Distal Bicep Tendon Repair- Rehabilitation Protocol

Transcription

1 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 postoperative 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 Week 3 Week 4 Week 5 Week 6 Week 8 45 to full elbow flexion 45 to full elbow flexion 30 to full elbow flexion 20 to full elbow flexion 10 to full elbow flexion 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

2 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 Week 2 Week 3-4 Week 8 Sub-maximal pain free isometrics for triceps and shoulder musculature. Sub-maximal pain free biceps isometrics with forearm in neutral. Single plane active ROM elbow flexion, extension, supination, and pronation. 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 Distal Biceps Tendon Repair Accelerated Rehabilitation Protocol Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 2

3 Department of Rehabilitation Services Physical Therapy Distal Bicep Tendon Repair- Accelerated Rehabilitation Protocol The intent of this protocol is to provide the clinician with a guideline of the postoperative 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 Week 6 Full extension to full flexion 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 Distal Biceps Tendon Repair Accelerated Rehabilitation Protocol Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 1

4 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 Week 2 Week 3-4 Week 6 Sub-maximal pain free isometrics for triceps and shoulder musculature. Sub-maximal pain free biceps isometrics with forearm in neutral. Single plane active ROM elbow flexion, extension, supination, and pronation. 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. Formatted by Ethan Jerome, PT 04/06 Distal Biceps Tendon Repair Accelerated Rehabilitation Protocol Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 2

5 Department of Rehabilitation Services 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: 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: The intent of this protocol is to provide the clinician with a guideline of the postoperative 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 postoperative 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: Week 1: Protect healing tissue Decrease pain/inflammation Retard muscular atrophy Promote scar mobility 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

6 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 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 degrees (Gradually increase ROM 5 degrees extension/10 degrees flexion per week) Exercises: Continue all exercises listed above 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 degrees Exercises: Wrist curls, extensions, pronation, supination with light weight (1-2#) Elbow extension/flexion AAROM/AROM ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING AUTOGENOUS GRAFT PROTOCOL 2

7 Progress shoulder isometrics to isotonics, emphasize rotator cuff strengthening (Avoid resisted external rotation until 6 th week to minimize forces on repaired UCL) Week 6 Brace hinged elbow brace set degrees. Brace may be discontinued at the end of week 6 Exercises: AROM 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: Continue all exercises listed above 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 ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING AUTOGENOUS GRAFT PROTOCOL 3

8 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 (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) Formatted by Ethan Jerome, PT 04/06 ULNAR COLLATERAL LIGAMENT OF THE ELBOW RECONSTRUCTION USING AUTOGENOUS GRAFT PROTOCOL 4

9 BRIGHAM AND WOMEN S HOSPITAL A Teaching Affiliate of Harvard Medical School 75 Francis St. Boston, Massachusetts Department of Rehabilitation Services 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 postoperative 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 hyperextension (HE). Splint worn continuously. 6-8 weeks Provide 2 splints, 1 for showering. Remove splint for exercise, otherwise splint is worn continuously. >8 weeks Gradually wean from splint during day.continue splint at night D/C splint weeks A-AAROM of MP and PIP. AROM of DIP flex/ext, 10 reps hourly. Start at 10 degrees flexion, progress in degree increments per week, if no extensor lag develops. Can introduce AAROM as needed. PROM/PREs Daily skin checks while maintaining DIP in HE No active DIP motion. If extensor lag develops > 10 degrees, resume continuous splinting (no ROM) for 1-2 weeks and reassess. PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. If swan-neck deformity develops, splint PIP at flexion via dorsal block splint. Casting is an option, and may have better outcomes via constant circumferential positioning. Prehension and coordination exercise should supplement ROM program. 1

10 ZONE III: Over the proximal interphalangeal joint (PIP)-Boutonniere deformity ZONE IV: Over the proximal phalanx * IMMOBILIZATION PROTOCOL WEEK SPLINT THER EX PRECAUTIONS OTHER 1-6 weeks Volar digit static splint, PIP at absolute 0 degrees, or serial cast Lateral bands Repaired: include DIP at 0 degrees. If the lateral bands are not repaired the DIP is left free. 6-8 weeks Gradually wean from splint during day. ROM may be initiated anytime during week 3 to 6, depending upon healing. Initiate AROM PIP flex to 30 degrees. If no extensor lag develops, progress in degree increments each week. 10 repetitions hourly. If lateral bands are repaired, begin gliding at week 3, and at week 1 if lateral bands not injured. AAROM or dynamic flexion splinting may be initiated, as well as combined flexion of the wrist and No forceful flexion. No gripping. Splint remains on continuously between ROM sessions. Continue splint at night. digits 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) Serial cast may be chosen if there is a PIP joint flexion contracture, if there is a closed injury, or if the patient is unable to adhere to splinting program. Timing of initiating AROM is determined based on severity of laceration, strength of repair, and patient profile. Light function out of splint. ** PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 2

