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

Neiduski, R. L. & Powell, R. K. (2019). Flexor tendon rehabilitation in the 21st 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.

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