Flexor Tendon Rehabilitation : Simplified

Immobilization Protocol

Dorsal blocking orthosisEarly stage (0-3/4 weeks)Intermediate stage (4-6 weeks)Late stage (6-8 weeks)
Wrist: 20-30 degrees flexion
MCP: 40-60 degrees flexion
IP: Neutral
ROM of elbow and shoulderIncrease wrist extension (towards neutral) within splint

Tendon gliding exercises (hold each position 3 seconds, repeat 10 times, do 3 sessions per day)
– Straight
– Hook fist
– Full fist
– Straight fist
– Platform position
Discard splint

Isolated joint blocking exercises of FDP and FDS

Cast immobilization is necessary in children younger than 10 years of age due to lack of compliance with motion protocols.

Early Passive Motion Protocols

ProtocolKleinertDuranModified Duran
Dorsal blocking orthosisInvolved finger secured with elastic thread or rubber band into full composite flexionFingers strapped into extension at night
1. Wrist flexion30 degrees20 degrees-20 to +20 degrees
2. MCP flexion40-60 degreesLoose flexion40-50 degrees
3. IP flexionNeutralNeutralNeutral
Early stage (0-3/4 weeks)Passive flexion (by rubber band traction) and active extension of fingers (repetitions: 10x per waking hour)Passive DIP joint extension with MCP and PIP held passively in flexion; Passive PIP joint extension with MCP and DIP held passively in flexion (repetitions: 6-8x twice daily)As in Duran + Composite passive finger flexion with active finger extension; Synergistic wrist and finger out of splint (only in therapy)
Intermediate stage (4-6 weeks)Gentle active finger flexion is initiatedSplint is replaced with a wrist band and traction to prevent simultaneous finger and wrist extension; Gentle active finger flexion is initiatedGentle active finger flexion is initiated
Late stage (6-8 weeks)Resisted exercises are initiatedResisted active finger flexionResisted active finger flexion
Duran protocol

Early Active Motion Protocols

There are many protocols for EAM including Gratton, Strickland, Tang, etc. Here, we will be discussing MGH protocol.

Day 1:

  • Dorsal blocking splint: Wrist neutral, MCP 70 degrees, IP neutral
  • Modified Duran
  • Place and hold exercises (passively flex digits and allow patients to actively contract muscles to hold digits in fist – composite and differential)

3 week:

  • Gentle tenodesis exercises out of splint
  • Continue place and hold exercises

4 week:

  • Active composite flexion exercises out of splint
  • Differential tendon gliding exercises
  • No passive extension, no blocking
  • Continue dorsal blocking splint between exercises

5 week:

  • Initiate blocking exercises
  • Splint at night and for protection only during the day

6 week:

  • Discontinue splint
  • Initiate passive extension

7 week:

  • Start composite passive extension

8 week:

  • May start light strengthening

12 week:

  • Normal activities


Grabb and Smith’s Plastic Surgery – 7th Edition


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