11 ZONE III IV: Over the PIP joint to proximal phalanx SHORT ARC MOTION (SAM) PROTOCOL WEEK SPLINT THER EX PRECAUTIONS OTHER Week 1 Digit volar immobilization splint: PIP and DIP at 0 degrees. Splint worn at all times except during exercise. Remove immobilization splint hourly for reps of AROM PIP and DIP motion in both template 1 & 2 splints. Week 2 Week 3 Week 4 Two volar static exercise splints: template 1 PIP 30 flex, DIP 20 flex template 2 PIP 0, DIP free If no extensor lag: Progress template 1 to PIP 40-50, DIP If no extensor lag: Progress template 1 to PIP 50-60, DIP If no extensor lag: Progress template 1 to PIP 70-80, DIP Wrist is held in 30 flexion, MP at 0. If lateral bands are repaired, limit DIP flexion to in template 2. If not injured, fully flex and extend DIP. If an extensor lag develops, flexion increments should be more modest and exercise should focus on extension. Week 5 Begin splint weaning. Composite flexion and gentle PREs. Week 6 D/C splint. Splint at PROM & PREs, night only PRN. reverse putty scraping PIP joint must be positione d at 0 degrees in immobili zation splint to prevent extensor lag. Patient is instructed in technique of controlled motion with minimal active tension. If rupture is suspected, refer patient to MD for assessment. If PIP is stiff, splint intermittently into flexion, but continue static extension splinting into week 5 or 6. Initiate light functional activities out of splint. PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 3

12 ZONE V: over the metacarpalphalangeal joint (MCP). ZONE VI: over the metacarpal bone (MC). CONTROLLED PASSIVE MOTION WEEK SPLINT THER EX PRECAUTIONS OTHER 1-3 days post-op through week weeks 6 weeks Forearm based dynamic digital extension splint Wrist degrees ext, MP at 0, PIPs free Fabricate static forearm based Splint at night, wrist at ext, MPs at 0, PIPs free. Come out of splint for exercise D/C splint. Dynamic flexion splinting PRN. AROM flexion: isolated joint and tendon gliding (hook and straight fist). Passive extension via elastic recoil of the dynamic splint reps hourly. Begin active MP flexion to degrees (via flexion block on dynamic splint). Progress MP flexion as tolerated. Perform wrist and digit PROM in extension and tenodesis out of splint 10 repetitions hourly. Progress MP flexion to (week 4), (week 5). Initiate full fisting if not already done. Composite wrist and finger flexion. Active digital extension exercises out of splint. AAROM, PREs, heat and stretch, reverse putty scraping Full fisting may place too much stress on the repair. Assess on a case-bycase basis. No resistance until 6-8 weeks May consider option of total immobilization if necessary. Volar static digital IP extension splints can be made to facilitate MP excursion by immobilizing IP joint (splint placed in slings). Allows greater pull-through at MP joint. May initiate NMES, therapeutic heating via ultrasound if needed. PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 4

13 ZONE VII: at the level of the dorsal retinaculum in the wrist. EARLY ACTIVE MOTION PROTOCOL WEEK SPLINT THER EX PRECAUTIONS OTHER 1-3 days post-op through week 3 Weeks 4-5 Static or dynamic splint * : Wrist 30 ext MPs at 0 If dynamic splint chosen, also fabricate static forearm based splint at night, wrist at 30 ext, MPs at 0, PIPs free. If EDC is repaired, tenodesis from 40 ext to 10 ext. If wrist extensors are repaired, tenodesis from 40 ext to 20 ext. In both cases, allow active MP flexion to degrees of flexion (via flexion block on splint) while the wrist is held in extension. If EDC is repaired, hook fisting only. If just wrist extensors repaired, hook, full and straight fisting. All exercises are 10 repetitions hourly. Progress MP flexion to (week 4), (week 5). Can modify wrist to neutral in night splint. No active wrist extension or resistive activity with the hand. *Choice of static vs. dynamic splint is a clinical decision based on severity of injury, strength of repair, concomitant injuries and patient profile. See SOC for discussion on number of suture strands and strength (usually between 2 and 4); issues are strength vs. bulk. Communication with MD is necessary to determine Rx plan. Can begin light function in the 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 PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 5

