Rationale

Early motion protocols have greatly improved outcomes after flexor tendon surgery. There has been considerable debate on the optimal postoperative rehabilitation strategy for zone II flexor tendon repairs. Medical professionals remain divided on protocols that employ only passive flexion or a combination of passive and active flexion.¹–³

Clinical comment

Zone II flexor tendon injuries are associated with poorer outcomes than injuries in other parts of the flexor tendon system. Following repair, there is a competing demand on the tendon for gliding through the sheath to prevent adhesions and minimizing excessive forces on the repair to prevent rupture. Although, intuitively, early active motion will decrease adhesions and improve outcomes, this is not necessarily supported in the literature.

Available literature and quality of the evidence

• Level Ib: randomized controlled trial (RCT).⁴
  
• Level IIb: RCT.⁵
  
• Level V: expert opinion.⁶

Findings

Trumble et al. compared a group of patients using early passive ROM using a passive flexion and active extension protocol with a group using a combined passive and active flexion rehabilitation protocol employing place and hold.⁴ The total finger ROM was significantly better (p <0.05) in the combined passive and active place and hold group (μ156° ± σ25°) compared to the early passive ROM only group (μ128° ± σ22°). Rupture rates appeared to be equivalent between early passive ROM only and early active with place and hold groups.

A second RCT by Farzad compared early active motion with a place and hold and early passive motion only. This study showed a significant increase in total active motion (p = 0.001) eight weeks after surgery in the early active motion group (μ146° ± σ29°) than the early passive motion group (μ114° ± σ38°). There were no ruptures reported among the 54 patients. This trial represents level II evidence due to underpowering of the control and study groups.⁵

A review by Tang highlighted the challenges in comparing outcomes even amongst what appeared to be similar therapy protocols. These authors compiled flexor tendon repair therapy protocols of 10 of the world’s leading hand surgery centers and showed great variability in the protocols used as well as variability in the method of passive and/or active ROM utilized by each center. Synergistic wrist movement in passive motion protocols and midrange finger active motion are two examples of state‐of‐the‐art strategies that could improve tendon excursion while minimizing force applied to a healing tendon.⁶

Resolution of clinical scenario

• Patients with isolated flexor tendon lacerations in zone II likely benefit from an early active ROM protocol that combines elements of early passive motion and early active motion with place and hold, which will result in the greatest total arc of motion for the repaired fingers.
  
• There is no increase in rupture rates of the repaired tendon(s) compared to passive ROM protocols with active extension.
  
• There are a large variety of postoperative flexor tendon protocols that vary by center. There is a trend toward a combination of early passive with early active ROM in leading hand surgery centers.

Rationale

Early motion postflexor tendon repair has resulted in dramatically improved composite motion of the fingers compared to immobilization. The decision of when to commence early motion therapy after surgery varies by center.

Clinical comment

Early motion protocols can be considered those that begin motion within seven days of repair.⁷ Work of flexion reflects the resistance against which a repaired tendon must pull to permit gliding within the sheath.⁸

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