tensile strength increased after seventh day of early
passive mobilization.

 Gelberman et.al performed a series of experimental studies on early passive mobilization on repaired
flexor tendon of dogs tensile strength and excursion of the mobilized tendons was superior
compared to the immobilized.

 Studies stated that early controlled passive and active motion has a beneficial effect on tendon
nutrition.

 In 1987 a study was done on healing of FDP tendon , compared immobilized tendon with immediate
controlled passive mobilization. Immobilized tendon healed with less tensile strength and softened
tendon ends at exudative phase.
 Factors Affecting Healing and Rehabilitation

Patient-Related Factors
 Age
 General health and healing potential
 Rate and quality of scar formation
 Patient motivation/education
 Socioeconomic factors ( Case report from Nigeria,2012)

Injury-and Surgery Related Factors

 Level of injury
 Type of injury
 Sheath integrity
 Surgical technique

Therapy Related Factors

 Timing

 Technique

 Expertise (Elliot and Harris)

 POSTOPERATIVE MANAGEMENT

Flexor tendon injuries of hand is divided into three groups on the basis of the exercises
instituted during the first 3 to 4 weeks after tendon repair

(1) Immobilization

(2) Early passive mobilization

(3) Early active mobilization

 IMMOBILIZATION
Rationale and Indications

 Immobilization is treatment of choice for patients who are young, those with cognitive
deficits and unable or unwilling to participate for complex rehabilitation program.

 Some tendons must be immobilized to protect other injured structures.

 In some cases the patient is not referred for therapy , simply remains in the post
operative cast until sent to therapy at 3-4 week after surgery. It may be very difficult to
mobilize these repairs because of heavy adhesion formation.

 Therefore all the therapists must be prepared to treat the immobilized tendon with skill,
care, proper clinical reasoning and patient decision making.
Treating the Immobilized tendon Repair

Cifaldi Collins and Associates developed sufficiently aggressive therapy after immobilization.
Early Stage (from 0 to 3 or 4 weeks):
Orthosis :-
 The dorsal forearm-based postoperative orthosis or cast holds the wrist in 10 to 30 degrees
of flexion, the MCP joints in 40 to 60 degrees of flexion and the IP joints in full extension
(Dorsal Blocking Splint).
Exercise :-
 At home patient perform ROM exercise of uninvol-
ved joints (elbow, shoulder) to prevent stiffness.
Intermediate stage (starting at 3 to 4 weeks):
Orthosis :-
 At 3 to 4 weeks- the orthosis is modified to bring the wrist to neutral.
Patient taught to remove the orthosis hourly for exercise.
Exercise :-
 With wrist at 10 degrees of extension patient performs Passive digit flexion
& extension followed by active differential tendon gliding exercises.
 After 3 to 4 days of these exercises the tendon function has to be
evaluated.- measure active and passive flexion of MCP and IP joints. If
there is discrepancy of more than 50 degrees between total active and
passive flexion suggests poor gliding and heavy adhesion formation.

Late Stage( Starting at 4 week or later, depending on the tendon glide):

Orthosis :-

 The dorsal blocking orthosis will be discontinued. If flexor muscle-tendon

unit shortening is a problem then patient can wear forearm based palmar
nigh time orthosis, which hold the wrist and fingers in maximum
comfortable extension.
Exercise :-
 Patient begins with gentle blocking exercise for isolated FDP and FDS glide.
 Studies also supporting MFR for muscle tightness and fascial adhesions.
 EARLY PASSIVE MOBILIZATION
Rationale and Indications Early passive mobilization

Inhibit restrictive adhesion

formation

Synovial diffusion - Promotes

intrinsic healing

Masson and Allen, Stronger repair, prevent decrease

Ubaraniak and collegues in tensile strength
Published Protocols
2 basic types of early mobilization programs
1. Duran and Houser
2. Kleinert and colleagues

Duran and Houser :-

Early stage (from 0 to 4.5 weeks)
Orthosis – wrist 20 degree flexion and MCP in relaxed position
Exercise – Duran and Houser demonstrated – 3-5mm glide is sufficient to prevent adhesion
formation
 6-8 reps twice a day– Duran and Houser’s exercises
Duran and Houser’s exercise (Duran R J et al. 1990)
Intermediate stage (from 4.5 weeks to 7.5 or 8 weeks)
 Orthosis : Replace dorsal blocking splint with a wrist band with rubber band
traction.
 Exercise :Gentle active extension against the rubber band traction.
*Active flexion(blocking, FDS-
gliding and fisting) is initiated
on removal of the wrist band at
5.5 weeks.