14 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: April/June of Splint Design 2 Components 1. Wrist splint degrees of wrist extension 2. Yoke splint * with involved MP joint in 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 S Phase I: AROM digit motion, Week 0-3 including full fisting Phase II: Week 4-5 Phase III: Week 6-7 Both wrist and yoke splint at all times. Yoke splint at all times. Yoke and wrist splint during mod-heavy activities. D/C wrist splint Yoke splint or buddy strap worn during activity, wean as tolerated. Initiate AROM wrist with digits relaxed. If no extensor lag, progress to composite wrist flexion with fisting & composite wrist and digits ext. Vigor of exercise is monitored to prevent inflammatory response. No resistive activity. OTHER Edema control Scar management Goal: Full AROM digits prior to progressing to Phase II. Goal: Full wrist AROM prior to removing wrist splint for light activities. Goal: Full composite wrist and digit motion prior to removing yoke splint for activities and D/C from therapy. PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 6

15 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. PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 7

16 THUMB TI: over the IP joint IMMOBILIZATION PROTOCOL WEEK SPLINT THER EX PREC OTHER 1-3 days post-op through week 3 Splint IP joint at 0 or slight hyperextension Non-operative: 8 weeks continuously Operative: 5-6 weeks continuously 5-6 weeks May remove splint for exercise, otherwise continue splint at all times for 2-4 more weeks. None at this time Operative: AROM IP flexion in 20 degree increments per week, modifying progression if extensor lag develops. 10 repetitions/ hourly. No flexion of IP joint. Remove splint daily for skin checks. No gripping or pinching, even in splint. Issue 2 nd splint for showers. May also use McConnell tape to hold digit in place during splint changes. 8weeks Gradually wean from splint during day. Continue splint at night weeks D/C splint Non-operative: No ROM at this time. Operative: May start AAROM if needed, provided no extensor lag. Non-operative: Initiate AROM IP flexion in 20 degree increments Operative: PROM and PREs (light gripping and pinching) Non-operative: AAROM, progress to PROM, PREs as tolerated PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 8

17 THUMB TII: over the proximal phalanx of the thumb IMMOBILIZATION PROTOCOL WEEK SPLINT THER EX PRECAUTIONS OTHER Week 1 Hand based static splint (short opponens) MP and IP at 0 degrees, thumb in radial abduction. No active motion at this time. Week 3 Week 4-5 Week 6 Begin to wean from splint. Dynamic flexion splinting PRN. Initiate AROM flexion at each joint; progress in degree increments each week. AAROM flexion, isolated and combined joint The problems of tendon-tobone adherence may become an issue in this zone. Light prehension ADL out of splint Moderate prehension ADL out of splint Week 8 D/C splint PREs Full function PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 9

18 THUMB T III: over the metacarpophalangeal joint (MP) THUMB T IV: over metacarpal bone CONTROLLED PASSIVE MOTION PROTOCOL WEEK SPLINT THER EX PRECAUTIONS OTHER Week 1 Forearm based splint, static or dynamic, thumb MP joint at 0 (not HE) and slight abduction, wrist at 30 ext. Initiate AROM flexion in 20 degree increments per week. No active extension. No gripping or pinching, even in splint. Week 2-4 If dynamic splint chosen, also fabricate static forearm based splint at night, wrist at 30 ext, MP at 0 PROM extension (either via dynamic traction, or self- PROM to static splint limit). Increase AROM flexion arc as tolerated. Choices for exercise and splinting are based on MD preference, strength of repair, potential for scarring, and patient. Week 4 Week 5-6 Week 6-8 Initiate dynamic flexion splinting PRN. D/C splint Place and hold extension may be initiated at 3 weeks. AROM in extension Full AROM flexion, isolated and combined PREs PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 10

