Flexor Tendon Rehabilitation Joanne Mimm, MPT, CHT University of California, Irvine Irvine, CA February 9-11, 2018 Objectives Understand tendon healing/repair Tensile strength Controlled Stress Rehabilitation protocols Decision making strategy and problem solving Keys to Successful Treatment Doing the wrong thing can lead to injury Not doing enough of the right thing can cause poor outcomes Use Resources Mentors Surgeon Protocols Evidence current literature Anatomy Review FDP and FDS Interrelationship Annular Pulleys A2, A3, A4 Nutrition to the tendon Perfusion vs diffusion Perfusion via vinculum brevis vinculum longus 4 Vincula V1 V2 supply FDS V3 V4 supply FDP Arise at the neck of the Proximal and distal phalanges.
Synovial Sheath Surrounds flexor tendons produces synovial fluid Smooth gliding Lubrication highest lubricating capacity known to man. Nutrition synovial diffusion Zones Zone I: FDP only Zone II: No man s land FDP and FDS within the finger pulleys Zone III: Over metacarpals Zone IV: within the carpal tunnel Zone V: Proximal to the Carpal tunnel Thumb Zones T I Distal to the IP joint TII From A1 pulley extending to the IP joint TIII Over the thenar eminence TIV within the carpal tunnel TV Proximal to the transverse carpal ligament Only FDP Distal to FDS insertion Amount of retraction varies Vincula may be intact Mechanism of injury Laceration open Jersey finger closed Forced extension while FDP is maximally contracted 4 th finger most common Zone 1 Zones III Proximal to the A1 pulley and distal to the transverse ligament of the Carpal Tunnel Less complications/adhesions No tight pulleys Repair may glide through carpal retinaculum Lumbricals can become adhered PARODOXICAL EXTENSION Zone 4 Carpal tunnel Uncommon Often involve nerves Must move each finger individually Superficialis tendon gliding Differential tendon gliding Hook fist Hook fist differential gliding Individual finger extension
Tendon Healing Extrinsic Healing Adhesion formation between tendon and surrounding tissue Potenza and Peacock (1960 70's) Tendons healed by fibroblastic response (adhesions) Tendon cells were incapable of proliferating "One wound" concept= tendon healing through scar adhesion Intrinsic Healing Tendons ability to heal without adhesions Intrinsic vascularity and synovial diffusion Fibroblasts needed for healing Supplied by the endotenon and epitenon Tenocytes appearing at 2 3 weeks Gelberman et al., Manske et al, Lundborg et al. (1980's) Factors that affect tendon healing Age vincula decrease in size with age Individual Biochemical response general health Diabetes, cardiovascular disease Nutrition: Smoking causes vasoconstriction infarct to the tendon Alcohol increased nerve sensitivity toxin to nerves Mechanism of Injury Crush untidy laceration/infection Controlled Stress Mobilization Clinical Application of controlled Stress Purpose: Promote intrinsic healing Decrease adhesions Encourage longitudinal orientation of adhesions associated with extrinsic healing Decrease joint stiffness Evans JHT 1993; Halikis JHS 1997 Physiologic Response to controlled stress Gentle active motion Tensile Strength increases Improved tendon excursion Improved penetration of synovial fluid (synovial profusion) nutrition Improved repair site cellularity Reorganization, elongation and orientation of extrinsic scar Immobilized Mobilized Considerations for Application Type of injury Delayed repair greater than 2 weeks may have poor strength Other tissue involved bone, nerve, blood vessels Swelling degree of trauma around the tendon WORK of FLEXION sum of forces that resist flexion Level of Injury Zone II Repair technique: Number and type of suture and Confidence of the surgeon Tension on the repair
