Chapter 5 Appendix

Insufficient Finger and/or Thumb Flexion Syndrome

The principal impairment in insufficient finger and/or thumb flexion syndrome is limited finger or thumb flexion AROM, but the key to prescribing the appropriate interventions is differentiating between the sources causing the limited flexion. The sources of the limited flexion can be broadly classified into two main categories: hypomobility (physiological and accessory motion) or force production deficit (decreased strength). Insufficient finger and/or thumb flexion syndrome is most commonly secondary to a trauma or injury or after a period of immobilization to allow for tissue healing. Initially, these patients may be assigned a movement system diagnosis of hand impairment Stage 1, but an underlying movement system diagnosis of insufficient finger and/or thumb flexion syndrome may help guide treatment. As the tissues heal, the diagnosis may change from hand impairment to another movement system diagnosis such as insufficient finger and/or thumb flexion syndrome. The “Source of Signs and Symptoms” column provides key information regarding the cluster of findings identifying the source of the limited flexion. The identified source or cause of insufficient finger and/or thumb flexion comprises the second part of the name of the syndrome.

Treatment

See Box 5-2 for treatment of scar and edema. The usual expectation is that AROM should increase by a minimum of 10 degrees per week except when the cause of the limitation is due to profound weakness or rupture. Pain and edema should decrease gradually over the course of treatment. The therapist must avoid applying excessive force when performing passive stretching exercises on patients that have hand injuries. Overly aggressive exercise increases swelling and may result in increased fibrosis and limitation of ROM.

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Flexor Tendon Adhesion

Treatment of adhesions requires active and resistive contraction of flexors and stretching into composite extension (see Box 5A-1 for General Guidelines for Treatment Progression).

A. Soft tissue massage⁴,²²

1 Adhesions: Retrograde massage over flexors pushes skin distally while actively flexing fingers and pulls skin proximally while extending wrist and fingers.

BOX 5A-1 General Guidelines for Treatment Progression

General guidelines for progression of treatment from easiest or least aggressive to most aggressive for an adhered tendon:

1 Circular massage and active exercise

2. Retrograde massage with active exercise

3. Composite stretching passively into limited ROM

4. Static progressive or dynamic composite splinting into limited ROM

5. Resistive exercises

B. Passive stretches⁴,¹⁶ (flexor tendon gliding distally; Figures 5A-1 and 5A-2)

1 Composite finger extension: Progression is accomplished by sequentially adding wrist extension, forearm supination, and elbow extension as tolerated (Figure 5A-2, A).

2. A static splint stabilizing fingers in extension may be helpful during passive wrist extension⁴ (Figure 5A-2, B).

Figure 5A-1 Direction of tendon glide. Flexor tendon glides proximally with active flexion. Flexor tendon glides distally with active or passive finger extension.

Figure 5A-2 Composite stretching fingers and wrist into extension for distal gliding of adhered finger flexor tendons or lengthening the finger flexors. A, Manual stretching using opposite hand. B, Stretching with assist of splint to maintain finger extension.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

Figure 5A-3 Flexor tendon gliding exercises. Straight fist: FDS glides maximally with respect to sheath and bone. Hook fist: Maximum gliding between FDS and FDP. Fist: FDP glides maximally with respect to sheath and bone.

(Reprinted from Wehbe MA, Hunter JM: Flexor tendon gliding in the hand. II. Differential gliding, J Hand Surg 10A:575-579, 1985.)

C. Active flexion (flexor tendon gliding proximally) (Figure 5A-3)

1 Composite, blocked flexion and isolated flexor tendon exercise⁴,²² (Figure 5A-4).

2. Differential tendon gliding²² (see Figure 5A-3).

Figure 5A-4 Active finger flexion exercises to increase flexor tendon gliding proximally. A, Active braced or blocked DIP flexion to increase gliding of flexor digitorum profundus. B, Use of thermoplastic splint to isolate movement to DIP joint and block PIP and MP joint motion. C, Use of Bunnell block to isolate DIP flexion. D, Active braced or blocked PIP flexion to increase gliding of flexor digitorum superficialis. E, Exercising flexor digitorum superficialis by actively flexing middle finger PIP joint, preventing flexor digitorum profundus from working by stabilizing other fingers in extension. F and G, Use of thermoplastic splints to isolate movement to PIP joint and block MP joint motion.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

D. Resisted flexion (proximal flexor tendon gliding with additional force)

1 Resistive putty, hand grippers (adjust grip size to maximize effectiveness), elastic band⁴,²² (Figure 5A-5)

Figure 5A-5 Resistive finger flexion exercises to increase proximal tendon gliding of the finger flexors. A, Finger flexion into putty resting on table. B, Composite finger flexion done incorrectly: Involved index finger is not touching putty. C and D, Composite finger flexion done correctly with putty and hand gripper, respectively, resisting involved index finger.

(A to C, Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

E. Static progressive/dynamic splinting into extension¹⁶

1 Composite wrist and finger extension splint positioned in slightly better extension than when the patient presents. Straps are adjusted to tolerance for a gradual stretch of the flexors and the splint is used at night⁴ (Figure 5A-6, A).

2. Dorsal forearm splint with a tolerable force from fishing line, rubber band, or spring, holding the digits in extension. Static progressive splint should be worn 30 minutes 3 times/day. Dynamic splint may be worn 20 to 30 minutes 3 to 5 times/day. The patient may need to start with 10 minutes and gradually increase the time to 30 minutes⁴ (Figure 5A-6, B).

Figure 5A-6 Splinting for insufficient finger flexion caused by flexor shortness or adhesions. A, Static splint to maintain wrist and fingers at end-range extension used at night. B, Static progressive or dynamic splint to increase composite wrist and finger extension.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

F. Modalities (used when other treatment options are not effective)

1 Electrical stimulation (Russian) to flexors to assist active contraction⁴

2. Ultrasound over adherent tendon⁴

G. Progression of resistance for return to function

1 Upper extremity ergometer, isokinetic, and Baltimore Therapeutic Equipment (BTE) machines²³

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Extensor Tendon Adhesions/Extrinsic Extensor Muscle Shortness

Treatment of both shortness and adhesion requires stretching into composite flexion. Treatment of adhesions only requires active and resistive contraction of extensors.

A. Soft tissue massage²² (Figure 5A-7)

1 Adhesions: Retrograde massage over extensors pushes skin distally while actively extending fingers and pulls skin proximally while flexing wrist and fingers.

Figure 5A-7 Massage for Insufficient finger flexion caused by extensor tendon adhesions. A, Pushing scar distally the opposite direction of the tendon glide during active finger extension. B, Pushing scar proximally during active finger flexion.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

B. Passive or active stretches (provides extensor tendon gliding distally)¹⁶ (Figure 5A-8, A, B, and D to F)

1 Composite finger flexion: Progression is accomplished by sequentially adding wrist flexion, forearm pronation, and elbow extension as tolerated.

2. A flexion glove stabilizing fingers in flexion may be helpful during passive wrist flexion.

3. Holding a dumbbell weight and working on wrist flexion is another method of stretching the extensors.

Figure 5A-8 Exercises for insufficient finger flexion caused by extensor tendon adhesions or shortness. A and B, Active composite finger flexion for shortness or adhesions. C, Active composite extension for adhesions to increase extensor tendon gliding proximally. D, Passive finger flexion for adhesions to increase extensor tendon gliding distally. E and F, Composite passive finger flexion for adhesions to increase extensor tendon gliding distally or lengthen short extensors.

(B to F, Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

C. Active extension (proximal extensor tendon glide) (Figure 5A-8, C)

1 Composite and isolated: Differential tendon gliding (claw position for EDC)²²,²⁴

D. Resisted extension (proximal tendon glide with additional force)²⁴ (Figure 5A-9)

1 Resistive putty, rubber bands, elastic band

Figure 5A-9 Insufficient finger flexion caused by extensor tendon adhesions. Resisted finger extension exercises to increase extensor tendon gliding. A, Manually resisted MP extension. B and C, Resistive putty. D, Elastic band.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

E. Static progressive/dynamic splinting into flexion¹⁶ (Figure 5A-10)

1 Wrist cock-up splint in slight wrist flexion with flexion glove⁵ can be worn, if tolerated, at night or periodically through the day (minimum of 20 minutes).

2. Dorsal splint with outrigger for MP and IP flexion (wrist positioned in neutral or slight flexion) can be worn 20 to 30 minutes 4 to 6 times/day.

