HAND REHABILITATION

PROTOCOLS

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 Hand Rehabilitation Protocols | 2

TABLE OF CONTENTS
EPL Repair Early Active Motion 3

Extensor Tendon Injury Zone III-IV

Short Arc Motion (SAM) Program 5

Extensor Tendon Repair Zones IV to VII

Relative Motion Extension (RME) 7

Flexor Tendon Repair Zones I, II,

III-Early Active Motion (EAM) 9

Flexor Tendon Repair Zones I, II,

II-Modified Duran 12

FPL repair Early Active Motion 15

FPL repair Modified Duran 18

Percutaneous Pinning P1 Fracture 20

Proximal Row Carpectomy (PRC) 22

Therapy Management of Tendon Transfers 24

Total Wrist Arthrodesis 28

Total Wrist Arthroplasty 30

Flexor Tendon Repair Zones IV

and V-Early Active Motion 32

Four Corner Fusion 36

Mallet Finger Zone I-II Extensor Tendon Injury 38

ORIF Distal Radius 39

Trapeziectomy with LRTI 41

Trapeziectomy with Tightrope Suspension 43

Flexor Tendon Reconstruction Stage I 45

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 Hand Rehabilitation Protocols | 3

EPL REPAIR EARLY ACTIVE MOTION

Phase I Precautions: The primary goal is to protect the surgically repaired extensor tendon while providing
early motion to prevent tendon adhesion. All exercises must be completed within the protective orthosis. Patient
compliance and good communication with MD is extremely important.

Emphasis on... Orthosis Exercise

Phase I Gentle AROM to Post-op dressing - Initiate AROM of unaffected fingers to
(0-4 weeks) unaffected fingers removed and custom limits of orthosis.
forearm-based thumb - Short arc thumb IP flexion to the limits
1 week One-handed ADLs
spica with dynamic of the rubber band block, emphasize
IP extension assist relaxation for rubber band assist to extend
is fabricated. Wrist IP joint. NO thumb MP or wrist ROM.
should be positioned
in 20° extension - Initiate edema control including: light
and thumb midway coban wrapping, ice, elevation.
between palmar and
radial abduction. Block
IP flexion at 20°.
2-3 weeks Goal is to achieve Custom orthosis is - Initiate gentle scar management
full AROM of continued between techniques.
unaffected fingers exercise sessions and - Gentle AROM of wrist with NO thumb
to the limits of the at night. IP block can AROM.
orthosis. be adjusted to 40°
flexion assuming no - Gentle thumb MP AROM with no wrist
extension lag. AROM.
- Light ADL activities are permitted with
affected hand while in orthosis. Activities
may include picking up paper, passively
stabilizing light objects less than 1-2 lbs.

Phase II Precautions: Continue to protect surgical repair and monitor for signs of extension lag.

Emphasis on... Orthosis Exercise

Phase II Goal is to restore Custom orthosis is - Continue AROM outside of brace.
(4-8 weeks) full ROM of wrist, continued between - With wrist and thumb in slight flexion add
fingers, and thumb exercise sessions and full IP extension.
4 weeks
with minimal to no at night. IP block can
extension lag by be adjusted to allow - Add composite active flexion and
the end of phase II. full flexion assuming extension of thumb and wrist.
no extension lag is
present.

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 Hand Rehabilitation Protocols | 4

Emphasis on... Orthosis Exercise

6 weeks Goal is to restore Discontinue FB thumb - May add PROM exercises to the wrist and
full ROM of wrist, spica. May require thumb.
fingers, and thumb step down orthosis
with minimal to no if IP lag is present
extension lag. including: static thumb
IP extension orthosis.
Phase III Precautions: It is important to continue to monitor for any signs of extension lag during phase III. If no
lag is present, client may be instructed in exercises to resolve any extrinsic extensor compartment tightness and
focus on restoring muscle balance.

Emphasis on... Orthosis Exercise

Phase III Continue to focus If extrinsic extensor - Medium ADL activities are permitted (no
(8-12 weeks) on active ROM and compartment tightness heavier than 5 lbs). Such activities may
begin to focus on is present, may add include carrying ½ gallon of milk, light
8 Weeks
strengthening for dynamic flexion housework, light community level activities.
ADL’s. orthosis, continue to
monitor for extension
lag.

