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Early Active for Flexor Tendon Repairs
1k Plays2 years ago
Miranda and Josh talk about early active range of motion for Flexor Tendon Rehabilitation.
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Transcript
Introduction and Approach to Tendon Injuries
00:00:06
Speaker
Hi, I'm Josh McDonald. And I'm Brandon Materi, and we are Hand Therapy Academy.
Protocols for Flexor Tendon Injuries
00:00:11
Speaker
Today we're talking our approach for flexor tendon injuries. What we do, there's all these different protocols. We thought we'd take just a couple of minutes to talk about how we address a flexor tendon injury. And I think this is how we would ideally approach it, right? So we're going to approach it differently based on surgeon preference, but if it was our choice, you know, and all the scenarios lined up would be early active, right?
Timing Post-Surgery: Balancing Healing and Inflammation
00:00:33
Speaker
So we're going to be talking about early active,
00:00:35
Speaker
When would you ideally like to see this patient in your clinic? I want to see them three to five days post-operatively. That has everything to do with tissue healing timeline and when they're ready to move, but not too early before we're going to create excessive inflammation and keep that cycle rolling too long. Yeah. So really research shows seeing them post-op day three to five is
Splint Fabrication and Wrist Positioning
00:00:57
Speaker
ideal. And on that visit, we're going to be fabricating a dorsal walking splint and what
00:01:03
Speaker
type of dorsal blocking splint, are we going to be fabricating? Is it wrist free? What position do you have them in? So because I don't have as direct communication with some of my surgeons as I would like to, very few of them do I know would be comfortable with a wrist free from day one of therapy. So I usually make a forearm-based dorsal blocking wrist in about 15 to 20 degrees of wrist extension.
00:01:26
Speaker
MCPs flexed in that intrinsic plus position as much as I'm able to get if they were put in a giant post-operative dressing fingers flexed Then I'm only going to take them to where they can get without tension and then slowly progress that as they're able Yeah, and one thing I like to do with the dorsal walkings I think is to not put them in so much MCP flexion Is because I like for them to be able to initiate that DIP flexion so if they're not in such an you know, so much flexion if they're
00:01:55
Speaker
The MCPs are flexed to 80 to 90 degrees. It's really hard to initiate flexion at the DIP. They usually initiate it at the PIP. So if they're in a little bit less, then you can get that FDP going
Splint Techniques: Wrist Extension vs. Flexion
00:02:06
Speaker
a little earlier. Cause it's usually the FDP that gets stuck in my experience. Yeah, definitely. So research shows that an intrinsic plus position should be like 80 degrees of flexion. Both of us are more like 40 to 50 degrees of MCP flexion with IPs and extension as able. Yeah.
00:02:23
Speaker
And we'll talk about putting the wrist in extension versus flexion. Why are, why are you doing extension over flexion? So if I put them into flexion, it does protect that flexor tendon more in static position. But when I asked them to do early active half fist, three quarter, quarter fist, whatever, it increases the work of flexion because I've put tension on the extensor tendons, the long extensor tendons. And so it wants to keep those fingers straight in a tenedesis response.
00:02:52
Speaker
So it's harder for them to pull into flexion if their wrist is flexed in that splint. Yeah, so work of flexion is greater when the wrist is inflection. Yeah, yeah, definitely. Miranda always finds a quicker way to say something than I took too many words to say.
Communicating with Surgeons About Splints
00:03:06
Speaker
Well, no, I just like to recap because we feel like our audience probably, you know, it's nice to hear it two or three times to hit the highlights. But yeah, that is true. You are a long winded. Yes. So when, if at all, will you put them in a wrist-free dorsal blocking?
00:03:21
Speaker
So this is, if I have the surgeon on board, I will. And sometimes even if I'm like, okay, maybe I can't get ahold of the surgeon on that first visit, I can get ahold of them like 10, 14 days later, I'll be like, hey, do you mind if I cut this down to risk-free? But it's always about communicating with the surgeon because if you put them in a risk-free and you don't have the surgeon's buy-in on it and that patient ruptures, you're going to be probably in some trouble, right? Because this is a new concept.
00:03:49
Speaker
Um, I think we're getting more and more familiar with it. More and more people are doing it. Um, but I definitely just, it's at the physician agrees, but I do know from studies that the rupture rate with the risk free dorsal blocking are very similar with the foreign based dorsal blocking. So there's no greater risk of rupture based on research. Yeah. Yeah. And it's got to be the right patient. If it's a patient that you're not sure you can trust to follow with precautions, then I might try to lock them down
Initial Exercises: Passive Flexion and Active Extension
00:04:12
Speaker
a little bit more. Yeah, that's very true. Yeah.
00:04:14
Speaker
Okay, so exercises or initial treatment plan, they come in, you make a splint. Do you send them out? Do you teach them stuff right away? And what do you teach them? I'm teaching them stuff right away on that first visit. So I'm usually teaching them three things. And one of the first things I tell them is I want you to move it, but not use it. So I want you to be moving it just a little bit, but do not be using it to pick up stuff.