Precise transmission of controlled stress Provide enough stress to move the tendon a controlled amount Muscle contraction is needed to glide the tendon proximally uncrimp Avoid gapping or rupture Force is measured in N (Newtons) or gm (grams) 1 N= 102 gm More repetitions promotes better tendon gliding Least force of flexion is in 20 degrees of wrist extension and MP flexion Savage: Effect of Wrist Position on Force on Flexors Movement Wrist 30 degrees flexion With fingers flexed to palm Wrist 0 degrees Fingers flexed to palm Wrist 30 degrees flexion Extend the fingers Wrist 0 degrees Extend the fingers Recorded force FDS 7.2 N 5.7 N 3.2 N 4.7 N 3.1 N 4.0 N 4.8 N 4.6 N Recorded force FDP Estimated strength of tendon repair with epitendinous suture Type of Repair 2 strand 2500 gm 25 Newtons 4 strand 4300 gm 43 N 0 weeks 1 week 3 weeks 6 weeks 1200 gm 12 N 2150 gm 21 N 1700 gm 17 N 2800 gm 27 N 2700 gm 27 N 5200 gm 51 N Flexor Tendon tensile demands PROM 500 gm Light grip 1500 gm Strong Grip 5000 gm Tip pinch (palmar pinch) 9000 gm Index finger FDP 6 strand 6000 gm 59 N 3000 gm 29 N 4000 gm 39 N 7200 gm 71 N Applying Basic Science Clinically to Early Motion Programs Tendon gaps at 2/3 of the full reported repair strength Tendon softening decreases repair strength Decreases another 10 20% Weakens during the first week, then starts to increase Immediate controlled stress reverses the weakening Safe zone: begin with the reported strength and subtract 43 53% Importance of controlled stress during active flexion
Retrieving the tendon end Tendon retracts proximally With flexion injury May go to Carpal tunnel Milking proximal to distal Needle and catheter/ feeding tube Any Trauma/touch leads to adhesions Surgical Repair of flexor tendons Core suture 4 strand is preferred Suture material 4 0 fiberwire less bulky and stronger 3 0 or 4 0 braded synthetic suture commonly used Placed in the volar 1/3 of the tendon Many types of suture techniques Multiple strands add strength Also add bulk Allow early active motion New suture materials add strength to repair Thinner sutures may break Thicker suture more likely to fail at the knot Epitendinous Cross Stitch Adds strength to the repair Reduces gapping by 10 50% Improves gliding decreases friction Combined with core suture technique 4 strand allows early active protocols Goal: Tendon Gliding Prevent Gap Factors controlled in therapy Clinical Pearls Joint stiffness Edema Soft tissue adherence Limit the amount of flexion to control stress Gradually increase each week WORK OF FLEXION Controlled by the therapist
Limiting force during Active motion Lalonde: 10 mm of glide is produced with the 1 st ½ of composited flexion Tang: Final 1/3 of fist produces 5 10x more force than the first 2/3 of the motion Steep increase in force in the last 1/3 of finger flexion motion More reps show greater benefit (10 15) Use nails of involved hand to scratch How much glide is needed to prevent adhesion Passive motion does not produce tendon glide proximally Wet noodle through a tube Duran Protocol 3 5 mm (1975) of distal glide How much active motion is needed Silverskiold 6 9 mm (1992) Normal Reported Tendon Excursion FDS FDP Straight fist 28 mm 27 mm Hook fist 13 mm 24 mm Full fist 23 mm 34 mm Max FDS occurs in Straight fist Max FDP occurs in Full fist Max differential is in Hook fist A small amount of excursion can prevent peritendonous adhesions History of Zone II repairs Bunnell 1940 s Zone II not repaired Tendon graft was recommended so there would be a smooth surface to glide through the Zone II Lindsay and Thomson 1960 s researched healing of tendons Chicken Club research done on chicken tendons Originally thought that vinculae were the only source of nutrition if cut could not regenerate Began to see tenocytes and fibroblasts Kleinert 1967 Began doing first tendon repair in Zone II Started movement in 3 days Types of Protocols Immobilization no stress on tendon Immediate Controlled Passive Mobilization Modified Duran Houser/ Duran Houser Modified Kleinert rubber bands not used any more Washington Regimen Immediate controlled active mobilization Short arc active (SAM): MAMTT Minimal Active Muscle Tendon Tension Evans 1993 Indiana Tenodesis/ Place Hold Wide Awake Protocol Lalonde Tang 4 3 2 1 finger Technique