Figure 5A-10 Insufficient finger flexion caused by extensor tendon shortness or adhesions. A, Flexion glove for gentle composite stretch to fingers into flexion. B, Addition of elastic band around hand and middle phalanges to flexion glove to increase MP and PIP flexion. C, Dynamic MP and IP flexion splint.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

F. Modalities

1 Moist heat²⁵ over dorsal surface with extensors on a stretch (wrist or fingers flexed)

2. Electrical stimulation (Russian) to extensors to assist active contraction²⁴

3. Ultrasound²⁵ over adherent tendon or shortened muscle while on a stretch

G. Progression of resistance for return to function

1 Upper extremity ergometer, isokinetic, and BTE machines²³,²⁴

See guidelines for progression of treatment in section on flexor tendon adhesions (see Box 5A-1).

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by MP Collateral Ligament and/or IP Dorsal Capsule Shortness or Adhesion⁵,¹⁶

Treatment isolates motion to the joint that is stiff so that the joint that is relatively most flexible does not move. Often, decreasing the amount of effort is helpful to obtain precise movement at the involved joint.

A. AROM and PROM specific to short structure (Figures 5A-11 and 5A-12)

1 Passive or active blocking exercises for MP joint flexion to stretch collateral ligaments

2. Passive or active blocking exercises for PIP or DIP flexion to stretch the dorsal capsule

3. Joint mobilization techniques (e.g., volar glide and distraction to increase MP or IP flexion).

4. Most patients with limited PIP flexion also have limited PIP extension so the following exercises would also be appropriate:

a. Passive or active blocking exercises for PIP or DIP extension to stretch volar plate

b Joint mobilization gliding distal joint surface dorsally to increase IP extension

Figure 5A-11 Exercises for insufficient finger flexion caused by joint structures. A, Active braced or blocked PIP flexion. B, Active braced or blocked MP flexion. C, Active MP flexion with uninvolved IP joints immobilized in extension. D, Passive MP flexion with wrist stabilized.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

Figure 5A-12 Insufficient finger flexion caused by joint structures. Treatment using joint mobilization.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

B. Static splints

1 To increase PIP extension, static splints can be worn at night or periodically throughout the day (e.g., a volar gutter splint in 0 degrees extension with dorsal strap over PIP joint).

2. Splints maintain gentle stretch on short structure.

C. Static progressive/dynamic splints

1 Specific to short structure (20 to 30 minutes/4 to 6 times/day).

2. Flexion glove, often worn at night, is best for increasing MP flexion unless an additional strap is added to increase PIP flexion⁵ (see Figure 5A-10, A and B).

3. Static progressive/dynamic MP⁵ or IP flexion splint (Figures 5A-13 and 5A-14).

4. Static progressive/dynamic PIP extension splint.

Figure 5A-13 Insufficient finger flexion caused by shortness of PIP or DIP dorsal capsule. Elastic flexion splint to increase PIP and DIP flexion (best for DIP).

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

Figure 5A-14 Insufficient finger flexion caused by MP collateral ligament shortness or adhesions. A, Treatment initiated early while still casted by adding slings to pull MP joints into flexion. B, Dynamic MP flexion splint. C, Static progressive MP flexion splint.

(Used with permission from Ann Kammien, PT CHT, St Louis, Mo.)

D. CPM²⁶

1 For isolated or composite motions, CPM is most helpful acutely while in hand impairment Stage 1 or after tenolysis.

E. Modalities²⁵: Not usually the priority for treatment but used when exercise, splinting, edema, and scar management techniques alone are not effective

1 Hot/cold packs/paraffin

2. Electrical stimulation to assist active contraction and provide feedback

3. Ultrasound for increased tissue extensibility

a. Underwater

b Continuous at 0.5 to 1.0 W/cm² (using 3 mHz frequency)

c Always with restricted tendon/muscle on a stretch

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by ORL Shortness²⁴ (Figure 5A-15)

Treatment is simultaneous DIP flexion with PIP extension exercises performed actively, passively, or with resistance. In some cases, splinting to hold the PIP joint in extension may be helpful.

Figure 5A-15 A and B, Exercises for insufficient finger flexion caused by short ORL.

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Intrinsic Muscle Shortness¹⁶

A. Passive stretches: MP joint positioned in full extension while passively flexing the IP joints (Figure 5A-16, A)

B. Active “hook grip” position: MP joint extension and IP joint flexion (Figure 5A-16, B)

C. Active and passive MP joint abduction or adduction: IP joints held in flexion with the MP joint in full extension for unilateral finger intrinsic shortness or stiffness (Figure 5A-16, C)

D. Resistive hook grip with resistive putty (Figure 5A-16, D)

E. Static progressive/dynamic splinting: Dorsal hand or forearm-based splint extending to the PIP joint level (MP joints extended) with adjustable straps positioning the IP joints in end-range flexion

F. Patient education

1 Modify grip to avoid prolonged or repeated intrinsic-plus position as possible.

2. If intrinsic plus position is required for daily activities, performance of active and passive stretches is recommended frequently during day.

Figure 5A-16 Insufficient finger flexion caused by short intrinsic muscles. A, Passive IP flexion with MP in extension to stretch interossei. B, Active IP flexion with MP’s in extension. C, Index MP abduction with IPs flexed and MP in extension to stretch first palmar interossei. D, Resistive hook fist with resistive putty.

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Swan Neck Deformity

Treatment is controversial; some experts say no improvement occurs with conservative treatment or splinting. Others recommend splinting and exercises to correct joint contractures and intrinsic shortness in the early stages.²⁷ Surgery is usually necessary for lasting correction.

A. Exercise

1 Active and passive intrinsic muscle stretching exercises (see Figure 5A-16, A and B)

2. Active and passive composite finger and wrist flexion to maintain appropriate length of EDC if needed (see Figure 5A-8, A and B)

3. Patient education to correct faulty movement patterns (intrinsic plus position) during functional activities by increasing use of FDP, FDS, and extensor digitorum

B. Splinting²⁸

1 Night splint hand with MPs in extension and IPs flexed.

2. Daytime constant use of button-hole splint to prevent PIP hyperextension but allow PIP flexion. (Use 6 weeks and then as needed.) (Figure 5A-17, A and B)

3. If splints are needed long term, silver ring splints may be preferable to thermoplastic splints²⁷

4. Patient education regarding splint use, skin precautions (e.g., redness of skin, avoid leaving splint in hot place, instructions regarding how to don and doff splint)

Figure 5A-17 Insufficient finger flexion due to swan neck. A, Static buttonhole splint preventing PIP hyperextension. B, Static buttonhole splint allows PIP flexion.

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome caused by Weakness of Flexors

Overload the muscle progressively as appropriate for the specific strength of the muscle. Exercises should be done every other day, 3 sets of 10 to 15 repetitions each time, once strength is greater than 3+/5. Exercises can be performed more often at the weaker grades. May need to use tenodesis action with the wrist to achieve finger flexion if no finger flexion available actively.

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Rupture of Flexor Tendon

Contact physician same day and schedule appointment for patient to see physician.

Insufficient Finger and/or Thumb Extension Syndrome

The principal impairment in insufficient finger and/or thumb syndrome is limited finger and/or thumb extension AROM, but the key to prescribing the appropriate intervention is differentiating between the sources causing the limited extension. The sources of the limited extension can be broadly classified into two main categories: hypomobility (physiological and accessory motion) or force production deficit (decreased strength). Insufficient finger and/or thumb extension syndrome is most commonly secondary to a trauma or injury or after a period of immobilization to allow for tissue healing. Initially, these patients may be assigned a movement system diagnosis of hand impairment Stage 1, but an underlying movement system diagnosis of insufficient finger and/or thumb extension syndrome may help guide treatment. As the tissues heal, the diagnosis may change from hand impairment to another movement system diagnosis such as insufficient finger and/or thumb extension syndrome. The “Source of Signs and Symptoms” column provides key information regarding the cluster of findings identifying the source of the limited extension. The identified source or cause of insufficient finger and/or thumb extension comprises the second part of the name of the syndrome.

Treatment for Insufficient Finger and Thumb Extension

See Box 5-2 for treatment of scar and edema. The therapist must avoid applying excessive force when performing passive stretching exercises on patients that have hand injuries. Overly aggressive exercise increases swelling and may result in increased fibrosis and limitation of ROM.

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Flexor Tendon Adhesions/Shortness

Treatment of adhesions requires active and resistive contraction of flexors. Treatment of both adhesions and shortness require stretching into composite extension (see Box 5A-2).