Late stage (starting at 7.5 to 8 weeks)

Resisted flexion waits until 7.5 to 8 weeks.
Modified Duran Protocol :-
• Eliminate the rubber‐band traction
• Extend the DBS hood to the fingertips (dorsal protective orthosis)
• Strap the fingers in IP extension at night.
Exercises:-
1) Passive flexion to individual joints
2) Active IP extension exercises
3) Passive exercises described in the original protocol
for the early stage
4) Protected tenodesis in therapy if appropriate
Kleinert Protocol :-
Duran and Kleinert use dynamic traction to rest the digit in flexion, but the Kleinert and
colleagues uses the rubber band to resist full active extension.
 Orthosis :- Original Klinert protocol- Dorsal blocking orthosis

Original Kleinert (Duran & Modified Kleinert (kleinert &

Kleinert)
Wrist flexion- 45 deg.
MCP flexion – 10-20 deg.
Rubber band traction directly to
the finger nail from the wrist of
just proximal to wrist.
chow)
 Wrist flexion- 20 deg.
 MCP flexion – 40 deg.
 Directed traction through a
palmar pulley
 Exercises :-
Patient actively extend the fingers to the limit of the orthosis every hourly for 10 times
(allowing rubber band to flex the fingers).
0‐4/6 weeks
• Active IP extension against rubber bands
3‐6 weeks
• Remove splint for wrist motion at 4 weeks.
• Begin gentle active flexion
6 weeks
• Discontinue splint.
• Add differential tendon gliding exercises.
6‐8 weeks
• Begin gentle resistance
May & Colleagues :-

 May EJ, Silferskiold KL, Solerman CJ, 1992 – Early passive mobilization protocol

 Wrist- 30-45 deg flexed

 MCP joint- 50-70 deg flexed

 Dorsal orthosis extends only to the PIP joints to allow full active extension of PIP.

 Rubber band traction through a palmar pulley

 Patient perform active extension of IP joint hourly.

 EARLY ACTIVE MOBILIZATION
Rationale
 Applied to recently injured, oedematous tendon with added bulk at the suture site.
 Active contraction of injured flexor muscle, pulling the tendon proximally, produce
better glide.
 Horbie et.al in 1993 found that passive IP joint flexion does not provide much of passive
FDP glide.
 Kobuta and coworkers , investigating the breaking strength and increase in cellular
activity produced by early mobilization and tension to tendon repairs. They found that
early mobilization with out tension on the repair was not as effective as active
mobilization and they concluded that active mobilization produces a stronger repair with
better excursion.- Synovial diffusion increases with active mobilization (keidin N et.al,
2000)
 Do with proper clinical reasoning in cooperation with surgeons.
Published Protocols

Belfast and Sheffield :- (Harris S, 2008)

Early stage (from 0-4 or 3 weeks)

Orthosis :- Post operative cast

• Wrist- 20 deg. flexion

• MCP- 80-90 deg. flexion

• IP- full extension

The cast extends 2 cm beyond the finger tips to prevent hand movements.
Exercises :-

For zone 3 – 24 hours after repair

For zone 2 - 48 hours after sx.

 Exercises perform every 4 hours within the orthosis consist of full passive flexion, active
flexion and active extension.
 1st week goal
Gradually increase in
following weeks.

Active flexion
DIP-30 deg.
PIP- 5-10 deg.

Full active extension

Full passive flexion

Intermediate stage (starting at 4-6 weeks) :-
Orthosis :- Discontinue at 4 weeks if tendon glide is poor ( cannot achieve full fist at 5th
week).
Exercise :-
 In the presence of flexion contracture the only exercise specified for is protected passive
IP joint extension.
 Small and associates stated using blocking exercise to increase tendon glide at 6 week.
 Cullen and colleagues initiate progressive resisted exercise and moderate to heavier hand
use at 8th week with full hand function expected by 12th week.
 A systematic review was done by Liying P and Duan LT on early active mobilization
rehabilitation protocol after flexor tendon repair in zone II of the hand.
 The review included study with (1) sustained flexor tendon injury to zone II of the hand
(2) had surgical repair done, and (3) underwent early active mobilization rehabilitation-
which was defined as any form of active digital flexion exercises within the first 4 weeks
post repair, including place and hold
 In 112 studies 12 studies met the inclusion criteria.
 The primary outcomes were rupture rates and range of motion
 During the first 4 weeks of postoperative rehabilitation, a combination of high therapy
frequency (daily to once a week) and daily repetitions of active finger flexion exercises
(not more than 2 repetitions per hour) involving active fisting with wrist in extension,
place and hold were shown to contribute to low rupture rates (85%).
 The study concluded that early active mobilization this protocol can potentially improve
the outcomes of flexor tendon repair in zone II.
Place Hold Active Mobilization
A study by Savage in 1988, force required for active IP flexion reduces when wrist keep at
45 deg. Extension and MCP 90 deg. Flexion
Active hold or
place hold Digits passively
active placed in flexion
mobilization