Indications for Protocols Immobilization (child, or severe injury limiting motion) Used when cognition is impaired, too young <8 12 y/o Immediate passive mobilization (2 strand repairs) Used when the surgeon was unable to achieve a 4 strand repair or strong repair. Not used often, should call to confirm this is what the MD wants May add in place hold with MD consent Immediate controlled active mobilization (4 strand+) Higher level of controlled stress on repaired tendon Gentle active contraction, with minimal force of the repaired musculotendinous unit to allow the minimum needed for glide Results in definite proximal gliding of the repaired tendon. Outcomes with protocols Higgins, Amanda B, Lalonde et. al Avoiding Flexor Tendon Rupture with Intraoperative Total Active movement Examination. Plastics and Reconstructive Surgery, Sept 2010 Volume 126 Issue 3 pp 941 945 Passive motion results Short Arc active Strikland 2000 Early active motion protocol Lalonde 2010 Excellent 3% 43% 96% (not reproduced) Good 25% 32% Fair 50% 14% Poor 22% 11% 4% ruptured (122 subjects) Non complient Assessment of Results Strickland & Glogovac, 1980 Active PIP + DIP flexion extension lag x 100 175 = % of normal active PIP and DIP motion Excellent: 85 100% Good: 70 84% Fair: 50 69% Poor: <50% Modified Strictland is less stict 75 100% considered Excellent 50 75% considered good ASSH Assessment Uses total active motion (TAM) Adds flexion of all joints subracts extension lag Divide by normal TAM of 260 degrees X 100 Excellent = 100^%^ Good = 65 99 Fair= 50 74% Poor= less than 50% Pyramid of Progressive Force Application by Groth (2004)
Pyramid of progressive force The Force of the exercise must be appropriate for stage of tendon healing Level is advanced if there is a flexion lag Indication of adhesion Lag is measured by PROM AROM < 10% active lag = no adhesion Stay at same level >10 % advance one level Reassess next session Pyramid of progressive force exercises Level 1 (500 gm) Passive Protected Digital Extension All joints are flexed while one is extended slowly First post op visit Hand can be taken out of the splint to allow full wrist flexion Achieve distal glide 6 mm Frequency 5x/day or every hour Level 2 place and hold 900 grams Warm up passive ROM done first Passively flex to loose fist Allow fingers to slip back a bit The patient is asked to hold 3 5 sec Can be used with 2 4 strand repair with MD consent, short range Level 3 active fist 1500 gm light fist/4000 tight fist Limit force varies greatly Tenodesis may be used Less force with partial range Level 4 Hook (1300 gm) and Straight fist (1100 gm) No Force Wrist protected Maximal differential glide between FDP &FDS Level 5 Isolated joint motion blocking exercises (as high as 1900 gm) blocking to small finger not recommended Careful not to resist FDS if repaired/ hold sides of the fingers Minimal resistance let go if pressure is felt Splint is discontinued after level 5
