1 Department of Rehabilitation Services Occupational Therapy

Flexor Digitorum Superficialis and Profundus Repair Early Active Motion Protocol

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Department of Rehabilitation Services Occupational Therapy

Flexor Digitorum Superficialis and Profundus Repair Early Active Motion Protocol for Zones 1-5

This protocol is by not intended to be a substitute for one’s clinical decision making regarding the progression of a patient’s post-operative course

based on their physical exam/findings, individual progress, and/or the presence of post-operative complications. If a clinician requires assistance in

the progression of a patient, they should consult with the referring surgeon. The time frames of phases I-IV are examples and can be adjusted based

on the given procedure. Progression to the next phase is based on the clinical criteria and/or time frames, as appropriate. Exercise frequency is

determined by therapist. Exercises may range from 10 repetitions for 3 sets four to six times/day to 10 repetitions hourly when awake.

Zone I: distal to FDS insertion

Zone II: over the A1 pulley to FDS insertion

Zone III: distal from transverse carpal ligament to A1 pulley

Zone IV: within the carpal tunnel

Zone V: proximal to transverse carpal ligament

Photos: pages 6 -7; Tendon Surgery of the Hand (2012).

Goal: Protect flexor tendon repairs to prepare for functional use of hand while improving tendon glide, avoiding gapping or rupture and limiting

adhesions.

Precautions: No passive wrist extension beyond 0̊ for zones 4-5 if median or ulnar nerves were repaired until 6 weeks post op. Avoid “place and

holds” due to buckling of the repaired tendon against the pulley. Consider tendon tension, nerve repair, nicotine or long-term steroid usage, diabetes

and reliability of patient. When early active motion is deferred by surgeon, perform Modified Duran protocol.

Flexor Digitorum Superficialis and Profundus Repair Early Active Motion Protocol

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Frequency: one to two times/week for 8 to 12 weeks.

Early Active Controlled Motion:

PHASE

ORTHOTICS

THERAPEUTIC EXERCISES

CONSIDERATIONS

I Immediate

phase: day

3 to 2

weeks.

Zones 1 -3: dorsal forearm-based

blocking with wrist extended 20̊

with MCPs flexed 30̊-40̊, PIP & DIP

joints 0̊.

Zones 4 & 5: dorsal forearm-based

blocking orthotic: wrist 0̊, MCPs

flexed 60̊-75̊, PIP & DIP joints 0̊.

Pulley ring orthosis is pulley

repaired.

1. Passive DIP flexion & active

extension to orthosis.

2. Passive PIP flexion & active extension

to orthosis.

3. Passively MCPs in 60̊-80̊ flexion and

active extension of PIP, DIP joints to

0̊ to orthosis.

4. Passive wrist flexion & active wrist

extension to orthosis.

5. On day 4-5, following passive

exercises, perform active motion to

gain 25% of fist & active extension to

orthosis.

Repaired tendon strength reduces as the

angle of tension is increased around the

joint axis. Tendon repair is weakest post op

day 5-21.

Refer to photo in attached page 5 addendum

for 25% of fist.

II:

Protective

phase: 2-4

weeks

Week 4, transition orthosis to hand

based.

1. Active motion to gain 50% of fist &

active extension to orthosis.

2. Week 3-4, active 75% of fist & active

extension to orthosis.

3. Week 3, remove orthosis in clinic for

light fine motor activity.

4. Week 4, begin flexor tendon gliding

and FDS isolated gliding to repaired

finger with wrist in 0˚-20̊. Wrist

tenodesis. Begin light fine motor

activities at home.

Refer to photo in attached page 5 addendum

for 50% fist.

III:

Intermediate

phase 4-6

weeks

Gradually wean from orthosis

during day. Discharge orthosis by 6

weeks.

6 weeks post op, if IP joints are stiff

in flexion, convert dorsal block to

1. Flexor tendon gliding with wrist

extended 20̊-30̊.

2. 5 weeks, DIP & PIP blocking.

3. 6 weeks, progression of functional

activities.

No composite wrist beyond 30̊ & combined

finger extension until 6 weeks.

Avoid PIP & DIP joint blocking to small

finger (increases risk of rupture).

Flexor Digitorum Superficialis and Profundus Repair Early Active Motion Protocol

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volar hand based nighttime orthosis

for zone 2 or to volar forearm based

for zone 3.

Weight lifting restriction.

IV:

Minimal

protection

phase: 6-12

weeks

Discharge night time orthosis when

digital active extension is 0̊.

Week 8: begin light graded strengthening.

Resisted isolated DIP & PIP flexion.

Progress with work and sport activities to

unrestricted participation with MD

authorization.

No resisted grip or pinch exercises until 8

weeks post op.

Author: Reviewers:

Monique Turenne, OT Marjorie Helman, OT

04/2020 Nancy Kelly, OT

Monica McDonagh, OT

Flexor Digitorum Superficialis and Profundus Repair Early Active Motion Protocol

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REFERENCES

Evans, R. B. (2012). Managing the injured tendon: current concepts. Journal of Hand Therapy, 25(2): 173-186.

Geetha, K., Hariharan, N.C., and Mohan, J. (2014). Early ultrasound therapy for rehabilitation

after zone II flexor tendon repair. Indian Journal of Plastic Surgery, 47(1); 85-91.

Higgins A., & Lalonde D. (2016). Flexor tendon repair postoperative rehabilitation: the Saint John protocol. Plastic Reconstructive Surgery Global

Open. 4(11). Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMCS142. Accessed 12/18/2018.

Howell, J.W., & Peck, F. (2013). Rehabilitation of flexor and extensor tendon injuries in the hand: current updates. Injury, International Journal

Care Injured, 44, 397-402.

Pettengill, K., & Van Strein, G. (2011). Postoperative management of flexor tendon injuries. In T.M. Skirven, A.L. Osterman, J.M. Fedorczyk, &

P.C. Amadio (Eds.), Rehabilitation of the hand and upper extremity 6

th

ed., (pp. 457-478). Philadephia, PA: Elsevier.

Pettengill, K., & Van Strein, G. (2012). State of the art of flexor tendon rehabilitation. In: J.B., Tang, P.C., Amadio, J.C., Guimberteau, J.,

Chang, D., Elliot & J.C., Colditz, (Eds.), Tendon surgery of the hand. (pp. 6-7; 405-414). Philadelphia, PA: Saunders.

Flexor Digitorum Superficialis and Profundus Repair Early Active Motion Protocol

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Addendum:

EAM: Week 1 to 2 touching IF or 25% EAM: Week 2 to 3 touching LF or 50% EAM: Week 3 to 4 touching RF or 75%