Patient maintain the Biofeedback to monitor

flexion with a gentle the strength of
muscle contraction contraction

EMG
biofeedback
Early stage (from 0-4 weeks) Exercise orthosis
Orthosis :- 2 different orthosis are used
i. Dorsal blocking orthosis Wrist- Hinged wrist, allows full wrist flexion,
Extension limited to 30 degrees
ii. Exercise orthosis
IP- Full flexion and extension are allowed
MCP- Extension is limited to 60 degrees

Dorsal blocking orthosis

Wrist- 20 degree flexion

MCP- 50 degree flexion
Exercise :-

 Every hour patient performs modified Duran exercises in the dorsal blocking orthosis followed
by place and hold exercise in the exercise orthosis.

Intermediate stage (from 4 weeks to 7 or 8 weeks)

Orthosis :- Exercise orthosis is discontinued. Patient wear dorsal blocking orthosis except for
active flexion exercise.

Exercise :- Tenodesis exercise, at 5-6 weeks add blocking exercise and tendon gliding exercise.
Late stage (starting at 7 to 8weeks)

Orthosis :- Discontinued

Exercise :- Progressive resistance exercise is initiated

 TREATING ADHESION PROBLEMS
 Most common complication after immobilization.
Break the
adhesion
Internal trauma
Aim is to gradually lengthening the adhesions
to allow greater glide.
Greater fibrosis

New adhesions
 Blocking exercises

 Tendon gliding exercises

 Sustained grip activities

 Therapy putty squeezing

 Therapeutic Ultrasound

 Orthotic positioning and gentle passive extension

 Myofascial release
Tendon Blocking Exercise
Dangerous for a newly healed tendon if not performed correctly.
Tendon Gliding Exercise
Recent Advances

Matrix Rhythm Therapy –Sari Z et.al in Robotic Therapy – Patoglu V et.al in

2014 for Scar mobilization in flexor 2010 to find the scope and effect of a
tendon injury associated with thermal tendon rehab robot for management of
burn. hand tendon injuries.

LASER Therapy – Gaida et.al, 2010 Cryo-ultrasound Therapy –Velonia HK on

400mW 670 nm soft laser has a positive postoperative inflammation and tendon
effect on scar management healing

Title and study design
Cetin A et al. Oct. 2001
Rehabilitation of Flexor
tendon injuries by Use of a
Combined regimen of
Modified Kleinert and
Modified Duran Techniques
EVIDENCES
Result/Conclusion
Methodology
Thirty-seven patients with Patient-assisted passive
repaired flexor tendon exercises (modified Kleinert)
Injuries. are very safe and more cost
effective than therapist-
assisted passive exercises
 Title and study design
Methodology
The standard modified Kessler’s
technique was used to repair 46
Hung L K et. al., 2005 digits in 32 patients with flexor
tendon injuries. Early active
Active mobilisation after
mobilisation of the repaired digit
flexor tendon repair:
was commenced on the third
comparison of results postoperative day. Range of
following injuries in movement was monitored and
zone 2 and other zones recovery from injury in zone 2
was compared with injury in other
zones.
Result/Conclusion
Preliminary results of this
study showed that active
mobilisation following flexor
tendon repair provides
comparable clinical results
and is as safe as
conventional mobilization
programmes although
recovery in patients with
zone-2 injury was delayed
Title and study design Methodology Result/Conclusion

34 patients with cut flexor tendons in The early active mobilization

zones II–V. Postoperative of cut flexor tendons in zones
Saini N et.al, 2018 immobilization was done with a splint II–V using the modified
in 10°–15° palmar flexion of the wrist mobilization protocol has given
and 70° flexion of MCP joints and IP good results, with minimal
Outcome of early active
joints in mild flexion. The complications
mobilization after flexor rehabilitation program adopted was a
tendons repair in zones modification of Kleinert’s regime and
II–V in hand Silfverskiold regime.
Title and study design Methodology Result/Conclusion