A. Soft tissue massage⁴,²²

1 Adhesions: Retrograde massage over flexors pulls skin proximally while actively extending wrist and fingers and pushes skin distally while actively flexing fingers.

2. Muscle shortness: Soft tissue massage techniques can be helpful before stretching.

BOX 5A-2 General Guidelines for Treatment Program

General guidelines for progression of treatment from easiest or least aggressive to most aggressive for an adhered tendon:

1 Circular massage and active exercise

2. Retrograde massage with active exercise

3. Composite stretching passively into limited ROM

4. Dynamic or static progressive composite splinting into limited ROM

5. Resistive exercises

B. Passive stretches (flexor tendon glides distally)⁴,¹⁶

1 Composite elbow extension, forearm supination, wrist, and finger extension (modify to tolerance by adding one joint at a time) (see Figure 5A-2, A).

2. A static splint stabilizing fingers in extension may be helpful during passive wrist extension⁴ (see Figure 5A-2, B).

C. Active flexion (flexor tendon glides proximally) (see Figure 5A-4)

1 Composite and blocked flexion⁴,²²

2. Differential tendon gliding²² (Figure 5A-3)

D. Resisted flexion (flexor tendon glides proximally with increased force)

Resistive putty, hand grippers (adjust grip size to maximize effectiveness), elastic band⁴,²² (see Figure 5A-5)

E. Static progressive/dynamic splinting into extension¹⁶ (see Figure 5A-6)

1 Composite wrist and finger splint positioned in slightly better extension than that with which patient presents. Straps are used to apply gentle tension for a gradual stretch of the flexors (to be used at night).⁴

2. Dorsal forearm splint with attached rubber band, spring, or elastic Velcro applying a gentle force to the wrist, MP, and IP joints into extension. Worn 20 to 30 minutes 4 to 6 times/day.⁴

G. Modalities²⁵

1 Moist heat over volar surface with flexors on a stretch

2. Electrical stimulation (Russian) to flexors to assist active contraction⁴

3. Ultrasound²⁵ over adherent tendon or shortened muscle while on a stretch⁴

H. Progression of resistance for return to function

1 Upper extremity ergonometer, isokinetic, and BTE²³ machines

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Extensor Tendon Adhesion

A. Soft tissue massage²² (see Figure 5A-7)

1 Adhesions: Retrograde massage over extensors pushes skin distally while actively extending fingers and pulls skin proximally while flexing wrist and fingers.

B. Passive and active stretches (provides extensor tendon gliding distally¹⁶ (see Figure 5A-8, A, B, and D to F)

1 Composite elbow extension, forearm pronation, wrist and finger flexion (modify to tolerance by adding one joint at a time).

2. Flexion glove stabilizing fingers in flexion may be helpful during passive wrist flexion.

C. Active extension (proximal extensor tendon glide) (see Figure 5A-8, C)

1 Composite and isolated

2. Differential tendon gliding (claw position for EDC, MP blocked in flexion with active IP extension for intrinsics)²²,²⁴

D. Resisted extension (proximal extensor tendon glide with additional force)²⁴ (see Figure 5A-9)

1 Resistive putty, rubber bands, elastic band

E. Static progressive/dynamic splinting into flexion¹⁶ (see Figure 5A-10)

1 Wrist cock-up splint in slight wrist flexion with flexion glove can be worn, if tolerated, at night or periodically through the day (minimum of 20 minutes).⁵

2. Dorsal splint with outrigger for MP and IP flexion (wrist positioned in neutral or slight flexion). Worn 20 to 30 minutes 6 to 8 times/day.

F. Modalities²⁵

1 Moist heat over dorsal surface with extensors on a stretch (wrist or fingers flexed)

2. Electrical stimulation (Russian) to extensors to assist active contraction²⁴

3. Ultrasound over adherent tendon or shortened muscle while on a stretch

G. Progression of resistance for return to function

1 Upper extremity ergonometer, isokinetic, and BTE machines²³,²⁴

General guidelines for progression of treatment as with flexor adhesions (Box 5A-2).

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by MP, PIP, or DIP Volar Plate and Accessory Collateral Ligament Shortness or Adhesion⁵,¹⁶

A. AROM and PROM specific to tight structure

1 Passive or active PIP extension to stretch volar plate (Figure 5A-18)

2. Joint mobilization techniques (e.g., dorsal glide to increase IP extension)

Figure 5A-18 Exercises for insufficient finger extension caused by shortness of PIP volar plate and accessory collateral ligaments. Active PIP extension while preventing MP extension.

B. Static progressive splints (Figure 5A-19, A and B)

1 Can be worn at night or periodically throughout the day (e.g., a volar gutter splint in 0 degrees extension with dorsal strap over PIP joint)

2. Maintains gentle stretch on tight structure

Figure 5A-19 Insufficient finger extension caused by shortness of PIP volar plate and accessory collateral ligaments. A and B, Static progressive PIP extension splint to increase PIP extension. C, Dynamic PIP extension splint (DeRoyal LMB Spring Finger extension assist [DeRoyal Industries, Powell, Tenn.]) used during the day to increase PIP extension ROM. D and E, Anti-claw splint can be used as an aide to exercise, preventing MP extension while working to increase PIP extension.

C. Dynamic splints specific to tight structure (20 to 30 minutes/6 to 8 times/day)

1 Dynamic PIP extension splint (Figure 5A-19, C)

2. Anti-claw splint to encourage PIP extension with MP extension blocked by splint (Figure 5A-19, D and E)

D. CPM

1 For isolated or composite motions, CPM is most helpful acutely while in hand impairment Stage 1 or after tenolysis.

E. Modalities²⁵

1 Hot/cold packs/paraffin

2. Electrical stimulation to assist active contraction and give feedback

3. Ultrasound for increased tissue extensibility

a. Underwater

b Continuous at 0.5 to 1.0 W/cm² (using 3-mHz frequency)

c Always with restricted tendon/muscle on a stretch

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Shortness of ORL²⁴

Treatment is active, passive, or resistive exercises into simultaneous PIP extension with DIP flexion. In some cases, splinting to hold the PIP joint in extension may be helpful (see Figure 5A-15).

Treatment for Insufficient Finger and/or Thumb Extension Syndrome caused by Intrinsic Muscle Shortness¹⁶ (see Figure 5A-16)

A. Passive stretches: MP joint positioned in full extension while passively flexing the IP joint

B. Active “hook fist” position: MP joint extension and IP joint flexion

C. Active and passive MP joint abduction or adduction: IP joints held in flexion with the MP joint in full extension (for unilateral finger intrinsic shortness or stiffness)

D. Resistive hook grip with resistive putty

F. Patient education

1 Modify grip to avoid prolonged or repeated intrinsic-plus position as possible.

2. Performance of active and passive stretches frequently during day is recommended if intrinsic plus position is required for daily activities.

Treatment for Weakness of ED

Treatment overloads the muscle progressively as appropriate for the specific strength of the muscle. Exercises should be done every other day, 3 sets of 10 to 15 repetitions each time, once strength is greater than 3+/5. Exercises can be performed more often at the weaker grades (Figure 5A-20).

Figure 5A-20 Insufficient finger extension caused by weakness of extensor digitorum. Exercise for MP extension, isolating extensor digitorum.

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Radial Nerve Injury with Paralysis of Finger and Thumb Extensors¹⁶,²⁹

A. Exercises

1 AROM and PROM exercises to all affected joints (especially finger, thumb, and wrist flexion and forearm supination).

2. As motor function returns, begin active and active assistive exercises to affected muscles.

3. Progress to resistive exercises as appropriate.

B. Splinting

1 Dynamic finger MP and thumb extension splint to be worn at all times, except for PROM exercises to be done 3 times a day and for hygiene. A wrist cock-up should be worn at night.