10 weeks Focus shifts - Initiate gentle resistive exercise with soft

to increased therapy putty.
independence - May also add light resistive hand grippers
with ADL’s, IADL’s, for exercise.
and return-to-work
goals. - Continue to increase in IADLs (no heavier
than 8 lbs)
12-16 weeks - Progressive resistive exercises, BTE to
address return-to-work goals
- Continue to increase ADLs/IADLs
- Work conditioning and FCE to facilitate
return to work.

Clinical Pearls: Throughout the rehab process it is extremely important to monitor for signs of extension lag and
modify plan of care accordingly. It is important to remember that the client will continue to improve after discharge
from therapy. Progress will continue for up to 6 months following tendon repair and clients should be instructed to
continue to focus on HEP until all of their goals are met.

Evans, Roslyn B. “Rehabilitation Following Extensor Tendon Injury and Repair.” Rehabilitation of the Hand and Upper Extremity,
Seventh ed., vol. 1, Elsevier, 2021, pp. 464–478.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 5

EXTENSOR TENDON INJURY ZONE III-IV

SHORT ARC MOTION (SAM) PROGRAM
Phase I Precautions: Protect surgical repair with well-fitting orthosis to prevent gap formation and attenuation
of the surgical repair should position the PIP joint in 0° extension and should be monitored closely. Monitor for
extension lag and good communication with MD is vital.
Emphasis on... Orthosis Exercise
Phase I: Initiate hand - Post-operative - Exercise position for SAM protocol
(0-4 weeks) therapy for short dressing removed and during first 3 weeks includes: 30° wrist
arc motion within fabricate custom volar flexion, 0° MCP joint extension, PIP
3-5 days
limits of orthoses thermoplastic protective joint motion from 0-30° flexion, DIP
and AROM of orthosis to involved joint motion from 0-25° using exercise
unaffected digits finger positioning PIP template orthosis 1.
while wearing and DIP joints in 0° - Exercise Template orthosis 2 allows
protective orthosis. extension. full DIP flexion if lateral bands were not
-Exercise Template repaired; if lateral bands are repaired
orthosis 1 allows 30° DIP motions is to 30-35° flexion.
PIP flexion and 20-25 - Edema Control including: Coban, ice,
degrees DIP flexion. elevation.
-Exercise Template - Exercises performed 6-8 times per day
orthosis 2 is fabricated for 10-minute sessions.
to position PIP in 0°
extension and allows full
DIP flexion.
-Protective orthosis is
worn at night and in
between exercises.

2 weeks In the absence -Template 1 is adjusted to - Continue exercises as above with

of extension lag allow 40° PIP flexion. adjusted template.
SAM protocol is -Continue with Protective
advanced. orthosis at night and in
between exercises.

3 weeks - Template 1 is adjusted to - Continue exercises as above with

allow 50° PIP flexion. adjusted template.
- Continue with Protective - Initiate scar management techniques.
orthosis at night and in
between exercises.

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 Hand Rehabilitation Protocols | 6

Phase II Precautions: Continue to protect surgical repair and monitor for signs of extension lag. If extension lag
develops, flexion increments can be more modest with focus returning to active extension.
Emphasis on... Orthosis Exercise
Phase II: In the absence of - Continue with Protective - Exercise sessions can be performed
(4-8 weeks) extension lag, client orthosis at night and in outside of thermoplastic exercise
can perform up to between exercises. orthoses templates focus on PIP and
4 weeks
70-80° flexion by DIP flexion and active IP extension.
end of fourth week.

5 weeks - Composite flexion exercises may be

added.

6 weeks - May discontinue - May initiate PROM exercises with less

protective orthosis than 10° extension lag.
during day but continue
to wear at night.
Phase III Precautions: Continue to protect surgical repair moderate to heavy activity and monitor for signs of
extension lag. It is important to remember that the client will continue to improve for 3-6 months following tendon
repair and should continue to focus on HEP until all goals have been met.
Emphasis on... Orthosis Exercise
Phase III: Continue to focus - Discontinue protective - Medium ADL activities are permitted
(8-12 weeks) on active ROM and orthosis during day and (no heavier than 5 lbs). Such activities
begin to focus on may continue to wear at may include carrying ½ gallon of milk,
Week 8
strengthening for night. light housework, light community-level
ADL’s. activities.
- Initiate gentle resistive exercise with
soft therapy putty.
- May also add light resistive hand
grippers for exercise.
Week 10 Focus shifts - Progressive resistive exercises, BTE to
to increased address return-to-work goals.
independence
with ADL’s, IADL’s,
and return-to-work
goals.
Week 12 - Work conditioning and FCE to facilitate
return to work.

