Flexor tendon rehabilitation in the 21st century: A systematic review

Neiduski, R. L. & Powell, R. K. (2019). Flexor tendon rehabilitation in the 21^st century: A systematic review. Journal of Hand Therapy, 32, 165-174.

The Skinny

The objective of the study was to determine if there was evidence to support 1 type of exercise regimen.  Exercise regimens reviewed include place and holds, early passive or true active.  The inclusion criteria included anything published after the year 2000 and study outcomes measure had to include range of motion. 

The articles were grouped into three separate categories and these included

1. Early passive (which included Kleinert protocol and Duran Protocol flexor tendon repair)
2. Place and holds- includes isometric hold of the involved digit in flexion (Indiana protocol flexor tendon repair)
3. True Active range of motion: those who initiated early active movement within the first week

In the Weeds

Of the 241 articles identified only 9 meet the inclusion criteria and only 8 were on adults.  Of the eight, 4 compared early passive motion to place and holds.  These studies yielded that places and hold had better results than passive range of motion protocols.

The remaining 4 compared early active motion flexor tendon protocol with a least one other range of motion protocol.   No definitive conclusions could be made. 

Brining It Home

Only one of the articles clearly stated a repair strength of 4 strands should be utilized when initiating early active.  Meaning if you only have a 2-strand repair, it is not safe to perform early active.   It is important to review  the literature on repair strength before advancing the patient. Many of the patient’s outcomes measures were all performed at the 12-week mark which does not consider those patients who may have had gapping and late rupture. 

The review supported using place and holds over passive flexion protocols.  This information conflicts with the work done by Dr. Lalonde showing a buckle and jerk at the edge of the pulley with performing place and holds. 

No support could be drawn as to if early active was superior to place and holds.  

No strong conclusions could be made based on the review as to which exercise regime yields the best outcome.

The article review is helpful in knowing that despite recommendation for early active motion we do not have high level evidence supporting its use.  However, this does not consider clinical experience and expert opinion.  It is believed that early active is the superior intervention based on recommendation by the American Association of Hand Surgery and the Maintenance of Certification.    The literature review leaves you with several questions as to which treatment to utilize in the clinic.   It is difficult to compare post-operative exercise regimes as there are many variables to account for in treating flexor tendon repairs.  Treating flexor tendon injuries is truly the blending of science and art.