00:04:37
Speaker
And when you're doing the exercises, you're doing them all in your splint, except for one. And so the first exercise I always show them is passive flexion with active extension because I want those joints to be loose. The second exercise I show them is the short arc range of motion so that I'll give them a small down or a guide and tell us. So it's usually I want you to move your fingers like 30, 30%, so 30% of
00:04:58
Speaker
the total fist and so I don't tell them 30% of a total fist because that doesn't usually compute for patients but I just give them a dial where I want them to be and I show them I want you to touch this dial or I want you to scratch this dial and usually I'll tell them to scratch that dial because they get more FTP activation than they would with just touching it, right? So you can just touch it just by doing your FDS usually. So I'll also tell them to scratch that dial and then I show them synergistic wrist. So those three exercises, passive extension with active flexion,
00:05:28
Speaker
short arc range of motion and then synergistic wrist. And so the two that are in the splint are the passive extension, the passive flexion active extension and the short arc so that they only go to the dorsal blocking and not all the way open.
Ensuring Exercise Compliance
00:05:42
Speaker
That's an important that they learn. We don't want you to go all the way open into extension. Yeah. And I tell them, Hey, at any point you don't understand this exercises or you're not, you feel like you can't do it correctly. Just wait till you see me in clinic the next time, especially for the synergistic wrist, right?
00:05:57
Speaker
People have a hard time getting that. I'll show them on their non-involved side first. So that one I want to make sure that they really understand. And if they're not getting it in clinic, I tell them, hey, let's scratch this one off today and we'll get it at another time. Yeah. I'll have patients that I know nailed it in one session. They come back the next one and they're doing it all wrong. And so you're right. That's one that you want to make sure they're not making things worse than how they do it. Right. So usually the, I feel like the fist one they get pretty easily and the passive extension one they get pretty easily.
00:06:26
Speaker
and they need to know not to squeeze whatever dowel size you've given them as you progress it smaller. At no point are we squeezing it, we're just scratching it lightly. Yeah, and I will write on there, don't squeeze.
00:06:37
Speaker
Yes. Sometimes we have like one inch PVC pipe cutoffs. We have toilet paper tubes. We have sometimes built up grips with Dyson or foam wrapped on them. Literally with a Sharpie, right? Do not squeeze. Right. Just scratch or
Assessing Progress with Strickland and Gray-O-Groth
00:06:51
Speaker
touch. Yes. What's your plan for follow-up visits? Once a week, twice a week. How often? When do you ramp up?
00:06:58
Speaker
You know, and that just depends on the patient. If I can see them early on, a few more visits to make sure they're doing everything correctly, I will do that. And then if they're really compliant, I might say, hey, like you can come in once a week, but usually the first few weeks, I'm seeing them two or three times per week, and then I'm advancing them accordingly. And then with this early active, then sometimes I'll start implementing some of the gale growth or braille growth pyramid things. I'm saying, well, if they're getting stuck, I'm going to be doing more. If they're not getting stuck, I'm going to be doing less.
00:07:27
Speaker
Yeah, yeah. And we should be able to identify their progress by using our Strickland measure where we look at what percentage of improvement they have from one week to the next to know if we should advance them to the next step. If they have a 10% improvement or greater in active range, great, keep doing what you're doing. If they don't have a 10% or greater improvement in active range from previous session, then you need to advance them because they might be scarring in.
00:07:55
Speaker
if they're active and passive is within 10 degrees of each other, then you're worried they're not scarring in enough.
Advancing Therapy: Finding the Right Pace
00:08:04
Speaker
And so slow them down a little bit. Let them scar in a little bit more. So we don't want, if I have a patient on week three and I'm like, oh, look, I'm moving great. I can make a full fist. I'm worried they're not scarring in. And if they're active and passive are the same or darn close, slow them down, back them off.
00:08:20
Speaker
And you can use the Strickland measure that Josh talked about, or you can use the Gray-O-Groth formula. They're similar. And I think they both give you, I think the thing I like about the Roth one is that you can see how you should advance upon the pyramid. And I think this is key for new therapists. Yeah, yeah. And that means we should be measuring them each time they come in. We should be identifying what kind of range of motion they have actively. Otherwise, how do I know if I should be advancing them or not? Yeah, that's very true. Yeah, we want to keep track on, keep dibs on them.
00:08:50
Speaker
Yeah, yeah.
Summary and Contact Information
00:08:51
Speaker
All right, that was a super quick run-through of what we do for flexor tendon early active protocol. That's if your doctor's cool with it and they're okay with it. Maybe you can get by with a wrist free. Maybe you can get by with advancing or seeing them less often, but all kind of reading the patient's situation and kind of using your clinical judgment. Yeah, definitely. All right, thanks guys. Check us out. If you need more information, you could email us at info at handtherapyacademy or you can find us on Instagram at handtherapyacademy.