Evans, Roslyn B. “Rehabilitation Following Extensor Tendon Injury and Repair.” Rehabilitation of the Hand and Upper Extremity,
Seventh ed., vol. 1, Elsevier, 2021, pp. 464–478.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 7

EXTENSOR TENDON REPAIR ZONES IV TO VII

RELATIVE MOTION EXTENSION (RME)
Phase I Precautions: Goal is to protect the surgically repaired extensor tendon while allowing early motion. All
exercises must be completed within the protective orthosis. Patient compliance and good communication with the
MD is extremely important for an excellent therapy outcome.
Emphasis on... Orthosis Exercise
Phase I: Initiate hand Post- operative - Initiate AROM within RME orthosis
(0-4 weeks) therapy for dressing removed and including hook fist, composite finger
gentle AROM to flexion / extension.
0- 10 days custom RME orthosis
unaffected fingers - Perform 20 repetitions every 2 hours.
with 15-20° finger
and light hand use
extension and - Initiate edema control including: light
(such as picking up
combined wrist coban wrapping, ice, elevation.
paper, passively
extension orthosis
stabilizing light
with 30° extension are
objects less than 1-
fabricated. Protective
2 lbs.)
orthoses are always
worn.

3 weeks Goal is to achieve Continue with - Initiate gentle scar management

full hook fist to protective orthoses. techniques.
the limits of the - Light ADL activities are permitted.
orthosis.

4 weeks Avoid combined May discontinue - Initiate gentle wrist motion including: wrist
composite fist with wrist extension flexion and extension
wrist flexion, except orthosis upon MD - Light to medium ADL activities are
zone VII. recommendations permitted (no heavier than 5 lbs). Such
for zones IV to VI. activities may include carrying ½ gallon
May discontinue RME of milk, light housework, light community
orthosis upon MD level activities.
recommendations for
zone VII.

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 Hand Rehabilitation Protocols | 8

Phase II Precautions: Continue to protect surgical repair and monitor for signs of extension lag.
Emphasis on... Orthosis Exercise
Phase II: Goal is to restore Discontinue all - May introduce composite fist with
(4-8 weeks) full ROM of wrist orthoses during day combined wrist flexion.
and fingers with but continue at night.
6 weeks
minimal to no
extension lag.
8 weeks Continue to focus - Medium ADL activities are permitted.
on active ROM and - Initiate gentle resistive exercise with soft
begin to focus on therapy putty.
strengthening for
ADL’s. - May also add light resistive hand grippers
for exercise.

Phase III Precautions: It is important to remember that the client will continue to improve for 3- 6 months
following tendon repair and should continue to focus on HEP until all goals have been met.
Emphasis on... Orthosis Exercise
10 weeks Focus shifts Progressive resistive exercises, BTE to
to increased address return-to-work goals.
independence
with ADL’s, IADL’s,
and return-to-work
goals.
12 weeks Work conditioning and FCE to facilitate
return to work.

Clinical Pearls: Research has shown good ROM by weeks 3- 4 with relative motion program compared to other
protocols with relatively few tendon ruptures. RME participants typically demonstrate grip strength returns to 85%
by week 8 and WNL’s by 12 weeks.