2. A simple wrist cock-up during the day is preferred by many patients instead of the dynamic extension splint.

C. Patient education

1 The risks caused by decreased sensation

2. Potential loss of ROM if exercises are not done regularly

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Severe Weakness of Intrinsic Muscles

Treatment for severe weakness of intrinsic muscles (“clawing” secondary to ulnar nerve injury)¹⁶,²⁹ is as follows:

A. Anti-claw splints (used to increase function when there is motor loss)

B. PROM (especially MP flexion and IP extension if loss of AROM)

C. Patient education

1 The risks caused by decreased sensation

2. Potential loss of ROM if exercises are not done regularly

Conservative Treatment for Injury to Extensor Tendons

For conservative treatment for injuries to extensor tendons that do not require surgery, refer to established protocols.⁶,³⁰

• Boutonnière

• Mallet

Insufficient Thumb Palmar Abduction and/or Opposition Syndrome

The principal impairment in insufficient thumb palmar abduction and/or opposition syndrome is limited thumb opposition and/or palmar abduction AROM, but the key to prescribing the appropriate intervention is differentiating between the sources causing the limited opposition/abduction. The sources of the limited thumb opposition/palmar abduction can be broadly classified into two main categories: hypomobility (physiological and accessory motion) or force production deficit (decreased strength). Insufficient thumb palmar abduction and/or opposition with hypomobility is most commonly secondary to a trauma or injury or after a period of immobilization to allow for tissue healing.¹⁶ Initially, these patients may be assigned a movement system diagnosis of hand impairment Stage 1, but another underlying movement system diagnosis of insufficient thumb opposition/palmar abduction may help guide treatment. As the tissues heal, the diagnosis may change from hand impairment to another movement system diagnosis. Insufficient thumb palmar abduction and/or opposition with hypomobility may also be secondary to paralysis after a median nerve injury.¹⁶ However, if there is any active function of the median nerve–innervated muscles, then force production deficit instead of hypomobility would guide treatment. A third reason for the insufficient thumb palmar abduction and/or opposition with hypomobility might be joint subluxation and deformity secondary to osteoarthritis of the CMC joint of the thumb.⁹,³¹ The “Source of Signs and Symptoms” column provides key information regarding the cluster of findings identifying the source of the insufficient thumb palmar abduction or opposition. The identified source or cause of insufficient finger and/or thumb extension comprises the second part of the name of the syndrome.

Treatment

Insufficient Thumb Opposition/Abduction

See Box 5-2 for treatment of scar and edema.

Force Production Deficit

Insufficient Thumb Opposition/Abduction Caused by Median Nerve Injury with Strength 2/5

1 Opposition splint for night use to prevent contracture of first web space¹⁶,²⁹ (Figure 5A-21, A)

2. Thumb web active and passive stretching to prevent contracture²⁹ (Figure 5A-21, B)

3. Exercises to strengthen thumb APB and OP⁴¹ (Figures 5A-21, B and C)

Figure 5A-21 Insufficient thumb opposition/abduction. A, Use of custom static splint for stretching of first web space or prevention of contracture. B, Palmar abduction exercising the abductor pollicis brevis. C, Exercise for the opponens pollicis. D, Opposition splint for functional use after median nerve injury. E and F, Use of Otoform K for progressive stretching of limited first web space.

Hypomobility

Insufficient Thumb Opposition/Abduction Caused by Median Nerve Injury with Strength 0/5 to 1/5

1 Opposition splint for functional use¹⁶,²⁹ (Figure 5A-21, D)

2. DC electrical stimulation to motor points for paralyzed muscle 3 times/day, 10 repetitions (only if regeneration is anticipated; a controversial treatment [some say it is contraindicated, others say it may be useful initially])

3. Thumb web stretching to prevent or decrease contracture²⁹

Insufficient Thumb Opposition/Abduction Caused by Contracture of Thumb Adductor Muscles, CMC Joint Structures, or Scar

1 Progressive stretching of web space using Otoform K or elastomer with splinting to be worn as much of the day as possible¹⁶ (Figure 5A-21, E and F)

2. Exercises to actively and passively stretch the first web space (e.g., thumb abduction and opposition and extension)

3. Practice grasping objects as a method to stretch the first web space

Insufficient Thumb Opposition/Abduction Caused by CMC Subluxation/Deformity

A. Patient education/assistive devices²⁸,⁴²

1 Joint protection/patient education: Instruct patient in good protection principles (e.g., how to use thumb with balanced forces and good alignment).

2. Adaptive equipment

a. Provide assistive devices for joint stability as needed.

1) Build up pencil to facilitate correct movement pattern and decrease range of flexion required during writing.

2) Avoid strong grip and pinch; key turner, jar opener, and use of Dycem may be helpful.

B. Splinting¹⁶,⁴⁰: The main purpose of a splint is to decrease pain by providing increased stability to the CMC joint. The CMC joint is most stable in a position of abduction and opposition. However, abduction and opposition will likely not be achievable in the presence of subluxation and deformity. Correcting MP alignment can facilitate correct CMC alignment. Splinting is most effective for patients with Eaton’s Stage I or II CMC arthritis but can be tried in the later stages. Although thermoplastic splints provide stability to the CMC, the hard plastic in the palm of the hand inhibits function so compromises often have to be made to insure patient compliance with splint use.

1 Forearm-based thumb spica for severe pain for total rest of joint and involvement of the scaphotrapezial joint (Eaton Stage IV) (Figure 5A-22, A).

2. Hand-based thumb spica to position thumb in abduction with IP free for functional splint (Figure 5A-22, B). Many patients prefer a neoprene thumb spica splint (Comfort Cool, North Coast Medical, Inc.) versus a thermoplastic thumb spica splint because it is easier to use the hand functionally, yet the neoprene splint still provides some support and stabilization to the CMC joint⁴³ (Figure 5A-22, C).

3. If the MP joint hyperextends, a splint to prevent MP hyperextension may be helpful⁴⁴,⁴⁵ (see Figure 5A-22, B).

Figure 5A-22 Splinting for insufficient thumb opposition/palmar abduction. A, Thermoplastic forearm-based static thumb splint immobilizing the wrist, CMC, and MP. B, Thermoplastic hand-based static thumb splint immobilizing the CMC and MP. C, Neoprene hand-based Comfort Cool static thumb splint immobilizing the CMC and MP. D, Hand-based static thumb splint immobilizing the CMC.

Stabilizing the MP joint in 30 degrees of flexion may unload the anterior compartment of the CMC joint, which is often involved.⁴⁶

4. Some recommend a splint immobilizing the CMC joint only⁴⁷ (Figure 5A-22, D).

C. Modalities

1 Paraffin: Can be useful for pain relief and can be done at home after one trial and patient education in clinic.

Thumb Carpometacarpal Accessory Hypermobility Syndrome

In the thumb CMC accessory hypermobility syndrome, pain is located at the CMC joint, but the alignment and movement impairments occur at all joints of the thumb. The CMC joint may be either extended/abducted or adducted/flexed. The impairments at the CMC joint are associated with either (1) MP flexion with IP extension or (2) MP extension with IP flexion and result in loss of the normal longitudinal arch of the thumb. This movement pattern is due to an inability to coordinate the timing and sequencing of the movements between the IP, MP, and CMC joints of the thumb and adaptive changes in the tissues. Correction of the impairments decreases the symptoms. The adductor pollicis and FPB are frequently overused relative to the APL, APB, OP, EPB, and FPL. Patients assigned to this diagnosis must have a modifiable movement pattern. This diagnosis is not intended for patients with neurological injury or those in the later stages of arthritis.

Treatment for Thumb CMC Accessory Hypermobility

Patient Education

• Maintain arc of thumb during active, functional, and resisted isometric thumb movements.

• Work with patient during the therapy visits on correcting and practicing the movement pattern during the functional activity that is causing the problem. The symptoms should not be reproduced with correct alignment and movement patterns.

• Joint protection (see below).

Exercises

Exercises are recommended, especially for Stages I and II in which the joint is not already subluxed. The focus of the exercises is increasing the performance (timing) of the underused muscle. In doing so, the extensibility of the antagonistic muscle is simultaneously increased (stretched). The exercises are used to correct the movement patterns, thus balancing the mechanical forces to which the joint is subjected.⁴⁰

Recommendations have been made to begin isometric and then progressive resistive exercises for palmar abduction after the acute symptoms have subsided. The goal is to help to stabilize the thumb CMC joint subluxation.⁵¹

Strengthening of the APL helps maintain stability of the thumb CMC joint: Work on active contraction in the correct alignment. The APL helps to maintain stability of the joint if the joint is aligned well. The APB places the thumb in the position of maximal stability of the thumb CMC joint.⁵⁰^-⁵² The angle of pull of the first dorsal interosseous muscle is such that it would stabilize the base of the first metacarpal from dorsoradial subluxation.¹⁸

Exercises to correct arc of thumb are as follows (for figures refer to main text of chapter):

During active thumb extension if movement impairment is as follows:

• CMC extends relatively more (amount and timing) than MP (boutonnière), then cue to:

• Avoid excessive CMC extension (decrease use of APL).