Level 6 Discontinue splint resisted compostite fist Level 7 Resisted hook and straight fist putty or hand helper/ rubber band resistance X soft Paper crumbling sponge Level 8 Resisted isolated joint motion 9000 gm Putty drag pinch MAMTT: Minimal Active Muscle Tendon Tension Developed by Ross Evans to begin early active motion with a safe amount of tension Minimal tension required to overcome the viscoelastic resistance of the antagonist Place and hold exercises in Wrist in slight extension to decrease WOF (20 30) Prepare the injured digit with PROM and MEM Limiting the force applied partial range PIP flexes 75, DIP 30 40 MAMTT not a "protocol" but a concept Immediate Active Short Arc Motion (SAM) Minimal Active Muscle Tendon Tension MAMTT used in therapy only to provide early active motion DBS in wrist flexion 20 30 degrees; MP flexion 50, IP extension Elastic Traction is applied to the fingers (removed at night and strapped in extension Patient is instructed in hourly ex 10 20 reps passive flexion to the DPC 10 20 reps of active IP extension with the MP s blocked in 90 degrees of flexion Day 21 add home active tenodesis and place hold
Indiana Protocol Repair technique Tajima core suture plus horizontal mattress Equal to 4 strand repair plus epitendinous suture Criteria Motivated, understanding patients Minimal to moderate edema which does not restrict passive flexion Minimal wound complications Tenodesis splint Indiana Synergistic orthosis with hinge Allows full wrist flexion and 30 extension MPs blocked at 60 flexion IPs allowed 0 extension Indiana Protocol Early Week 0-4 Dorsal blocking orthosis Wrist 20 flexion, MPs 50 flexion, IPs allowed full extension Worn continuously Exercises- Once hourly: remove and apply hinged wrist splint 25 reps of place hold Immediately reapply dorsal blocking splint after exercises Indiana Protocol Intermediate Week 4: Discharge synergistic orthosis Continue dorsal blocking orthosis between exercise Exercises Synergistic motion: 25 reps every 2 hours Add light active finger flexion and extension Avoid combined finger and wrist extension Active Motion Protocol Initiate day 3 5 post op with MD direction Edema Control Elevation Manual edema mobilization Rest Passive Flexion 10 20 reps every 1 2 hours (varies) Place and hold with MAMTT Early Tenodesis like Indiana, but without the second splint Limit active flexion motion initially 50% Increase I cm per week 1 st 4 weeks Dorsal blocking Splinting Dorsal blocking splint (DBS) including all fingers Purpose: limit stretch force on the repair site Wrist position: 0 20 degrees of flexion MP Flexion 45 60 IP s allowed to extend Except if nerve is repaired
Tang 4 3 2 1 finger technique First week flex to 4 fingers Week 2 go to 3 fingers Week 3 go to 2 fingers; full IP extension in the splint Week 4 go to 1 finger Week 5 full fist Concept is gradual application of stress to avoid gap and influence healing tensile strength Home Program Instruction Always review precautions Don t forcefully pinch with the other fingers even if only the small finger was repaired Too much activity produces swelling Must use the splint at all times, even bathing 1 st 4 weeks Remove for hygiene, dressing changes, keeping the flexed position Light ROM every 1 2 hours Reps vary Lalonde 5x passive 5x active Frequent repetitions with low force Protected Finger extension In the splint only for the first 4 weeks May block in 90 degrees MP flexion during IP extension Flexed position with tendon on slack Careful of nerve repair protect 3 4 weeks post op May begin extension splinting in the DBS at 4 weeks p.o. if contracture develops Week 4 Advance tendon gliding Modified hook fist Tenodesis Wrist motion is allowed with fist Extension night splint in DBS Manual therapy Scar mobilization Treatment Progression If adhesions are significantly limiting tendon gliding PROGRESS If the tendon gliding is good PROTECT the tendon from resistance for a longer period of time Treatment of Adhesions Manage edema Scar mobilization Self scar mobilization Desensitization Soft tissue Mobilization Modalities Heat Ultrasound low intensity move fluid?