Retrospective analysis of There was a statistically

collected data of all patients significant difference between
receiving primary flexor tendon the TAM values of the EPM
Frueh FS et. al, 2014 repair in zones 1 and 2 from and the CAM protocols 4
2006 to 2011, during which weeks after surgery.
Primary Flexor Tendon
time 228 patients were treated, This study showed a
Repair in Zones 1 and 2:
and 191 patients with 231 favourable effect of
Early Passive Mobilization
injured digits were eligible for controlled active motion
Versus Controlled Active
study. The primary endpoint protocol on total active
Motion.
was the comparison of total motion 4 weeks after surgery.
active motion (TAM) values 4
and 12 weeks after surgery
between the EPM and the CAM
protocols.
Title and study design Methodology Result/Conclusion

A total of 100 patients and 139

digits with zone II flexor tendon After zone II flexor tendon
injuries were studied. After repair, pulsed ultrasound
randomization, they administered therapy during the early
Geetha K et.al, 2018 pulsed ultrasound therapy of rehabilitation phase is safe
different frequencies and and effective. The results are
Early ultrasound therapy intensities according to the dosage comparable to early
for rehabilitation after calculation for a total of 72 mobilization protocols.
zone II flexor tendon patients and 99 digits and
repair formulated three groups. The
results of ultrasound treated cases
were compared with each other
and with the results of cases
treated by immobilization protocol
Cont.
 Group 1- ultrasound of 1-MHz frequency at an intensity of 0.7 w/cm² was
administered from the seventh postoperative day. The pulse ratio was kept at 2:8. The
duration of therapy was 5 minutes. After 3 weeks, the intensity was increased to 1
w/cm2.
 Group 2- ultrasound therapy of 1-MHz frequency at an intensity of 0.3 w/cm² from
the third postoperative day. After 3 weeks the intensity was increased to 1 w/cm2.
The pulse ratio was maintained at 2:8. The duration of the therapy was 5 minutes.
 Group 3- ultrasound therapy of 3 MHz frequency at an intensity of 0.5 w/cm² was
administered from the fifth postoperative day.

In all the ultrasound therapy groups, the splint was removed after 3 weeks and
mobilization programme was commenced in addition to the ultrasound therapy. Passive
stretching and resisted exercises were added after 6 weeks. Patients were allowed to lift
weight after 8 weeks.
Group 2 showed better effect.
Title and study
Methodology Result/Conclusion
design

The study reports the results of Results of the study shows

physical therapy and splinting which that using a physical therapy
was applied to 75 patients with 76 and splinting achieve good
digits after flexor tendon repair in zone results in range of motion,
Rrecaj S et.al, 2014
II, Physical therapy and splinting muscle force and early return
Physical Therapy started the first day after surgery and of function of the hand.
and Splinting After have lasts until week 12. Physical
Flexor tendon Repair Therapy application was divided into 3
in Zone II phases. Patients were evaluated with
regarding to the range of motion and
grip strength. The assessments were
done at the 8, 10, 12 weeks and the
finale assessments were done after 6
months.
 Clinical CASES
1. Clinical showing (a) Cut FDS/FDP ring and little finger in Zone IV,
cut ulnar nerve, ulnar artery. (b), (c) 7 weeks post operative. (d) At 24
weeks follow up- showing good fist formation. (Saini N et. al Jul, 2018)

Early active mobilization

protocol
2. Clinical photographs are of a 19 years old male cut right wrist due to
assault (sword cut) showing (a) cut FPL, FDS/FDP of index and middle
fingers, cut FDS of ring and little finger is Zone III, IV. cut median nr.,
radial artery. (b), (c) 7 weeks post operative, showing good flexion. (d) At
24 weeks follow up- Right side showing good grip. (Duran protocol with
active hold)
3. Clinical photographs of 31 yrs old male, assault with Axe
showing (a) cut FPL, FDS/FDP of index, middle and ring fingers
(ZONE IV), cut median nerve and radial artery with cut I and III
extensor compartment and distal radius fracture. (b) Splint applied
and mobilization taught. ( Kleinert protocol with active hold in later
stage)
 SUMMARY

 Flexor tendon system and pulley system of hand

 Healing process of flexor tendons of hand

 Tendon nutrition

 Effect of motion on tendon healing

 Duran protocol

 Kleinert protocol

 Place hold active mobilization

 Treating adhesion problems following flexor tendon repair of hand

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