• Increase MP extension (increase use of EPB).

• Avoid IP extension (increase use of FPL, decrease use of thumb intrinsics).

• MP extends relatively more than CMC (swan neck), then cue to:

• Increase CMC extension and abduction (increase use of APL).

• Increase IP extension (increase use of EPL).

• Avoid excessive MP extension (increase use of FPB).

• CMC adducts; EPL dominates over APL, then cue to:

• Abduct CMC slightly during extension (increase use of APL).

During active thumb flexion, if movement impairment is as follows:

• MP flexes relatively more than IP and CMC (boutonnière), then cue to:

• Increase flexion at IP (increase use of FPL) and CMC.

• Avoid excessive MP flexion and IP extension (decrease use of thumb intrinsics).

• CMC is relatively more flexible than MP; CMC flexes and adducts, MP extends, and IP flexes excessively (swan neck), then cue to:

• Maintain CMC in extension and abduction (increase use of APL).

• Flex MP (increase use of FPB at longer length).

Correction of proximal joint alignments should correct IP joint alignment.

• CMC adducts and supinates then cue to:

• Keep CMC abducted and in neutral rotation by strengthening the OP and APB to help maintain the neutral rotation when the impairment is thumb supination.

During thumb palmar abduction, if movement impairment is as follows:

• MP abducts relatively more than CMC then cue to:

• Block MP abduction with splint and work on CMC palmar abduction (increase extensibility of adductor pollicis with use of APB).

Once patient is able to correct the movement pattern without added resistance, progress by exercising the muscles noted here with resistive putty or rubber bands. Increase extensibility of stiff muscles by instructing the patient to take frequent breaks to stretch throughout the day and especially during the functional activity that is contributing to the impairment.

Purpose of Splinting^16,^28,⁴⁰

Splint/taping assists maintaining the arc of the thumb. The first priority is usually to correct the movement impairment with patient education and exercises, but splinting may be a helpful adjunct. The main purpose of a splint is to decrease pain by stabilizing the CMC joint in the correct alignment. The CMC joint is most stable in a position of abduction and opposition. Correcting MP alignment can facilitate correct CMC alignment. Splinting is most effective for patients with Eaton’s Stage I or II CMC arthritis. Although thermoplastic splints provide stability to the CMC, the hard plastic in the palm of the hand inhibits function so compromises in the type of splint prescribed, often have to be made to ensure patient compliance with splint use. Additional purposes of splinting are as follows:

• Rest the joint to decrease inflammation and pain.

• Support the joint to alter the stresses on the painful structures.

• Allow more pain-free function.

• Position the thumb with the CMC joint abducted because this is the position of maximal congruence of the joint.

• Splinting at night to increase the extensibility of the adductor pollicis.

• Positioning the MP joint in flexion during splinting may offload the anterior aspect of the first CMC joint.³⁶,⁴⁶

Splint/Taping Options

• Static hand-based thumb postsplint immobilizing MP and CMC (see Figure 5A-22, B).

• Static hand-based thumb postsplint immobilizing CMC only (see Figure 5A-22, D).

• Static forearm-based thumb spica splint immobilizing MP and CMC (see Figure 5A-22, A).

• Taping to support thumb CMC.

Joint Protection/Adaptive Equipment

Joint protection/adaptive equipment can facilitate the correct alignment and movement pattern⁴⁰ as follows:

• Modify tools used at work when possible (e.g., hairdressers have different options available regarding scissor styles that help in modifying the movement pattern).

• Avoid strong grip and pinch.

• Use jar opener.

• Use Dycem or rubber pad to increase friction when opening jar.

• Use key holder.

• Build up circumference of grip on handles.

• Built-up pencil decreases range of flexion required.

Finger (or Thumb) Flexion Syndrome with or without Finger Rotation

The principal movement impairment of finger (or thumb) flexion syndrome is the inability to maintain the normal alignment of the finger during finger flexion. This includes one or more of the following: the longitudinal arch, neutral rotation, or neutral abduction/adduction of the finger. The movement impairment occurs during the pain-provoking functional or occupational activity involving grip or resisted isometric finger flexion. The movement pattern may be due to an inability to coordinate the timing and sequencing of the movements, an alteration of the relative amount of motion between the IP and MP joints of the finger, or overuse during a repetitive activity. Finger MP or PIP joint pain associated with rotation is due to insufficient performance of one interossei muscle and overuse of the antagonistic interossei muscle at the same joint.⁵³ The overused muscle is relatively stiffer than its antagonist. This results in the principal impairment of rotation at the painful joint and results from a repetitive activity. Finger AROM and strength are usually normal. Correction of the movement impairments does not always modify symptoms immediately but instead over time. Patients assigned this diagnosis must have a modifiable movement pattern. This diagnosis is not intended for patients with neurological injury or later stages of arthritis. This syndrome can be associated with a scapular movement impairment but the symptoms are not referred from shoulder or neck structures. Restoration of normal scapular alignment is believed to provide proximal stability, allowing distal segments to work optimally by decreasing excessive stresses on distal tissues.

Treatment for Finger (or Thumb) Flexion Syndrome with Rotation

Patient Education

• Modifying pattern of grip or finger movement during painful functional activity as follows:

• Increase the use of the finger flexors versus the interossei if possible.

• Maintain finger in neutral rotation.

• Maintain finger in normal longitudinal arc.

Exercises

Stretch or increase the extensibility of the short or stiff interossei—if the first palmar interosseous muscle is short or relatively stiff, abduct the index MP with the MP in extension and the IP joints flexed (Figure 5A-16, C).

Work the long or relatively less stiff interossei muscles (e.g., if the first palmar interosseous is short, the first dorsal interosseous muscle may need to be stiffer or strengthened). Working the first DI by abducting the index finger actively while maintaining the MP joint extended and the IP joints flexed would accomplish stretching the first palmar interosseous while strengthening the first DI.

Splinting

Use of a splint to hold the MP joint in extension while the finger is used with the IP joints flexed might be helpful in some instances. (e.g., spring splint used for preventing ulnar deviation at the MP joint).

Treatment for Finger (or Thumb) Flexion Syndrome without Rotation

Patient Education

Maintain arc of finger during resisted isometric finger flexion activities while maintaining proper scapular alignment and movement. Work with patient on correcting and practicing the movement pattern during the functional activity that is causing the problem.

Exercises

• Increasing performance (timing) of muscle that is underused (for figures, refer to Chapter 5).

• If movement impairment is the following:

• MPs flex with IPs in relative extension: Cue to correct arc of finger by increasing MP extension (use of ED) and increasing IP flexion (use of FDP and FDS).

• MPs flex with PIP in hyperextension and DIP flexed (swan neck): Cue to correct arc of finger by increasing MP extension (use of ED) and increasing PIP flexion (use of FDS).

• PIP flexed and DIP in hyperextension (boutonnière): Cue to correct arc of finger by increasing DIP flexion (use of FDP).

• Scapular: Refer to shoulder diagnoses in Sahrmann.⁵⁷

• Once patient is able to correct the movement pattern without added resistance, progress by exercising the muscles noted above with putty or rubber bands.

Increase extensibility of stiff muscles by taking frequent breaks to stretch throughout the day and especially during the functional activity that is contributing to the impairment.

Splint/taping may be helpful to assist maintaining the arc of the finger. The first priority is usually to correct the movement impairment with patient education and exercises, but splinting may be a helpful adjunct.

• MPs flex with IPs in relative extension: Splint to hold MPs in more extension but allow IP flexion.

• MPs flex with PIP in hyperextension and DIP flexed (swan neck): Splint to prevent PIP hyperextension (oval or buttonhole splint).²⁸

• PIP flexed and DIP in hyperextension (boutonnière): Splint to hold PIP in more extension but allow DIP flexion (oval or buttonhole splint).

Source or Regional Impairment of the Hand

The movement system diagnosis “hand impairment” is used when the pathoanatomical source diagnosis is not provided on the referral documentation. The focus of the treatment is protecting the injured tissues. Usually, there is a history of acute trauma or injury to the hand or the patient is in the early in postoperative phase. Medical precautions have been issued, thus the patient’s typical movement pattern cannot be assessed at this time. Prognosis is for tissue healing, and normal movement is expected. The determination of the use of component versus compensatory treatment methods depends on the expectations of the final outcome. Initially, while on precautions, compensatory methods may be necessary. The information for the regional impairment of the hand diagnosis in this appendix is intended only as a general guide; therefore the physician’s protocol for specific precautions and progression must be consulted. The therapist must be familiar with the tissues that are affected by the surgical procedure and the specific surgical approach.

