If you are an Occupational Therapist or Physical Therapist currently limited in your experience with flexor tendon cases, scared that you might rupture the tendon, or worse yet, make no progress with your patients.
Keep reading. This blog is for you!
Flexor tendons have a notorious reputation of being hard to treat for Occupational Therapists, not just the patient. However, as the Hand Therapist, you need to be and feel confident cause it’s the only way to help your patients feel confident with what they have to do themselves.
One of the most important things about a Flexor Tendon Therapy and Treatment case is that you don’t want them to go too fast, but you can’t go too slow. So it’s up to you to find that nice spot where you can advance your patients without injuring the surgery.
You want to teach them to be in a very relaxed position because when they come out of their splint for the 1st time, you don’t want them trying to move into a full fist.
When you take off the bulky dressing, you tell them, “go ahead and relax your hand.”
If you take a look at the hand, there’s a natural attitude to the hand. If you let the wrist go down into flexion, the fingers automatically extend, and when you move the wrist into extension, the fingers automatically close. That’s just the typical tenodesis attitude of the hand. Use that to your advantage.
You want to make sure that the PIPs are in an extended position in zero, if possible. So after making the splint, one of the most important things is to initially start to educate them on what they’re able to do at home. You want them to do everything inside of the splint – at first.
Now in therapy, I’m going to do things with them outside of the splint because I will get a better handle without the splint. But when you teach them, you will educate them on what you want them to do at home inside that splint.
Now, based on the patient, I’m able to decide if we need to go faster or slower based on what they are able to do. And how safe they are able to follow the precautions.
There are MANY flexor tendon protocols. So when I know the surgeon, and I can communicate with them, I’ll put that wrist in zero because it’s just going to be less work later on, especially if the surgeon has told me they did a strong repair and the integrity of the tendon looks good.
I’m going to start at zero versus 20 degrees. That makes a big difference already, because then when you take them out, you have to work on their wrists. So MPs are in a safe flex position. A safe position means 60 to 70 degrees.
If I’m working with someone, I’m going to have them flex their DIP. We’re going to go down as much as possible. Whatever is tolerable, and my pressure is going to be less. I’m going to do DIP flexion-extension. And you got to be able to extend to zero. So if you’ve got them in a relatively safe wrist position to zero, you can even put them in a little bit of flexion.
But zero is fine because the MPs are completely fleed. So you want to go into extension just as much as you go into flexion. And then you’re going to go PIP, flexion-extension. So the tension you feel because of your finger placement, you’re going to feel that on the tendon, and you’ll know how much to pull, usually, like a moderate resistance that you can go up against.
This is what I say on their first day of flexor tendon therapy “we’re going to take it nice and easy on each finger – small knuckle, middle, and then you want composite all the way straight, curl it in, and composite. This is all passive range of motion. So if you’re able to touch that palm, you’re in a great position.
You’re going to feel some resistance because the flexor tendons are going to be tight. They might have a certain moderate amount of swelling. So the patient is going to feel it, so as soon as you feel the pull, you have to tell them. They want a little bit of movement. You can just put the wrist into some flexion, open your fingers, and then you’re safe because you’re in a safe wrist position.
The way I check the wrist is I’ll bring the wrist into some extension. I’ll select the fingers and pull the wrist back a little bit because I want to feel how much give is there in the wrist. Everything looks good. And one very important way to do so is I always recommend testing their flexor tendon integrity on the first day.
I’ve had patients before where they come in with a ruptured tendon already. And everyone likes to blame the therapist. Ruptured tendon, right? The therapist’s fault.
But you just don’t know. I had somebody who came in, and she was fighting her post-op dressing, and we knew it, and she knew it. But she was starting to get some dementia, and under anesthesia, it brings out the forgetfulness. So when she came into therapy, her post-op dressing was half off.
She had been clawing at the dressing and it became unraveled. You always want to check the integrity of that tendon. You should be able to feel it pull. The best way to check it is you’re just going to keep the wrist into a little bit of flexion.
You’re going to keep the MPs in flexion. So you know that you’re in a safe position. If you’re testing for the Profundis, you should feel a little glide. So you want them to pull ever so slightly. You’re looking for is a little wiggle.
If you feel for that glide, you know that that tendon is intact. If they don’t move, you still can feel that glide because it’s trying to pull. But you already have in your mind an idea that, Oops, that tendon is going to start to adhere down fast.
And if anything, we just want to make sure that the patient doesn’t move too fast. I tell my patients, “If you try to move your hand and you’re making a fist and doing a lot trying to use your hand, you need two more surgeries. If you rupture a tendon repair and don’t do the exercises I need you to do, and you’re not moving that tendon, and you get stuck, you’re going to need one more surgery.”
Flexor tendons have a notorious reputation of rupturing or getting stuck. Limited progress can be frustrating for Occupational Therapists, not just the patient.
As the Hand Therapist, you need to be and feel confident cause it’s the only way to help your patients feel confident with what they have to do themselves.
If you are frustrated and feel alone when working with flexor tendons on how to progress and get great results for your patients, Join Us in the Hand Therapy Mentorship Program.