19 THUMB T V: level of the retinaculum of the wrist Week 1 Week 3 Dynamic extension splinting as described in Zones III and IV. As above May initiate AAROM flexion Dense adhesions may limit EPL excursions at the retinacular level. Proper wrist and thumb positioning are crucial. 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: Newport M, Tucket R. New Perspectives on Extensor Tendon Repair and Implications for Rehabilitation. Journal of Hand Therapy. April/June 2005; Howell J, Merrit W, Robinson S. Immediate Controlled Active Motion Following Zone 4-7 Extensor Tendon Repair. Journal of Hand Therapy. April/June 2005; Authors: Reviewers: Joanne Bosch, PT Gayle Lang, OT 9/07 Reg Wilcox, PT Maura Walsh, OT PRIMARY EXTENSOR TENDON REPAIR PROTOCOL (EDC, EIP, EDQ, EPL, ECRL, ECRB, ECU) Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. 11

20 BRIGHAM AND WOMEN S HOSPITAL A Teaching Affiliate of Harvard Medical School 75 Francis St. Boston, Massachusetts Department of Rehabilitation Services Physical Therapy Zone 1, FDP Flexor Tendon Repair Protocol 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 a flexor 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 postoperative patient, they should consult with the referring surgeon. Week Splint Therapeutic Exercise Precautions Other 0-3 weeks Forearm based dorsal block splint with wrist at 30 degrees of flexion, MP s at 30 degrees of flexion and IP s fully extended. Separate finger splint of repaired digits holding DIP in 45 degrees of flexion (taped onto finger proximal to DIP crease). This positions the FDP tendon repair proximal to the skin incision, and counteracts the effect of the oblique retinacular ligament. Note: Splint is the same, with or without a suture button (tendon repaired to tendon or repaired to bone). Home exercise program: 1. Passive DIP flexion to 75 degrees 2. Passive composite digit flexion 3. Passive modified hook fist (MP s extended only to 30 degrees). 4. Block MP in full flexion and actively extend PIP, keeping repaired digit in DIP splint. 5. Use distal strap to hold unaffected digits in extension against splint. Place/hold repaired finger in PIP flexion (tp glide FDS only). 6. Passive (or gravity assisted) wrist flexion, followed by active wrist extension to limits of splint. Therapist performs with patient in clinic: 1. Passive wrist extension with fingers flexed (splinted removed) 2. Passive wrist flexion with passive hook fisting to prevent intrinsic tightness No active DIP flexion of involved digits. No active wrist flexion. No passive finger extension, except as noted above.. Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 1

21 BRIGHAM AND WOMEN S HOSPITAL A Teaching Affiliate of Harvard Medical School 75 Francis St. Boston, Massachusetts Department of Rehabilitation Services 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. weeks Discard DIP flexion splint. Convert splint to hand based dorsal block splint. Continue with all previous exercises. (Patient may perform all exercises at home). Active tendon gliding in all three fist positions. Gentle DIP flexion blocking exercises for FDP gliding. No resistive exercise. Ensure smooth gliding tendons, minimal tension during ROM. Avoid resistance until weeks 7-8. Light prehensile activities OK in therapy. 5 weeks Discontinue splint. May use static progressive splints to regain DIP extension if needed 6 weeks Gentle passive DIP extension exercises if needed Light prehensile activities OK at home. May initiate NMES, therapeutic heating via ultrasound if needed. 8 weeks Resistive exercise; progress gradually. Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 2

22 BRIGHAM AND WOMEN S HOSPITAL A Teaching Affiliate of Harvard Medical School 75 Francis St. Boston, Massachusetts Department of Rehabilitation Services Physical Therapy Zones 2-5 Flexor tendon repair Protocol Timeline Splint Therapeutic Exercise Precautions Other Week 0-3 Dorsal Blocking Splint a. Wrist neutral b. MCP s 50 flexion c. IP s in full extension Reminder: If FDP of MF, RF, or SF repaired, must include all three digits in splint. Home exercise program: 1. Passive composite full fist 2. Passive DIP extension maintaining MCP and PIP in flexion 3. Block MCP in full flexion and actively extend IP s 4. Passive DIP flexion and active extension 5. Passive PIP flexion and active extension 6. Isolated FDS glide of unaffected fingers 7. Passive (or gravity assisted) wrist flexion, followed by active extension to splint limits. Therapist performs with patient in clinic: 1. Remove splint: passive wrist extension with fingers flexed. 2. Passive wrist flexion with passive hook fisting to prevent intrinsic tightness Early Active Motion Protocol: 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 a flexor 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 postoperative patient, they should consult with the referring surgeon. *If cleared by MD and suture of adequate strength (four strand core repair with epitendinous suture augmentation). Reminders: Severe edema increases tendon drag and likelihood of rupture. Therefore, wait until 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. No active flexion of involved digits unless cleared for early active motion (EAM). No passive wrist extension. No passive finger extension, except as noted above. No functional use of involved hand. Wound care Edema control Scar massage Note: If pulley was repaired, may need pulley ring fabricated. Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07)

