Extensor Tendon Injuries
Signs and Symptoms
- Unable to extend the joint(s) distal to the injury. It is important to note that because of the anatomy of the hand this may not always be the case. You could still cut a tendon and move the joint beyond it.
- Pain, especially with motion
- Skin cut (laceration). The tendons are very close to the skin and are easily injured with what may be a simple cut to the skin. It is important to have these evaluated soon after injury. If ignored they can lead to deformities of the finger and then loss of function.
Diagnosis
- History and Physical exam can usually provide all the information necessary
- MRI is occasionally required especially in older injuries
Background
The extensor tendons are located on the top/back of the forearm, running from the outside of the elbow (lateral epicondyle) to the top of the wrist and fingers. “Extensor tendon” is a general term we use to describe any one of the multiple tendons that serve to extend (or straighten) the wrist and finger joints.
Extensor tendons are often injured through cuts or trauma, sports-related injuries, crush injuries, animal bites, car accidents, shattered glass, etc. The rehab process will vary depending on where the injury happened on the body, and which structures were damaged — however, this is simply a general description of roughly what to expect during surgery recovery and healing, for injuries in the area between the fingernails and the wrist.
Treatment
Conservative (Non-Surgical)
- Only for those injuries with very minimal tendon involvement. The tendon would need to be evaluated either by the Surgeon (direct visualization) or MRI in order to make this determination.
- Splinting
- Hand Therapy
Surgery
- In order to explore the injury and determine the tendon involvement
- The tendons can be directly repaired if the injury is within three weeks
- Grafting of tendons or using non injured adjacent tendons (tendon transfer) may be required if there is significant loss or injury of the tendon or the injury is older than three weeks.
Hand Therapy
Week 1:
- One week after surgery, the bulky dressing will be removed. Compressive gloves, fingersocks, or dressings may be applied for swelling management. Your therapist will create a custom-fitted splint for you to wear, which will keep your fingers/hand protected. The splint design will vary based on your injury, but often stretches from the mid-forearm down to the finger tips. It is extremely important to wear this at all times; keep it on during the day and night, during showers (cover it to keep it dry), and during all activities.
- Sutures are typically removed between 10 and 14 days post-op. At this point, your therapist will begin manual massage techniques to reduce the swelling and soften scar tissue formation.
Week 3-5:
- After 3 weeks, or as soon as it is deemed safe, your therapist will instruct you in gentle exercises involving your wrist and fingers. You should perform these multiple times every day. Continue wearing your splint at ALL TIMES, except when completing the exercises. Your therapist will show you how to carefully take your splint off and put it back on to prevent damage to your healing hand.
- Your therapist may begin to incorporate other techniques into your sessions to help the tendons move freely, prevent excessive scarring, and help improve inflammation and swelling. This could include therapeutic ultrasound, manual massage, neuromuscular electrical stimulation, compression, and other methods. Post-op discomfort will typically have improved quite a bit by this point in time.
Week 5-6:
- If all has gone well up to this point, you will be able to gradually stop wearing the initial splint. Depending on how your range of motion has progressed, a smaller splint may be created for you to position your fingers and maximize range of motion. Continue exercises that are provided to you, but even if your splint is discontinued, do not attempt a tight grip, and do NOT squeeze your hand against resistance (this includes avoid any stress balls, tennis balls, hand exercisers, foam blocks, etc). Your repaired tendon is still very much healing, and still at high risk of ruptures/tears if you squeeze your hand/fingers.
Week 7-10:
- Depending on the type and location of injury, gentle strengthening may be initiated around this time. Carefully follow your therapist’s instructions — strengthening is easy to “over-do,” and you can end up doing more harm than good if grip strength exercises are done recklessly or excessively. Keep in mind that strength is typically pretty easy to regain once you start the exercises, so try to be patient. There is no need to rush into it too early in the rehab process.
- Your therapist and doctor will advise you on when you can return to specific activities such as work, sports, and home activities. The timeline for returning to these activities is difficult to generalize, and will be specific to the person, the injury, and the situation. Do not hesitate to ask questions, and always err on the side of caution. Tendon repairs are fragile, complex injuries.
Flexor Tendon Injuries
Signs and symptoms
- Unable to fully flex finger or thumb into the palm
- May experience pain where the tendon has been injured
Diagnosis
- The majority of injuries can be found by history and physical exam. However in some patients, especially if the injury occurred several weeks or months ago, an MRI may be necessary.