Merritt, Wyndell H. “Relative Motion Orthoses: The Concepts and Application to Hand Therapy Management of Finger
Extensor Tendon Zone III and VII Repairs, Acute and Chronic Boutonniere Deformity, and Sagittal Band Injury.”
Rehabilitation of the Hand and Upper Extremity, Seventh ed., vol. 2, Elsevier, 2021, pp. 1496–1510.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 9

FLEXOR TENDON REPAIR ZONES I, II,

III-EARLY ACTIVE MOTION (EAM)
Phase I Precautions: All exercises must be completed while wearing the dorsal blocking orthosis. It is important
to decrease work of flexion and stress on tendon repair from edema by removing bandages during exercise. Patient
compliance and good communication with MD is extremely important. Modalities including NMES and ultrasound may
be added 3- 4 weeks post op however, please check with MD prior to adding modalities the plan of care.
Emphasis on... Orthosis Exercise
Phase I
(0-6 weeks)
Goal during week Post-op bandages PROM within restraints of orthosis is
Week 1 1 is full supple are removed for light performed
PROM. This must compressive dressing and
25 repetitions every 2 hours.
be achieved prior custom orthosis.
to initiating early - passive MCP flexion/extension
active motion
- passive PIP flexion/extension
protocols. Zones I- II custom
- passive DIP flexion/extension
Dorsal Block Orthosis with
- composite flexion/extension of the
One-handed ADL Wrist 15-30° extension, MCP affected digit within limits of orthosis
activities 45°, and IPs at 0°
- Early edema control is critical including:
elevation, coban, ice
Zone III custom

Dorsal Block Orthosis with

Wrist 15 - 30° extension,

MCP 60° flexion, and

IPs at 0°

Week 2 Must have full Continue all exercises with - Continue PROM as warm- up.
supple PROM to the dorsal blocking orthosis - Initiate early short arc flexion to one
initiate early short on. quarter of fist.
arc active flexion
- Initiate short arc place and active hold
to one quarter of fist.

Continue - All exercises are performed 25

One-handed repetitions every 2 hours.
ADL activities. - Continue edema control techniques.

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 Hand Rehabilitation Protocols | 10

Emphasis on... Orthosis Exercise

Week 3 Continue to Continue all exercises with - Continue PROM as warm- up.
maintain supple the dorsal blocking orthosis - Advance early short arc flexion to one
PROM; monitor for on. third of fist.
signs of adhesion
formation, - Advance short arc place and active hold
triggering, or to one third of fist.
gapping. - All exercises are performed 25
repetitions every 2 hours.
- Continue edema control techniques.
Continue One-
- Initiate scar management techniques.
handed ADL
activities.
Week 4 Continue to The dorsal blocking orthosis - Continue PROM as warm- up.
maintain supple can now be removed to - Advance early short arc flexion to half a
PROM; monitor for perform exercises without fist.
signs of adhesion the orthosis. Continue with
formation, the dorsal block orthosis - Advance short arc place and active hold
triggering, or between exercise sessions to half fist.
gapping. and at night. - Initiate hook fist exercise, passively.
- All exercises are performed 25
repetitions every 2 hours.
Continue One-
- Continue edema control techniques.
handed ADL
activities. - Initiate scar management techniques.
Week 5 Continue to Continue with the dorsal - Advance early short arc flexion to full
maintain supple block orthosis between fist.
PROM; monitor for exercise sessions and at - Advance to full arc place and active
signs of adhesion night. hold.
formation,
triggering, or - Continue hook fist exercise, active.
gapping. - Continue all exercises as prescribed
above.
Continue One-
handed ADL
activities.

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 Hand Rehabilitation Protocols | 11

Phase II Precautions: Continue to monitor for signs of adhesion formation, triggering, or gapping. Never perform
blocking exercises to small finger due to increased chance of tendon rupture to the small finger. Continue to have
communication with MD prior to progressing the protocol.
Emphasis on... Orthosis Exercise
Phase II Focus shifts on Dorsal Blocking Orthosis is - Initiate differential tendon glides,
(6-10 weeks) unassisted active discontinued at 6 weeks. individual tendon glides.
flexion and - Continue with full arc place and hold.
Week 6
extension.
- Light ADL activities are permitted.

Week 8 Continue to focus May utilize relative motion - Joint blocking exercise may be added
on active ROM and extension orthosis to to program.
begin to focus on encourage FDP glide if - Gentle resistive exercise with soft
strengthening for there is DIP flexion lag. therapy putty in cylinder shape to
ADL’s. encourage DIP flexion.
Week 9 - Add light resistive hand grippers for
exercise.
Phase III Precautions: Client may need to be evaluated for return to work through a formal work conditioning
program and/or FCE.
Emphasis on... Orthosis Exercise
Phase III

(10-12 weeks) Focus shifts May begin corrective Progressive resistive exercises, BTE
to increased orthosis if needed for simulator may be added to address
independence with any unresolved flexion return-to-work goals.
ADL’s, IADL’s, and contracture.
return- to- work
goals.