General Hand Impairment Treatment Guidelines*

Moderators

Age, quality of tissue at repair site and tension on repair, extent of injury (degree of soft tissue involvement), location of injury, duration of immobilization, and surgical approach are moderators that should be considered. The patient may have an increased healing time with osteoporosis, a history of diabetes, or steroid use.

Impairments (Body Functions and Structures)

Pain

Stage 1 (surgical or acute injury): Within the first 2 weeks of the postoperative period, some pain will be associated with the exercises. (In contrast to the nonsurgical patient, in whom pain should not be reproduced with exercise.) Gradually, over the next few weeks, pain associated with the exercise should lessen. Pain should not be severe and should not be increased for more than 1 hour after exercise. Exercise can also help decrease complaints of stiffness. Severe pain can indicate being too aggressive with exercises. After a tenolysis, the patient must be able to work through pain to maintain the tendon glide.²² Complaints of increasing pain, pain that is not decreasing with treatment, or burning pain are all “red flag” indicators that treatment is too aggressive or there is a disruption in the usual course of healing (e.g., CRPS/RSD, nonunion of fracture, and so on). Coordinating the use of analgesics with exercise sessions is important. Splinting may be used during this period to protect the injured tissue.

Stages 2 to 3: Pain associated with the specific tissue that was involved in the surgery should be significantly decreased by weeks 4 to 6. Precautions may be lifted during or by postoperative weeks 4 to 6. As the exercises and activities of the patient are progressed, pain should be monitored closely. Although the patient may still have some increased pain with activity, the patient should report a decrease in pain overall, despite the increase in activity.

Edema

Stage 1 (surgical or acute injury): Early management of edema is the key to a successful outcome of therapy for a postoperative hand patient. The hand must be elevated above the level of the heart as much as possible. AROM, splinting to immobilize and rest the tissue, compressive garments or wraps, milking massage, and/or ice or other modalities may help decrease the edema. Caution must be used in donning a compressive garment when precautions regarding motion are present. An increase in edema or edema that is not decreasing with treatment are indications that exercises are too aggressive. This could also be an indicator of an infection. If infection is suspected, the physician should be contacted immediately.

Stages 2 to 3: Edema should decrease significantly in the first 2 to 4 weeks after surgery. Some edema, however, may persist for several months. As activities and exercises are progressed, the edema should continue to decrease gradually.

Appearance

Stage 1 (surgical or acute injury): Infection should be suspected if the area around the incision or the involved joint appears to be red, hot, and swollen.⁵⁸ The physician should be consulted immediately if infection is suspected. The incision will have stitches for the first 7 to 14 days. The patient may also have pins that protrude from the finger. Bruising is not uncommon postoperatively. Changes in hair growth, perspiration, or color may indicate some disturbance to the sympathetic nervous function, especially in combination with the complaint of excessive pain.⁵⁹ However, dark hair growth on the arm after casting is very common. Stages 2 to 3: The incision should be well healed. Bruising should be diminishing. Signs of increased bruising are a red flag and the patient should be immediately referred to the physician.

Scar

Stage 1 (surgical linear scars): Scarring, although a normal process of healing, must be managed well in the hand or it can severely limit function. Gliding between adjacent structures in the hand must occur to allow good motion and function. Early management of scar contributes to a good outcome. Exercise, massage, compression, silicone gel sheets, and vibration are used in the management of scar. The use of silicone gel is best supported by evidence in the literature. However, clinical experts also commonly use the other methods of scar management. Further research is needed to determine the efficacy of these other methods. The gradual application of stress to the scar or incision helps the scar remodel so that it allows the necessary gliding between structures. A dry incision that has been closed and reopens as a result of the stresses applied with scar massage indicates that the scar massage is too aggressive. Scars may be classified according to type. Linear scars that are immature are confined to the area of the incision. They may be raised and pink or reddish in the remodeling phase. As they mature, they become whitish and flatten. A hypersensitive scar requires desensitization. See Box 5-2 for treatment guidelines on managing scar.

Stages 2 to 3: A scar may continue to remodel for up to 2 years.¹⁹ Scar management techniques may be effective until the scar matures, although they are probably most effective early in the healing process.

Range of Motion

Stage 1

• The key to a successful outcome is early motion. The typical position of a stiff hand is with the MPs extended, IPs flexed, and thumb adducted (loss of first web space). Prevention of the stiff hand is the key.

• Depending on the type of injury, the patient may have ROM precautions per physician order to protect the healing tissues. Splinting is commonly used to adhere to the ROM precautions yet allow initiation of exercise soon after surgery. Generally the exercises are done frequently throughout the day within pain tolerance.

• The typical exercise progression starts with active, progresses to passive to increase the stretch, and then to resistive ROM (tendon injuries are an exception to this rule). Progression through the continuum is based primarily on the healing of the involved tissues. If there has been a tendon repair, the progression may be passive exercise before active. Composite stretches of the repaired tendon must be avoided in the early healing phase. The tissues must be allowed to heal and adapt to gradual application of stress. Active contraction of a repaired tendon is also often avoided, although this depends on several factors such as choice of suture material and method. Communication with the surgeon regarding the repair technique helps direct the choice of exercise.

• When performing ROM exercises on a finger with a fracture attention to finger placement during the exercises can minimize the stresses placed on the healing fracture site. Point tenderness to palpation at the fracture site indicates that the fracture is not well healed.

• When working on ROM at one joint, it is helpful to block the adjacent joints so they cannot move. This is based on the principle that the body takes the path of least resistance. The joint that moves most easily will move first and the most, so to increase the ROM at a stiffer joint, the more flexible joint must be stabilized. This can be done manually, using a splint or a Bunnell block.

• All uninvolved upper extremity joints should be exercised to prevent the development of restricted ROM at those joints.

• Decreasing pain and edema and improving ROM are usually signs that it is okay to progress the exercises. Refer to the specific diagnostic syndrome for guidelines regarding progression of the exercises.

• Joint mobilization may be a useful technique to facilitate increases in ROM. Consult with the physician before initiating joint mobilization after a fracture or joint injury.

Stages 2 to 3: Precautions regarding ROM will usually be lifted sometime in the first 6 weeks after surgery or injury so there are no precautions by this stage. Once precautions have been lifted, if there is a plateau in the improvement of ROM with the use of active exercise, exercises are progressed to passive. If ROM is still not improving by at least 10 degrees per week, then static progressive or dynamic splinting should be initiated. Increasing ROM may still be the primary focus of treatment, although strengthening can begin through increased functional use.

Strength

Stage 1: Generally, strengthening is not done during the first 4 to 6 weeks after an injury or surgery. During Stage 1, focus instead is either on immobilization, decreasing edema, scar management, or on gaining ROM, with the correct movement pattern. Occasionally, light resistance is used to increase the recruitment of a muscle versus overload and strengthening. If this is done, it should not violate any precautions that are still in force.

Stages 2 to 3: It is generally safe to begin strengthening exercises 6 weeks after a surgery or fracture. The specific protocol or the physician should be consulted for the exact time when strengthening can be initiated. Once the physician has lifted any precautions related to strengthening, progression to resistive exercise is based on the patient’s ability to perform AROM with a good movement pattern and without a significant increase in pain relative to the pain produced with the same movement without resistance. Refer to specific protocols for guidelines regarding progression to resistance. Vital signs should be monitored when initiating an upper extremity resistive exercise program, particularly at higher levels such as using the BTE.

Coordination

Stage 1: Exercises focusing on coordination are generally not initiated until later in the rehabilitation phase.

Stages 2 to 3: Often, specific exercises for coordination are not necessary. The patient will regain their coordination through increasing the functional use of their hand, as well as through the exercises prescribed for regaining ROM and strength. However, in certain instances, specific exercises for coordination may be useful. One example of this would be a patient who is learning to use his or her nondominant hand as his or her dominant hand. This patient may require specific writing exercises.

Cardiovascular and Muscular Endurance

Stage 1: Patients may become deconditioned after a severe hand injury. Resuming or initiating an exercise program, such as walking, to increase cardiovascular endurance is indicated as soon as pain allows, assuming the exercise does not violate any precautions related to the tissue healing.

