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Flexor Tendon Adhesions
222 Plays6 days ago
Emily and Josh dive into the challenges of flexor tendon adhesions, discussing why they occur and how to effectively manage them. They explore early intervention strategies like place-and-hold exercises, differential tendon gliding, and scar mobilization techniques.
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Transcript
Introduction and Therapy Duration Discussion
00:00:08
Miranda Materi
Hi, I'm Josh McDonald and we are Hand Therapy Academy.
00:00:10
Emily Kerr
Hi, I'm Emily Kerr.
00:00:13
Miranda Materi
So Emily's joining us for one more time asking us a question as a staff member. Emily, what do you have for us today?
00:00:19
Emily Kerr
Yeah, my question for you today, Josh, would be when you are seeing a patient post flexor tendon um and you've noticed that as they scar in, they're starting to become pretty stiff.
Spontaneous Stiffness and Proactive Measures
00:00:33
Emily Kerr
um How long do you continue your therapy?
00:00:37
Miranda Materi
ah So yeah, we, some patients aren't going to get stuck at all. And some patients, we had a patient who was doing great. And then around week three and a half to four, she came in and was stuck.
00:00:48
Miranda Materi
And sometimes it's just spontaneous. It happens out of nowhere. And you're like, oh, we're tracking great. We're tracking great. oh shoot, what went wrong? um Nothing you can do about it. Nothing the patient can do about it. They get, sometimes they're emotional about it. And I was awful. What happened?
00:01:02
Miranda Materi
So we start to step things up. And sometimes before we hit that six week mark, we're starting to do things a little bit more proactively because we know that they are internally splinting and they're scarring in.
Scar Tissue Management and Tracking Progress
00:01:13
Miranda Materi
And so while we're not going to have them do like heavy putty work and carrying kettlebells and things, I'm going to start to work scar more assertively. I won't say aggressively, but I'm to start do more. We can usually track to see after six weeks when I can start to do more stuff and I can do like a little bit of putty stuff, those kinds of things.
00:01:32
Miranda Materi
I can start to see that by week eight to 10, Hey, is this getting better? Are we like, okay, we had a little hiccup there, but we're on track again. Or are we really binding down?
00:01:43
Miranda Materi
And And then we start to look at like static progressive splinting.
When to Suggest Tenolysis
00:01:48
Miranda Materi
We start to work at nighttime extension stretching because when we do an extension load, it pulls, it does distal excursion of that tendon away from the scar.
00:01:56
Miranda Materi
And when we do static progressive flexion, it works on all of the restrictors and variables that limit flexion like edema and capsular tightness and scar bulk, all of those things, and then active pull through. is proximal excursion of the tendon away from the scar. So all of those things are useful.
00:02:13
Miranda Materi
um And so we'll start pursuing those. And then we start to get in some questions when when we're tracking our progress at week 12 to 14 to start to notice, like, are we seeing the changes we want to start to see, even if it's in small small amounts?
00:02:28
Emily Kerr
um Yeah. And at what point do you wait until that 12 week mark to suggest maybe it's time for antenolysis? Or at what point would you start to suggest that?
Rehab Process Post-Tenolysis
00:02:40
Miranda Materi
In general, I try not to be the one that starts that conversation. um I want that to usually come from the doctor to say, like, I think you should have this because I want to establish a relationship with the doctor.
00:02:50
Emily Kerr
Mm
00:02:52
Miranda Materi
And it kind of um it's kind of me. um going outside my lane, right? Like ah that's not necessarily my call. I will educate a patient if I think like I can see like maybe that's the direction we're going be headed.
00:03:04
Miranda Materi
I'll spend some time talking with them about, you know, there are other things if they're really getting frustrated and they're just not changing. I won't bring it up unless I think that's a... ah probability they're going to get that and like, Oh, there's this other stuff. And they have this procedure.
00:03:16
Miranda Materi
And then here's the therapy afterwards every day for a couple of weeks. And then three days a week is this whole involved process. So I'll touch base with them on that around week 12. And that's usually about when they're going back to the doctor for, and then, so they can have that like, Hey, is this a possibility?
Maintaining Movement Post-Tenolysis
00:03:33
Miranda Materi
But I'm usually reluctant to say, I think you should have this because I don't want to be the one that suggests a surgery that then goes poorly.
00:03:40
Emily Kerr
Sure, sure. You touched on it a little bit, but can you share what our rehab process is like for someone who is post-tenolysis and what does that look like in our clinic?
00:03:50
Miranda Materi
Yeah, um I want to see that person ideally the same day as the procedure, if not the very next calendar day. um I've come in on Saturdays for people who had to have their surgery on Fridays. um I want to see them within 24 hours, if not same day. If their surgery is at three o'clock in the afternoon, they're not going to make it in, that's fine. But i want to see them right away, partly because they still have that nerve block in place and I can do movement without them being painful post-operatively.
00:04:13
Miranda Materi
I'm seeing them every day of the week, five days a week for two, maybe three weeks. At the end of that time, at the end of two weeks, that's when scar really starts to bog down. So I want to know that whatever the doctor got on the table, we're still getting passive range of motion and beginning to get some active without having to beat them up too much.