Clinical Pearls: Throughout the rehab process it is extremely important to monitor for signs of tendon adhesion and
modify plan of care accordingly. It is important to remember that the client will continue to improve after discharge
from therapy. Progress will continue for up to 1 year following tendon repair and clients should be instructed to
continue to focus on a HEP until all of their goals are met. Therapy visits are most important during the first 2- 4 weeks
to achieve good motion and prevent tendon adhesion. Both active and passive ROM measurements should be taken
on each visit with a goal of 5- 10° gains in flexion each visit.

Cannon, Nancy M. “Therapy Management of Flexor Tendon Injuries and Repairs.” Rehabilitation of the Hand and Upper
Extremity, Seventh ed., vol. 1, Elsevier, 2021, pp. 421–431.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 12

FLEXOR TENDON REPAIR ZONES I, II,

II-MODIFIED DURAN
Phase I Precautions: All exercises must be completed while wearing the dorsal blocking orthosis. It is important to
decrease work of flexion and stress on tendon repair from edema by removing bandages during exercise. Patient
compliance and good communication with MD is extremely important. Modalities including NMES and ultrasound
may be added 3- 4 weeks post op however, please check with MD prior to adding modalities to the plan of care.
Emphasis on... Orthosis Exercise
Phase I Initiate PROM and Post-op bandages PROM within restraints of orthosis is
(0-6 weeks) edema control are removed for light performed
techniques with compressive dressing
Week 1 25 repetitions every 2 hours.
a goal of supple and custom orthosis.
passive ROM - passive MCP flexion / extension
within the custom
- passive PIP flexion/extension
orthosis. Zones I-II
- passive DIP flexion/extension
Dorsal Block Orthosis
- composite flexion/extension of entire digit
with Wrist 15-30°
One-handed ADL
extension, MCP 45°
activities.
flexion, and - Early edema control is critical including:
elevation, coban, ice
IPs at 0°

Zone III

Dorsal Block Orthosis

with

Wrist 15-30°extension

MCP 60°flexion, and

IPs at 0°

Weeks 2- 3 Continue to focus Continue to wear - Continue with PROM program every 2
on supple PROM. Dorsal Block Orthosis hours.
- Continue edema control
- Initiate scar management techniques.
one-handed ADL
activities.
Emphasis on... Orthosis Exercise

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 13

Week 3 Continue to focus - Initiate early short arc flexion to one

on full supple quarter of fist within confines of the
PROM. May begin orthosis.
gentle AROM. - Initiate short arc place and active hold to
Continue one- one quarter of fist.
handed ADL
activities.

Week 4 Gentle AROM from Dorsal Block Orthosis - Continue with short arc flexion exercises.
one quarter to one may be removed for - Continue with short arc place and active
third of a fist. AROM but continue hold.
wear between exercise
sessions and night. - Initiate wrist tenodesis
- NMES and ultrasound may be added to
program for heavy scarring or limited
tendon glide.

Week 5 Gentle AROM from - Advance early short arc flexion to full fist.
one third to one - Advance to full arc place and active hold.
half a fist.
- Initiate hook fist exercise, active.

Phase II Precautions: Continue to monitor for signs of adhesion formation, triggering, or gapping. Never perform
blocking exercises to small finger due to increased chance of tendon rupture to the small finger. Continue to have
communication with MD prior to progressing the protocol.

Emphasis on... Orthosis Exercise

Phase II AROM from one Dorsal Blocking - Initiate differential tendon glides,
(6-10 weeks) half fist to full fist. Orthosis is individual tendon glides.
discontinued at 6 - Continue with full arc place and hold.
Week 6
weeks.
- Isolated joint blocks may be added.
- Light ADL activities are permitted, such as
picking up paper, passively stabilizing light
objects less than 1-2 lbs.