Background
“Flexor tendon” is a general term that describes any of the tendons of the forearm/hand that facilitate active wrist and finger forward movement (flexion). Two tendons in particular, the FDS and FDP, control many important finger movements. These tendons are at risk of damage from anything that cuts, crushes, or otherwise creating trauma to the palm side of the hand or fingers.
A tendon repair is an immensely delicate procedure, and the repaired structures are very susceptible to tears if you do not follow doctor/therapist instructions. Listen closely to all education provided to you, and try to remain patient — recovery can take up to 4-6 months. However, if you try to rush the recovery process, you will likely end up interrupting or delaying the healing process. Any unintentional tendon damage that occurs post-operatively will likely require another surgery to fix it.
The following is a general guide, but everyone’s exact situation and rehabilitation process is slightly different. Flexor tendon injuries are typically severe and complex injuries that involve multiple structures. If more than one tendon was repaired, or more than one surgical procedure completed in the same operation, your recovery may be different and/or longer than the process described below.
Hand Therapy
Week 1:
- The bulky dressing will be removed. It may be replaced with a light compressive dressing, or wrap for swelling control. A custom-made removable splint will also be made which fits over the back of your hand/wrist/forearm and keeps your wrist and knuckles slightly bent, but your fingers straight. It is extremely important that this splint stay on at all times (day and night), until you are told otherwise. It will help protect your repaired tendons, while allowing you to do special exercises. You will need to cover it when you bathe, and keep it dry.
Week 2:
- Toward the end of week 2, you will meet with your therapist. He will instruct you on exercises to complete within the confines of the splint, in which you use your unaffected hand to passively move your surgically-repaired hand and fingers. Complete these exercises every single day, at least 4-5 times per day. The exercises are designed specifically to maximize movement and range of motion SAFELY, without putting unnecessary stress on the repaired tendon. If your therapist does not specifically instruct you to do something, do NOT do it. During this time period, scar management techniques will also be completed. Your therapist will perform these during therapy, but will also instruct you on how to do them at home. These massage techniques will help prevent sticky scar tissue from building up around your healing tendon, restricting its movement.
Week 3-4:
- Within the confines of the splint, active range of motion exercises will be initiated. Your therapist will show you how to do these safely, without straining the healing tendon. During therapy, massage techniques will continue to be used to soften and flatten your scar, and to prevent excessive scar tissue build-up. Your therapist may use other tools such as kinesiotaping, therapeutic ultrasound, manual techniques, and compression wrapping to facilitate healing and maximize motion.
Week 4-5:
- Your therapist will typically instruct you by this point to begin taking your splint off a few times a day while completing the exercises. You will be shown how to do this safely and carefully, and on a regular basis — however, you must continue to wear the splint between exercise sessions and while sleeping.
Week 5-6:
- If all has gone well up to this point, you will be able to gradually stop wearing the initial splint. Depending on how your range of motion has progressed, a smaller splint may be created for you to position your fingers and maximize range of motion. Continue exercises that are provided to you, but even if your splint is discontinued, do not attempt a tight grip, and do NOT squeeze your hand against resistance (this includes avoid any stress balls, tennis balls, hand exercisers, foam blocks, etc). Your repaired tendon is still very much healing, and still at high risk of ruptures/tears if you squeeze your hand/fingers.
Week 8:
- VERY GENTLE strengthening exercises may be started around this time, depending on your doctor/therapist’s instructions. Again, your tendon is still actively healing, and you MUST still avoid any heavy hand use (no gardening, cooking, cleaning, squeezing, pushing/pulling, sports, picking up grandchildren, etc). Your therapist will slowly progress you toward increasingly-resistive exercises and activities.
Week 10-12:
- You can start slowly incorporating your hand into light activities like dressing, combing hair, and turning door knobs.
Week 15-16:
- Heavier weights and resistance to the hand and fingers can slowly begin. You can begin using your hand in progressively-heavier home activities like sweeping, gardening, yard work, etc.
*There are several numbered “zones” that surgeons use to classify flexor tendon injuries, ranging from the tips of the fingers to the far end of the forearm. This is a general guide, but different zones heal at different rates and require different considerations; your doctor/therapist will give you more information about your particular injury.