Stages 2 to 3: The intensity, duration, and frequency of the exercise can be progressed as tolerated. Cardiovascular endurance exercises may have an added benefit of helping decrease pain and generally increase the patient’s feeling of well-being.

Patient Education

Stages 1 to 3: The patient will need to be educated regarding the specific medical precautions, how to maintain precautions during hygiene, and the definition of PROM or assisted AROM. Educate the patient regarding the structures and tissues involved. Use of a hand model, anatomical pictures, handouts, and books are helpful. Also, the patient must be educated regarding the care, use, precautions, schedule for use, and how to don and doff his or her splints.

Changes in Status

Stages 1 to 3: Consider reports of increased pain or edema, decreased strength, or significant change in ROM carefully, especially in combination. The patient should be questioned regarding precipitating events (e.g., time of onset, activity, and so on). If the integrity of the surgery is in doubt, contact the physician promptly. If patient has fever and erythema spreading from the incision, the physician should be contacted because of the possibility of an infection.

Function (Activity Limitations/Participation Restrictions)

General Guidelines

Stage 1: Early functional use of the hand must be encouraged while protecting the healing tissue. Educate the patient regarding precautions/restrictions and use of the involved extremity during ADLs such as eating, bathing, dressing, work, and so on). Educate patient regarding the use of splint as needed.

Stages 2 to 3: Once any precautions have been lifted, the patient may need to be instructed to specifically return to using the hand functionally since he or she may avoid using the hand because of habit.

Specific Suggestions

Writing

Stage 1: If the dominant hand is involved, the patient will frequently be unable to write in the immediate postoperative period. He or she may need to learn to write with their other hand temporarily.

Stages 2 to 3: Using a pen or pencil with a larger circumference is helpful if ROM is limited or grip is painful. This can be accomplished by purchasing a pen with a larger circumference or building up the pen with foam.

Driving

Stage 1: Patients are usually unable to drive in the immediate postoperative period.

Stages 2 to 3: Most patients will be able to return to driving without special treatment related to driving if they have regained their hand ROM, grip, and pinch strength. The patient should practice in their own driveway before returning to driving on the streets. If needed, once precautions are lifted, driving can be simulated on the BTE. If weakness is a limiting factor, task-specific strengthening can be done using the BTE.

Work and Sports

Stage 1: Many patients will be off work and unable to participate in sports during the immediate postoperative period. During the postoperative period, their rehabilitation is their “job” because it can be quite time consuming, especially with involved injuries. When the patient is cleared to return to work or sports, he or she should be instructed in gradual resumption of activities.

Stages 2 to 3: If the patient has a job that places high demands on strength or endurance, the BTE is a useful exercise tool. Strengthening can be initiated using the BTE once ROM has plateaued or returned to normal, the patient is able to perform light ADLs without problems and isolated strengthening has been initiated without an increase in pain. Many hand patients will be deconditioned if they have had a severe injury, so vital signs should be monitored when initiating resistive exercises to the upper extremity. Many hand patients also develop shoulder pain. Shoulder alignment and movement should be examined and any movement impairments corrected before initiating overhead resistive exercises. The alignment and movement of the shoulder and trunk should be monitored closely during the exercises on the BTE. Some patients will be able to return to work with “light duty” restrictions before regaining full strength and endurance. Sport-specific exercises can be initiated and progressed gradually once precautions are lifted. The patient may require a protective splint that is acceptable for the sport until full healing and rehabilitation have been completed.

Eating

Stage 1: Patients may require assistance or they may be able to eat independently using the opposite extremity. Foam can be used to build up utensils. During therapy practice sessions, resistive putty can be used to build up the utensil.

Stages 2 to 3: Once precautions have been lifted, the patient should be encouraged to use the affected hand with the normal pattern while eating.

Sleeping

Stage 1: The involved side should be supported with a pillow under the arm, keeping the hand higher than the heart to minimize edema. Sleep is usually significantly disrupted in the immediate postoperative period.

Stages 2 to 3: Once the edema has resolved or is minimal, the patient can return to sleeping in their preferred position without elevating the hand.

Support and Splinting

Stage 1: Splinting is used extensively but judiciously after surgeries or injuries to protect the healing tissue, yet allow as much ROM and functional use of the extremity as possible. It is very important to have a splint that fits well and is appropriate for the diagnosis. The patient must be educated in the use, precautions, and care of the splint. They must be taught how to don and doff the splint. Use of slings with patients with hand injuries is avoided to minimize problems with the shoulder and to minimize edema in the hand.

Stages 2 to 3: Static progressive or dynamic splinting may be used during this stage to help increase ROM. Protective splinting may be required to facilitate an earlier return to sports or work.

Hygiene

Stages 1 to 3: Patients may need assistance with bathing and other hygiene activities or they may be independent using the opposite extremity. Giving suggestions may be appreciated and helpful.

Medications/Modalities

Medications

During the immediate postoperative phase, physical therapy treatment should be timed with analgesics. This is particularly important in the first 2 weeks after tenolysis, so the patient is able to work through pain to maintain the ROM gains achieved during the surgery. Communication with the physician is vital to provide optimal pain relief for the patient.

Whirlpool Treatment²⁵

In general, use of whirlpools for treatment of patients with hand injuries is contraindicated because both the dependent position of the hand in the whirlpool and the warm water temperature encourage increased edema in the hand. If a whirlpool must be used, the water temperature should be no warmer than 98° F.

Paraffin or Hot Pack Treatment²⁵

The patient’s hand should be elevated while receiving either of these heat modalities to prevent an increase of edema. Paraffin can be used with the hand wrapped in a flexed position with Coban to increase the extensibility of the structures limiting finger flexion.

Electrical Stimulation²⁵

Electrical stimulation is used by some clinical hand experts to increase tendon gliding and increase strength.

Tissue Factors

Bone

The key to a good outcome is early active motion without compromising the stability of the fracture. Communicate with the physician regarding the adequacy of stabilization of the fracture (e.g., ORIF). Sometimes AROM can be begin as early as 5 to 15 days postoperative. Progression to PROM and static progressive or dynamic splinting is determined by x-ray (once the fracture is fairly well healed). Progression to strengthening is done once ROM is pretty good and fracture is well healed (usually 6 to 8 weeks). Generally, the joints proximal and distal to the fracture are immobilized when using a splint or cast.

Ligament

The key to a good outcome is prevention of shortness or adherence of the ligaments in the joints that are immobilized and maintenance of ROM at the upper extremity joints that are not immobilized. The typical posture of the stiff hand is with the MPs in extension, the IPs flexed, and the thumb adducted. In this position the collateral ligaments at the MPs get short or adhered, and the volar plate and accessory collateral ligaments at the IPs get short or adhered. Whenever possible, immobilize the hand in the functional position (MP flexion, IP extension, and thumb abduction) to maintain the length of the ligaments and to maintain the first web space. Recognize, however, that this position of immobilization will contribute to the development of intrinsic muscle shortness so exercises to correct this may need to be prescribed once the immobilization is no longer necessary.¹⁶

Nerve

Postoperatively, the tension on the nerve repair must be avoided, and this is done with immobilization using a splint. Early motion is started while protecting the site of repair. Nerves, whether repaired or normal, are sensitive to stretch so it is better to use an oscillatory motion during exercises rather than a prolonged stretch.⁶⁰ Patients may need education regarding skin protection when there is sensory loss, sensory re-education, or desensitization. Return of sensibility and motor function is tested periodically to document progress. Refer to a text on hand rehabilitation for more information about this topic.⁶¹ Another consideration related to nerves is the edematous hand. Edema may cause compression of nerve.

Cartilage

Grinding or crepitus may be a sign of loss of or damage to cartilage in the joint.

Skin

Edema in the hand takes up excess laxity in the dorsal skin, contributing to decreased finger and thumb ROM.¹⁶ Immobility of the skin caused by edema or scarring must be prevented to maximize ROM.

Wound care: Wound care of the incision or care of pin sites is often an important part of the treatment of the postoperative hand. Pin and suture care may be needed. In some settings, the therapist will remove sutures at the time ordered by the physician. The incision should be monitored for drainage or sutures that have become inflamed. At the time of the first PT visit, bulky dressings may need to be removed and replaced with a lighter dressing. Enough dressing should be used just to absorb any drainage. Generally, the lighter and less restrictive the dressing, the better. A bulky dressing restricts ROM. Check with the physician for his or her preferences regarding wound care and dressing changes. Watch for any maceration of the skin from straps, splints, or wound dressings.