Week 8 Focus shifts on - Begin resisted composite fist, hook, and

unassisted active straight fist with use of therapy putty and
flexion and progressing to hand exerciser.
extension. - Continue to gradually advance ADL/IADL
activities with affected hand.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 14

Phase III Precautions: Clients may need to be evaluated for return-to-work programs through a formal work
conditioning program and/or FCE around 12- 16 weeks.
Emphasis on... Orthosis Exercise
Phase III Focus shifts May add corrective - Progressive resistive exercises,
(10-12 weeks) to increased splinting options for - BTE to address return- to- work goals.
independence with unresolved flexion
Week 10 - Full participation in ADL’s/IADL’s
ADL’s, IADL’s, and contractures.
return- to- work
goals.

Weeks 12-16 - Work conditioning/FCE for return- to- work

goals.

Clinical Pearls: Throughout the rehab process it is extremely important to monitor for signs of tendon adhesion
and modify plan of care accordingly. It is important to remember that the client will continue to improve after
discharge from therapy. Progress will continue for up to 1 year following tendon repair and clients should be
instructed to continue to focus on a HEP until all of their goals are met. Therapy visits are most important during the
first 2- 4 weeks to achieve good motion and prevent tendon adhesion. Both active and passive ROM measurements
should be taken on each visit with a goal of 5- 10° gains in flexion each visit.

Cannon, Nancy M. “Therapy Management of Flexor Tendon Injuries and Repairs.” Rehabilitation of the Hand and Upper Ex-
tremity, Seventh ed., vol. 1, Elsevier, 2021, pp. 421–431.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 15

FPL REPAIR EARLY ACTIVE MOTION

Phase I Precautions: All exercises must be completed while wearing the dorsal blocking orthosis (DBO). It is
important to decrease work of flexion and stress on tendon repair from edema by removing bandages during
exercise. Patient compliance and good communication with MD is extremely important.
Range of Motion Orthosis Exercise
Phase I Full supple PROM of Post-op bandages - PROM to thumb within restraints of DBO
(0-6 weeks) unaffected digits must are removed for 25 repetitions every 2 hours including:
be obtained prior to light compressive - PROM MP flexion/extension,
Week 1
initiating early active dressing and custom
motion protocol in orthosis. - PROM IP flexion/extension,
week 2. Edema control - Composite MP and IP flexion and
is critical to decrease extension.
work of flexion. Dorsal Blocking - Early edema control is including:
Orthosis (DBO) with elevation, coban, ice.
wrist neutral to 20°
One- handed ADLs extension, Thumb
MP 15° flexion, IP
flexed to 30°. Fingers
are left free.

Week 2 Must have full supple Continue all exercise - Continue PROM exercise as warm- up.
PROM to initiate early within confines of - Initiate short arc flexion to one quarter of
short arc active flexion DBO. flexion.
- Initiate short arc place and active hold to
one quarter of flexion.
Continue one- handed Tenodesis
ADLs performed outside - Initiate tenodesis with passive wrist
DBO with controlled extension and simultaneous passive
supervision by thumb flexion.
therapist. - Continue edema control techniques.

Week 3 Continue one- handed - Initiate scar management techniques.

ADLs

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 Hand Rehabilitation Protocols | 16

Range of Motion Orthosis Exercise

Week 4 Continue to maintain DBO is continued - NMES and ultrasound may be added to
supple PROM; monitor between exercise facilitate FPL excursion.
for signs of adhesion sessions and at - unrestricted AROM of wrist and thumb
formation, triggering, night.
or gapping.

Continue one- handed

ADLs
Week 5 May use affected - Initiate active wrist and thumb flexion
hand/thumb in followed by wrist and thumb extension for
light ADL activities max excursion of FPL.
(less than 1-2 lbs of - Light ADL activities are permitted.
resistance).

Phase II Precautions: Continue to monitor for signs of adhesion formation, triggering, or gapping. Continue to
have communication with MD prior to progressing the protocol.

Range of Motion Orthosis Exercise

Phase II Focus on unassisted Dorsal Blocking - Initiate blocking exercises to FPL if
(6-10 weeks) active flexion and Orthosis is excursion is limited.
extension. discontinued at 6 - Initiate passive extension of wrist and
Week 6
weeks. thumb to resolve extrinsic flexor tightness.