00:04:32
Miranda Materi
I
Therapy Schedule and Progress Assessment
00:04:33
Miranda Materi
don't want to do no pain, no gain during that phase. I want to do... I wanna keep our range of motion. I wanna do passive without significant overpressure, partly because I don't stress the wound, right? Like that is a wound that needs to be respected. So I don't wanna just plow through it, but we've gotta keep moving. The whole benefit of ateneoliasis is, listen, you have new scar that replaced old scar, but I get to start working on it day one.
00:04:56
Miranda Materi
And so until that scar starts to bog down at the end of that two week mark, the proliferation phase, I wanna know that I'm getting as much as possible. And so when it does bog down,
00:05:07
Miranda Materi
we're of as far ahead of the game as possible.
00:05:07
Emily Kerr
Thank you.
00:05:09
Miranda Materi
So we do two weeks of five times a week-ish, two weeks of three times a week, and then off to two times a week from there. At the end of the 12-week mark from date of teen analysis, we kind of are where we're going to be. So usually we're 12 weeks post-op, and then we're kind of assessing where we're going to go from here.
Risks of Multiple Tenolysis Surgeries
00:05:28
Emily Kerr
Yeah, that makes sense. um How many tenolysis would you feel like ah is enough tenolysis? And when do you suggest after they've had one, is it time for a second one?
00:05:41
Miranda Materi
um One is too many, right? Two, we really don't want to do two. Those tissues, because they had a surgery to repair their tendon. So that was surgery number one.
00:05:52
Miranda Materi
Atenoliasis is surgery number two. That means we've opened up those that finger. The blood vessels are affected. The connective tissue is affected. Nerves are affected. Every time we open things up, now we, the doctors open things up, it's trauma.
00:06:06
Miranda Materi
It is ah not insignificant trauma to the system. So a second tenolysis is a third time of opening all of it up. And a tenolysis, we think of surgeries like being these delicate things.
00:06:18
Miranda Materi
There's this tool that he scrapes along to debride away scar tissue. How does he know where scar tissue ends and the tendon sheath begins? It's when you first see tendon sheath. And at that point, maybe you've already taken a layer of tendon sheath off.
00:06:31
Miranda Materi
Maybe the tendon sheath is gone. And so it's just tendon. And so you're beating all those tissues up. We really, really don't want to have to send a patient or see a patient go back for a second tenolysis.
00:06:43
Miranda Materi
In very, very rare circumstances, we'll see a patient who's had a third tenolysis. And the expectation for outcomes there is really low. um it's At that point, it's nothing else to lose.
00:06:55
Miranda Materi
Maybe they are so scarred into flexion on maybe ring and small finger that they can't put anything in that hand.
Managing Patient Expectations
00:07:02
Miranda Materi
And you're as much hoping that they scar in in a neutral cascade of flexion.
00:07:09
Miranda Materi
Not in massive PIP and DIP hyperflexion. Maybe you're hoping for, it's basically like, am I going for a fusion in a better position than a soft tissue fusion in a crummy position? So that's not ideal, um but our expectations for outcome with each subsequent tenoliasis are worse and worse.
00:07:28
Emily Kerr
Yeah, i like how you mentioned the idea about expectations. Because I think especially as and a new grad or when I was a new grad, um the expectation for everyone is is so high.
00:07:42
Emily Kerr
um i think like I expect everyone to have significant results and be able to use their hand as normal. And um so I think having and idea of better expectations um is helpful.
00:07:55
Miranda Materi
Yeah. And I tell patients that even going into the first tenolysis, when they're thinking about it, do I want to do it? The doctor mentioned this. Is is something I should consider? They won't do it until the four month mark, maybe the three month mark if it's a extenuating circumstances.
00:08:09
Miranda Materi
But I tell patients going into it, we have a discussion. Give me a ballpark number of how functional you are with your hand. And if they say I have 20% function, it is awful. I'm like, okay, then you stand to gain a lot with this procedure. You have a lot of room for improvement.
00:08:25
Miranda Materi
If that patient tells me I'm 85%, then you have a very small amount of room for improvement, but look how much you have to lose. Because I'll tell you, there's three outcomes with atenolysis.
00:08:36
Miranda Materi
They're better, they're worse, or they're the same. And if they're worse or the same, then why bother? And so those other two possibilities are very real. We see patients all the time who come out of atenolysis and because of how their body scars, maybe they're diabetic, maybe they're just a heavy scar, right?
00:08:54
Miranda Materi
They come out the same or worse. It's not worth it. And so we try to set those expectations early. Like, listen, you can do all the activities. You just want that full tuck under fist. You have a lot you could lose if this goes badly. And it can with a tenolysis.
00:09:08
Miranda Materi
Or you come out the same 12 weeks of therapy and another procedure later. Is that worth it? So I don't, I can't draw that line in the sand for them where I say like, okay, at 60% of function, it's worth it.
00:09:20
Miranda Materi
If
Q&A and Contact Information
00:09:21
Miranda Materi
it's less, it's not worth it. The patient has to decide that. I just give them that. What are you willing to risk losing? And if you can't do anything with your hand, why not go for it? Yeah. Maybe not a third time though.
00:09:32
Miranda Materi
Yeah.
00:09:34
Emily Kerr
Thanks for sharing.
00:09:35
Miranda Materi
Yeah. All right. If you guys have questions about teen eliasis or flexor tendons or anything else, reach out to us. We've got courses on a lot of this flexor tendon stuff. But yeah, reach out to us if you have any questions, info at handtherapyacademy.com, or you can find us on social media and our handle is handtherapyacademy.