This repetitive, noninvasive, and reproducible test, independent of the practitioner, is the most accurate test for skin sensitivity assessment. Nylon monofilaments of different diameters (from the thinnest to the thickest) are applied perpendicularly to the skin three times for about 1.5 s while the patient’s eyes are covered. The caliber noted is that of the thinnest monofilament felt by the patient (Fig. 11.2a).

Only the finger pulps and middle phalanges can be evaluated. This test measures the discriminative ability of two stationary points (Fig. 11.2b). Two small, sharp points are spaced with a variable distance around a disc (Weber’s compass) or a graduated stick. The therapist touches the patient with the two points on the pulp, until the skin turns white. The patient feels that one or two points have touched the skin. This test is relatively rough, but it allows for discriminative sensitivity (normal 0–5 mm, moderate 6–10 mm, low 11–15 mm).

This test is performed using two test tubes containing water at 10 and 40 °C and assesses thermal sensitivity. The stimulus must be applied for 1 s on each random area.

Rehabilitation aims to establish behavior patterns without interfering with surgery or immobilization. Free joints must be solicited, and the image of the movement must be preserved. Different exercises should be performed several times daily to avoid consequences associated with nonfunctioning limbs such as exclusion, ­muscle atrophy, and loss of motor skills. The athlete should mimic the movement for a few seconds on the healthy side and then do it simultaneously on both sides. The value of the bilateral imitation of movements is to make use of any proprioceptive input of the healthy side to assist the invalid side: This is referred to as “mirror work.” Transcutaneous vibratory stimulation can be used on the tendons of the antagonistic muscles, with the aim to stimulate the proprioceptive system and thus maintain a good body image. Psychological conditioning is more important when dealing with athletes than with regular patients.

The immobilization of one or more joints can lead to stiffness [2]. When the splint is removed, the athlete perceives the immobilized part as stiff and nonfunctional, resulting in an altered body image [1]. After first removal, the therapist’s role is to guide the patient to perform active or passive movements and to care for the skin. Passive mobilization is very important; the therapist should extend the wrist, with the thumb in abduction, and the palm hollow (tenodesis effect) (Fig. 11.6); the movement sought is the curving of the fingers and closing of the hand. It will be passive at first, involving the traumatized finger ray. This then progresses to active assisted mobilization by the hand therapist, then active work, and finally active resistance exercises (universal therapeutic program). These rolling movements are alternated with extension exercises, as well as spreading the fingers wide apart and then bringing them close together. Active shoulder and elbow exercises should also be encouraged.

This step involves blocking movements, speed of execution, swinging movements, or the association of movements involving the shoulder, neck, or half the body.

Strength conditioning exercises target the extrinsic and intrinsic systems of the fingers. The hand therapist should remember that each ray includes three extrinsic muscles and three intrinsic muscles. The first three allow rolling the finger and unfolding in extension with strength. The intrinsic system is responsible for the coordination of the proximodistal and distoproximal movements, with perfect axial stability and radial and ulnar rotational stability. During this period, the athlete must be educated to use his hand while protecting it; he must be taught, shown, and conditioned to the “hitting hand” (Fig. 11.7). This involves 20 to 30° of wrist extension and 40° of MCP flexion where the fingers should be firmly outstretched and slightly spread apart, with the palm hollowed, bringing the thenar and hypothenar eminences closer together. The thumb column should be 4 cm away from the second ray.

The learning process may require several sessions; otherwise return to sports will be delayed.

Progress requires sagittal, then lateral exercises, and finally rotatory constraints. The exercises are first fractionated and sequenced with increasing loads (deformable tiles molded on the finger with adhesive fabric or weighted metal rings fixed at the level of the nail). The range of motion is gradually increased. Circumduction exercises or “scissoring” movements with elastic resistance can then be implemented, either manually or using a Canadian board with a multicenter ring. In all ball sports, perfect mastery of the hand gesture and throwing is essential. The therapist should emphasize exercising the extrinsic muscles as well as the intrinsics, to achieve optimal ball grip (Fig. 11.8).