23 BRIGHAM AND WOMEN S HOSPITAL A Teaching Affiliate of Harvard Medical School 75 Francis St. Boston, Massachusetts Department of Rehabilitation Services Physical Therapy Zones 2-5 Flexor tendon repair Protocol Timeline Splint Therapeutic Exercise Precautions Other Week 3 May initiate serial static PIP extension splints at night if needed. Add place/hold if not yet done via EAM. 1. Place/hold for hook, full and straight fist with wrist extended. 2. Place hold for isolated FDS glide of involved digits. Same as week 1-3 Place/hold exercises should be done with gentle tension only. Week 4 Convert splint to hand based dorsal block splint. Initiate active, non-resistive digital flexion and extension in all three fist positions with wrist extended. Week 5 Discharge splint. Add gentle blocking exercises for DIP/PIP flexion if needed. Week 6 May initiate dynamic PIP extension splinting if needed. Week 8 Gradually add resistive exercise to home program. Avoid muscle cocontraction by patient during place hold exercises. Light prehensile activities OK in therapy. Light prehensile activities OK at home. May initiate NMES, therapeutic heating via ultrasound if needed. Functional use of 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)

24 BRIGHAM AND WOMEN S HOSPITAL A Teaching Affiliate of Harvard Medical School 75 Francis St. Boston, Massachusetts Department of Rehabilitation Services Physical Therapy Flexor Pollicis Longus (FPL) Repair Protocol (all zones) Timeline Splint Therapeutic Exercise Precautions Other 0-3 weeks 1. Dorsal Blocking splint a. Wrist at neutral b. Thumb CMC flexed and abducted under second metacarpal c. Thumb MP in full extension. Zone I only: 2. Separate dorsal gutter thumb IP splint blocking IP in 30 degrees flexion, to be worn with above splint. 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 a FPL 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 postoperative patient, they should consult with the referring surgeon. Home exercise program: 1. Passive composite thumb flexion/active extension to limits of splint. 2. Passive IP flexion/active extension to limit of splint. 3. Gravity assisted wrist flexion/ active extension to limit of splint. 4. Tendon gliding exercises for digits 2-5. Early Active Motion Protocol: *If cleared by MD and suture of adequate strength (four strand core repair with epitendinous suture augmentation). Reminders: Severe edema increases tendon drag and likelihood of rupture. Therefore, wait until 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. No active thumb flexion unless cleared for early active motion (EAM). No passive wrist extension. No passive thumb extension. No functional use of the involved hand. Wound care Edema control Scar massage May need pulley ring if pulley repair. Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 1

25 BRIGHAM AND WOMEN S HOSPITAL A Teaching Affiliate of Harvard Medical School 75 Francis St. Boston, Massachusetts Department of Rehabilitation Services Physical Therapy Flexor Pollicis Longus (FPL) Repair Protocol (all zones) Timeline Splint Therapeutic Exercise Precautions Other 3 weeks Continue with all previous exercises. Under therapist supervision in clinic: Add place/hold for thumb flexion with wrist passive extended (if not already done via EAM). Gentle muscle contraction only. 4 weeks Convert splint to hand-based. Initiate active, non-resistive thumb flexion with wrist extended. 5 weeks Discontinue splint Add gentle blocking exercises for thumb IP flexion. Continue with all previous precautions. Avoid cocontraction during place/hold exercises Light prehensile activities OK in therapy. Light prehensile activities OK at home. 6 weeks May initiate dynamic IP extension splinting if needed. 8 weeks May add putty scraping if needed. Gradually add resistive exercise to home program. May initiate NMES, therapeutic heating via ultrasound if needed Gradually allow resistive use of involved thumb in ADLs. Copyright 2007 The Brigham and Women's Hospital, Inc. Department of Rehabilitation Services. All rights reserved. (9/07) 2