Late stage Light grasp if stuck Blocking splint Late phase 8 weeks post op If tendon gliding is unrestricted keep the DBS until 8 weeks go slowly! Light putty Dowel grip May advance earlier if adhesions are present Groth Pyramid Assess progress Other Early Controlled Active Motion Studies: Trumble 2010 Randomized Prospective trial of active place and hold vs passive motion therapy 4 strand with epitendinous surture Indiana Protocol was used with tenodesis place hold using a hinge brace during exercises Passive group used elastic traction and place hold was initiated at 3 weeks post op Results showed significantly improved flexion at 6 and 52 weeks with the tenodesis place and hold group Silfverskiold et al Zone II study 1994 Introduced exercises hourly Elastic traction 10 reps active extension 2 reps of passive flexion with active assist held 2 3 sec Inpatient first 4 days until they demonstrated 80 degrees of PIP flexion and 40 degrees of DIP flexion Therapy 1x/week until 4 weeks p.o. when active flexion and extension were initiated 71% excellent results Immobilization Protocol Rationale/Used for: Children (those under age 10-12) Cognitively impaired Non-adherent patients (????) EXTRINSIC HEALING
Immobilization early stage Early stage (up to 4 weeks) Dorsal blocking orthosis or cast Wrist 10-30 flexion MPs 40-60 flexion IPs in extension If therapy is provided: Passive flexion of the digits Mobilization of uninvolved joints Wound/scar management Cifaldi-Collins & Shwarze, 1991 Immobilization intermediate stage Intermediate Stage (3 to 6 weeks) Orthosis modified to wrist neutral Removed for hourly exercises to include: Passive flexion and extension of fingers with wrist in 10 extension Active flexion: hook, straight, and full fist. Synergistic motion BE GENTLE immobilized tendon is generally weaker AdvancingAROM (3 6 weeks) After 3-4 days, assess tendon gliding Measure full MP/PIP/DIP flexion passively and actively If >50 difference is present, move to the late stage If <50 difference noted, continue with intermediate phase of the program until 6 weeks post-op Immobilization Late stage 5 6 weeks+ D/C dorsal blocking orthosis Add serial extension splinting Begin gentle blocking exercises After 1 week of gentle blocking, may initiate light resistance If tendon gliding is good, delay any resistance Early Passive Motion Protocols P Rationale: Promoting synovial diffusion for healing Inhibit dense adhesion formation Facilitate a stronger repair at an earlier stage Two main protocols Duran & Houser/ Modified Duran Kleinert Washington modification
"Original" Duran Houser 0-4 ½ Weeks Orthosis Dorsal block with wrist in 20 flexion, and MPs in a relaxed state of flexion: Orthosis ends at PIP joints to allow full IP extension Rubber band traction to the injured finger (loosely) during the day Between exercises stockinette is applied over the fingers and pinned to forearm All fingers resting in flexion within stockinette to prevent impulsive grasping Exercises 0 4 ½ weeks Exercises: 6-8 repetitions, 2x/day within orthosis that blocks MP in flexion Passively extend DIP while PIP is held passively in flexion Passively extend PIP while DIP rests in flexion "Original" Duran & Houser 4 ½ Weeks Replace dorsal block with a wrist band with rubber band traction for exercises then reapply splint Exercises: 10 repetitions every 2 hours as previous Add gentle active extension against the rubberband traction. "Original" Duran & Houser 5 ½ Weeks: Hourly exercises: 10-12 repetitions Remove wrist band and nail suture for rubber band attachment Active flexion is initiated: gentle blocking, FDS gliding, and composite fist Passive flexion of all joints IP passive extension with MP flexed "Original" Duran & Houser 6 Weeks Begin gentle PIP extension Dynamic splinting if needed 7 ½ Weeks Initiate gentle resistance No strong resistance to the tendon for another 2-4 weeks Modified Duran Eliminate the rubber-band traction Extend the DBS hood to the fingertips Modify at 3 weeks to wrist neutral Strap the fingers in IP extension at night??? Exercises: Passive flexion: isolated and composite Active IP extension Passive protected extension Protected tenodesis in therapy 3 weeks- begin place and hold exercises 4 weeks p.o. active tenodesis at home
