Tendon Rehabilitation Pyramid

Passive protected extension

Exercise Originator: Duran and Houser 1979

Rehabilitation stage: First post op visit

Duration: continues for the duration of protective splinting Frequency: >four times daily, 10 repetition

Function: provides a delivery of motion stress and maintains

finger mobility Description: Passive flexion and extension of the PIP and

DIP joints are performed independently.

the position of the wrist varies in a synergistic pattern. Wrist flx => low force-low Excursion

Wrist Ext=> high force-high excursion

It may be useful to remove the protective splint to allow wrist flexion/extension while the client is in the clinic or for home

Place and hold

Exercise Originator: Evans and Thompson 1993

Rehabilitation stage: used with 2 and 4 strand

solid repairs during first post op visit Duration: continues until just after progression to

next pyramid level

Frequency: 3‐5 times daily, but dependent on

individual situation Hold 3-7 sec

Function: allows for early detection of suboptimal

response to motion stress. Allows for early and careful tailoring of exercise and education

programs based on individual response

Description: Clients should complete a warm up of slow repetitious passive flexion and protected

extension with wrist in 20 degrees of extension.

The active hold position reduces viscoelastic drag on the tendon juncture. The metacarpophalangeal

(MP)/PIP/DIP digital joints are subsequently

actively held in a moderately flexed position.

Active composite fist

Rehabilitation stage: Prescribed for cli-

ents with an unresponsive active tendon lag

from second

week or at the 8 post‐op week Duration: continues until discharge

Frequency: 3‐5 times per day Function: excessive load application at the tendon

juncture is presented and high level of

tendon gliding resistance is overcome in those with binding adhesions Description: This level combines the

performance of active digital flexion to the distal palmar crease with wrist in slight

extension.

Maximum FDP excursion metacarpophalangeal (MP)/PIP/DIP digital

joints are subsequently actively held in a

moderately flexed position.

Hook and straight fist

Exercise Originator: Wehbe and

Hunter(1985) Rehabilitation stage: Prescribed for clients with an unresponsive active

tendon lag Frequency: 2:1 frequency ratio for the hook fist and straight fist. Function: provides greater stress in

the finger flexion positions, maintain-ing the wrist in neutral or slight flexion

minimizes the motion stress delivered Description: The hook fist position causes maximum differential excursion

between tendons up to 23–33 mm.

The straight fist position causes maxi-

mum FDS gliding between the sheath

and the bone and causes excursion that

varies from 17 to 30 mm. It may be useful to remove the protective splint

to allow wrist flexion/extension while

the client is in the clinic or for home exercises.

Isolated joint motion

Rehabilitation stage: Prescribed

for clients with an unresponsive

active tendon lag Function: maximizes motion stress

to adhesions. Description: External stabilization of the proximal and middle phalan-

ges allows for isolated DIP joint

motion and FDP function. External stabilization of the proximal phal-

anx allows for DIP and PIP joint

motion while blocking the MP joint and lumbrical function.

The prescription of isolated PIP

joint exercise is often overlooked in

the patient with a single laceration

to the FDP tendon.

Discontinuation of protective splinting. Significant increases in functional use.

A useful clinical technique is to grade the

discontinuance of protective splinting over a week to reduce sudden motion stress on

the hand.

Resistive composite fist

Function: maximizes motion stress to adhesions, finger exten-

sion exercise can also assist to reduce intrasynovial adhesions. Description: active composite digit flexion with an external mode of resistance such as with putty or a gripper ball.

Resisted hook and straight fist

Rehabilitation stage: Prescribed for clients with an unresponsive active tendon lag.

Description: This level uses the hook and straight fist described in level 4, but uses an external mode of resistance

to maximize force application.

Resisted isolated joint motion This level applies an external mode of resistance

to previously described positions.

creates a minimum of 12 exercise positions for the digit: four for the DIP joint (wrist/MP

flexed/extended) and eight for the PIP joint

(wrist/MP flexed/ extended, DIP blocked/free). If active lag remains unresponsive within two

weeks after the prescription of the exercise,

Groth suggests that the client be discharged as the maximum benefit from supervised therapy

has been reached.

Reference: Groth, G. (2004). Pyramid of progressive force exercises to

the injured flexor tendon. Journal of Hand Therapy, 17, 31-

42.

تهیه کنندگان:

محمد صادق فدایی، زینب اکبری، محسن اسالم پناه