Muscle

Positions of immobilization to protect the healing muscles and/or tendons may result in subsequent muscle shortness or tendon adhesions. After the initial postoperative period of precautions, examination should be done to check for muscle shortness and tendon adhesions. Exercises and splinting should be implemented to correct the impairment as necessary. The first web space is commonly decreased with swelling, resulting in shortness of the thumb adductor. Generally, function after a laceration and repair of a muscle is restored more easily than after laceration and repair of a tendon.

Tendon

The key to a good outcome after tendon repair or tenolysis is preserving tendon gliding by starting early protected ROM.⁴,²²

Tendon Repairs

Protocols for treatment s/p tendon repairs depend on the zone of the tendon in which the injury occurred. Healing tendons have their weakest tensile strength between 5 to 15 days after repair. The amount of tension that can be placed on the repaired tendon also depends on the type of suture and repair, the condition of the tendon at the time of repair, and so on. It is important to maintain full finger joint ROM while avoiding placing excessive stresses on the repaired tendon until it has healed sufficiently. Full PIP ROM is important for good differential tendon glide between the FDS and FDP. Splinting is used the first few weeks to prevent excessive stresses on the repaired tendon. If the patient is not getting good tendon gliding and seems to have a lot of scarring, they may need to be progressed faster than the guidelines provide on the protocol. If the patient has good motion and little scarring, the timeframes on the protocol may need to be more conservative.

References

1 Knight SL. Assessment and management of swan neck deformity. Int Congr Ser. 2006;1295:154-157.

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19 Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;1102:560-571.

20 Magee DJ. Orthopedic physical assessment, ed 3. Philadelphia: Saunders; 1997.

21 Goodman CC, Snyder TEK. Differential diagnosis for physical therapists: screening for referral, ed 4. St Louis: Saunders; 2007.

22 Mackin EJ, Callahan A, Osterman AL, et al, editors. Rehabilitation of the hand and upper extremity, ed 5, St Louis: Mosby, 2002.

23 Fess EE. Documentation: essential elements of an upper extremity assessment battery. In Mackin EJ, Callahan A, Osterman AL, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis: Mosby, 2002.

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26 LaStayo PC. Ulnar wrist pain and impairment: a therapist’s algorithmic approach to the triangular fibrocartilage complex. In Mackin EJ, Callahan A, Osterman AL, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis: Mosby, 2002.

27 Sandoval R, Kare JA, Washington IE, et al. Swan neck deformity. Available at http://www.emedicine.com/orthoped/topic562.htm Accessed June 29, 2010.

28 Biese J. Therapist’s evaluation and conservative management of rheumatoid arthritis in the hand and wrist. In Mackin EJ, Callahan A, Osterman AL, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis: Mosby, 2002.

29 Skirven TM, Callahan AD. Therapist’s management of peripheral nerve injuries. In Mackin EJ, Callahan A, Osterman AL, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis: Mosby, 2002.

30 Cannon NM, Beal BG, Walters KJ, et al. Diagnosis and treatment manual for physicians and therapists: upper extremity rehabilitation, ed 4. Indianapolis: The Hand Rehabilitation Center of Indiana; 2001.

31 Eaton RG, Glickel SZ. Trapeziometacarpal osteoarthritis. Staging as a rationale for treatment. Hand Clin. 1987;3(4):455-471.

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33 Swanson AB. Disabling arthritis at the base of the thumb: treatment by resection of the trapezium and flexible (silicone) implant arthroplasty. J Bone Joint Surg Am. 1972;54(3):456-471.

34 Tomaino MM, Pellegrini VDJr, Burton RI. Arthroplasty of the basal joint of the thumb. Long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am. 1995;77(3):346-355.

35 Eaton CJ, Lister GD. Radial nerve compression. Hand Clin. 1992;8(2):345-357.

36 Kovler M, Lundon K, McKee N, et al. The human first carpometacarpal joint: osteoarthritic degeneration and 3-dimensional modeling. J Hand Ther. 2004;17(4):393-400.

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38 Terrono AL. The rheumatoid thumb. J Am Soc Surg Hand. 2001;1(2):81-92.

39 Tomaino MM. Classification and treatment of the rheumatoid thumb. Int Congr Ser. 2006;1295:162-168.

40 Melvin JL. Therapists’ management of osteoarthritis in the hand. In Mackin EJ, Callahan A, Osterman AL, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis: Mosby, 2002.

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42 Terrono AL, Nalebuff EA, Philips CA. The rheumatoid thumb. In Mackin EJ, Callahan A, Osterman AL, et al, editors: Rehabilitation of the hand and upper extremity, ed 5, St Louis: Mosby, 2002.

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Insufficient Finger and/or Thumb Flexion Syndrome

Treatment

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Flexor Tendon Adhesion

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Extensor Tendon Adhesions/Extrinsic Extensor Muscle Shortness

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by MP Collateral Ligament and/or IP Dorsal Capsule Shortness or Adhesion5,16

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by ORL Shortness24 (Figure 5A-15)

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Intrinsic Muscle Shortness16

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Swan Neck Deformity

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome caused by Weakness of Flexors

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Rupture of Flexor Tendon

Insufficient Finger and/or Thumb Extension Syndrome

Treatment for Insufficient Finger and Thumb Extension

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Flexor Tendon Adhesions/Shortness

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Extensor Tendon Adhesion

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by MP, PIP, or DIP Volar Plate and Accessory Collateral Ligament Shortness or Adhesion5,16

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Shortness of ORL24

Treatment for Insufficient Finger and/or Thumb Extension Syndrome caused by Intrinsic Muscle Shortness16 (see Figure 5A-16)

Treatment for Weakness of ED

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Radial Nerve Injury with Paralysis of Finger and Thumb Extensors16,29

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Severe Weakness of Intrinsic Muscles

Conservative Treatment for Injury to Extensor Tendons

Insufficient Thumb Palmar Abduction and/or Opposition Syndrome

Treatment

Insufficient Thumb Opposition/Abduction

Force Production Deficit

Insufficient Thumb Opposition/Abduction Caused by Median Nerve Injury with Strength 2/5

Hypomobility

Insufficient Thumb Opposition/Abduction Caused by Median Nerve Injury with Strength 0/5 to 1/5

Insufficient Thumb Opposition/Abduction Caused by Contracture of Thumb Adductor Muscles, CMC Joint Structures, or Scar

Insufficient Thumb Opposition/Abduction Caused by CMC Subluxation/Deformity

Thumb Carpometacarpal Accessory Hypermobility Syndrome

Treatment for Thumb CMC Accessory Hypermobility

Patient Education

Exercises

Purpose of Splinting16,28,40

Splint/Taping Options

Joint Protection/Adaptive Equipment

Finger (or Thumb) Flexion Syndrome with or without Finger Rotation

Treatment for Finger (or Thumb) Flexion Syndrome with Rotation

Patient Education

Exercises

Splinting

Treatment for Finger (or Thumb) Flexion Syndrome without Rotation

Patient Education

Exercises

Source or Regional Impairment of the Hand

General Hand Impairment Treatment Guidelines*

Moderators

Impairments (Body Functions and Structures)

Pain

Edema

Appearance

Scar

Range of Motion

Strength

Coordination

Cardiovascular and Muscular Endurance

Patient Education

Changes in Status

Function (Activity Limitations/Participation Restrictions)

General Guidelines

Specific Suggestions

Medications/Modalities

Medications

Whirlpool Treatment25

Paraffin or Hot Pack Treatment25

Electrical Stimulation25

Tissue Factors

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by MP Collateral Ligament and/or IP Dorsal Capsule Shortness or Adhesion⁵,¹⁶

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by ORL Shortness²⁴ (Figure 5A-15)

Treatment for Insufficient Finger and/or Thumb Flexion Syndrome Caused by Intrinsic Muscle Shortness¹⁶

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by MP, PIP, or DIP Volar Plate and Accessory Collateral Ligament Shortness or Adhesion⁵,¹⁶

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Shortness of ORL²⁴

Treatment for Insufficient Finger and/or Thumb Extension Syndrome caused by Intrinsic Muscle Shortness¹⁶ (see Figure 5A-16)

Treatment for Insufficient Finger and/or Thumb Extension Syndrome Caused by Radial Nerve Injury with Paralysis of Finger and Thumb Extensors¹⁶,²⁹

Purpose of Splinting^16,^28,⁴⁰

Whirlpool Treatment²⁵

Paraffin or Hot Pack Treatment²⁵

Electrical Stimulation²⁵