Protected Tenodesis Modified Kleinert Dorsal blocking orthosis Wrist in 45 flexion MPs 40 flexion IPs allowed full extension Volarly applied PFT (postoperative flexor tendon) Modified Kleinert Protocol Exercises: 20 repetitions per hour 0-4 to 6 weeks Active IP extension against rubber bands 3-6 weeks Remove orthosis for wrist motion at 4 weeks Begin gentle active flexion 6 weeks Discontinue orthosis Add differential tendon gliding exercises 6-8 weeks Begin gentle resistance Washington Regimen Dorsal blocking orthosis Wrist at 20-45 flexion MPs at 40-60 flexion IPs allowed full extension A safety pin is applied to the palmar strap at the distal palmar crease, and on the forearm strap Zone 1 LEAF protocol Limited extension active flexion (LEAF) Evans, 1990 Rationale: Place the repaired FDP tendon in a shortened position 4.5mm proximal to normal resting length Decrease gap formation Therapy initiated at 24 48 hours post op Problem- Flexion contracture at the DIP Swan neck results
place and hold Can be used with 2 strand repair if MD ok s Slow passive movement, let the joint loosen up 5 10x Back off motion to 50% of motion first week Ask patient to hold gently no resistance Frequency varies may do 3x/day or hourly Not a natural motion New Trends in active motion Viewed with extreme caution Small sample size Must discuss with MD Rupture rate is not determined Lalonde Wide awake protocol Wide Awake procedure Done widely in Canada, DH Lalonde, MD Tang in China Local anesthetic only, no sedation No tourniquet is used Epinephrine Patient is asked to move the tendon through full active flexion and extension before the wound is closed Observe tendon gliding Repair any gapping or triggering, pulley venting Patient education in pain free active motion which is continued on a EAM post op rehab program Belfast and Sheffield (UK) Similar to Tang 4 3 2 1 Exercise frequency every 4 hours Full passive flexion Full active extension in DBS Limited partial range flexion gradually increasing Goal is flexion range of PIP 90 and DIP 60 Splint discontinued (5 6 weeks post op) Except in those patients that achieve goal in 2 weeks Held back in splint an additional 2 weeks Nantong Tang 2007 Changes DBS to wrist extension of 20 degrees at 2.5 weeks Mass and Saint John Coats et al, 2005; LaLonde 2013; Clancy & Mass 2013 DBS is in 20 30 degrees of extension with MP flexion of 60 75 degrees
Manchester Short splint UK not accepted by most surgeons in US Peck 2014 Showed decreased flexion contracture at the PIP joint and increased DIP flexion l Splinting Dorsal blocking splint Wrist neutral Thumb CMC flexed and abducted to the radial side of the second metacarpal Thumb IP in extension, MP in flexion of 20 30 degrees Flexor Pollicis Longus Rehabilitation Only one tendon in the sheath Pulleys can still cause limited gliding Early active and place hold are recommended as in the fingers GOAL Opposition to 5 th MP Overall improved results Early controlled active motion in managing FPL repair: Elliot 2005 Passive motion, edema control prior to active motion Active exercise portion Week 1 to middle finger Week 2 to the ring finger Week 3 flexing as far as possible Brace included the fingers to avoid FPL strain 73 77% good to excellent in 4 strand repairs Partial Tendon Lacerations Repair is recommended when over 60% of the tendon is lacerated Does not retract Vincula are intact Do well with early active protocols Untreated tendon complications Triggering Entrapment Rupture
Tenolysis p.o. therapy Tenolysis Consult surgeon Condition of tendon Pulley reconstruction Capsulodesis? ROM intraoperatively Extension splinting static vs progressive Splinting: Varies Maintain extension if flexion contracture Rest tissue between hourly exercises Night only after 1 week usually Exercise Precautions: No resistive exercises, No excessive stretching Goals: Control edema, achieve full intraoperative AROM, maintain A/PROM gains Exercises: Patient to perform differential tendon gliding every hour 10 reps; Daily therapy 1 st week, may use US early to control edema 2 Stage Tendon Reconstruction Primary vs. Staged Indications Repair is not possible Tendon bed scarred graft would probably fail Injuries requiring fracture fixation, flexor and extensor repair Contraindication infection Function: Stage 1 Maintain Fibroosseous canal and regenerate tendon sheath Enables passive flexion and active extension
STAGE II Active tendon graft is used Surgeons preferred tendon protocol Usually 3 6 months after stage I References Culditz, Judy Protecting Flexor Tendon Repairs Clinical Pearls No. 43 January 2017 Skirven, Osterman, Fedorczyk, Amadio. Rehabilitation of the Hand and Upper Extremity 6 th Edition; Mosby Philadelphia, PA. 2011 Skirven, Evans. Journal of Hand Therapy; Volume 18:2, April/June 2005 Tang, Jin Bo. Flexor Tendon Surgery of the Hand. Saunders/ Elsevier, 2012 Tang, JinBo. Wide Awake Primary Flexor Tendon Repair, Tenolysis, and Tendon Transfer. Clin Orthop Surg,, Sept 2015, vol 7(3); pages 275 281. Tang, youtube 6 strand tendon repair video March 2015.