Week 8 Continue to focus - Initiate progressive strengthening using

on active ROM and putty, hand exerciser, 1-2 # hand weights.
begin to focus on - Pt education to avoid heavy lifting and/or
strengthening for tight sustained pinch.
ADL’s.
Phase III Precautions: Client may need to be evaluated for return to work through a formal work conditioning
program and/or FCE.
Range of Motion Orthosis Exercise
Phase III Focus shifts
(10-12 weeks) to increased - Progressive resistive exercises, BTE to
independence with address return- to- work goals.
ADL’s, IADL’s, and
return- to- work goals.
12-16 weeks - Work conditioning and FCE to facilitate
return to work.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 17

Clinical Pearls: Throughout the rehab process it is extremely important to monitor for signs of tendon adhesion
and modify plan of care accordingly. It is important to remember that the client will continue to improve after
discharge from therapy. Progress will continue for up to 1 year following tendon repair and clients should be
instructed to continue to focus on a HEP until all of their goals are met. Therapy visits are most important during the
first 2- 4 weeks to achieve good motion and prevent tendon adhesion. Both active and passive ROM measurements
should be taken on each visit with a goal of 5- 10° gains in flexion each visit.

Cannon, Nancy M. “Therapy Management of Flexor Tendon Injuries and Repairs.” Rehabilitation of the Hand and Upper
Extremity, Seventh ed., vol. 1, Elsevier, 2021, pp. 421–431.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 18

FPL REPAIR MODIFIED DURAN

Phase I Precautions: All exercises must be completed while wearing the dorsal blocking orthosis (DBO). It is
important to decrease work of flexion and stress on tendon repair from edema by removing bandages during
exercise. Patient compliance and good communication with MD is extremely important.
Emphasis on Orthosis Exercise
Phase I PROM within limits Post-op bandages - PROM within restraints of DBO 25
(0-6 weeks) of DBO and edema are removed for repetitions every 2 hours including:
control to decrease light compressive - PROM MP flexion/extension,
Week 1
work of flexion. dressing and custom
orthosis. - PROM IP flexion/extension,
- Composite MP and IP flexion and extension.
One- handed ADLs. - Early edema control is including: elevation,
DBO fabricated with coban, ice.
wrist neutral to 20°
extension, Thumb
MP 15° flexion, IP at
30° flexion, fingers
are left free.

Week 2 Goal is full supple Continue all exercise - Continue PROM exercise
PROM. within confines of - Continue edema control techniques.
DBO.

Continue with one-

handed ADLs.

Week 3 Continue with Continue all exercise - Initiate scar management techniques.
one-handed ADLs. within confines of - Initiate short arc flexion to one quarter of
DBO. flexion.
- Initiate short arc place and active hold to
one quarter of flexion.

Week 4 Continue to maintain DBO is continued - NMES and ultrasound may be added to
supple PROM; monitor between exercise facilitate FPL excursion.
for signs of adhesion sessions and at
formation, triggering, night.
or gapping.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 19

Emphasis on Orthosis Exercise

Week 5 May use affected - unrestricted AROM of wrist and thumb
hand/thumb in - Initiate active wrist and thumb flexion
light ADL activities followed by wrist and thumb extension for
(less than 1- 2 lbs of max excursion of FPL.
resistance).
- Light ADL activities are permitted.
Phase II Precautions: Continue to monitor for signs of adhesion formation, triggering, or gapping. Continue to
have communication with MD prior to progressing the protocol.
Emphasis on Orthosis Exercise
Phase II Focus on unassisted - Dorsal Blocking - Initiate blocking exercises to FPL if
(6-10 weeks) active flexion and Orthosis is excursion is limited.
extension. discontinued at 6 - Initiate passive extension of wrist and
Week 6
weeks. thumb to resolve extrinsic flexor tightness.
- Wrist and thumb
static splint may be
needed at night for
full extension.
Week 8 Continue to focus - Initiate progressive strengthening using
on active ROM and putty, hand exerciser, 1-2 # hand weights.
begin to focus on - Pt education to avoid heavy lifting and/or
strengthening for tight sustained pinch.
ADL’s.
Phase III Precautions: Client may need to be evaluated for return to work through a formal work conditioning
program and/or FCE.
Emphasis on Orthosis Exercise
Phase III Focus shifts - Progressive resistive exercises, BTE to
(10-12 weeks) to increased address return-to- work goals.
independence with
ADL’s, IADL’s, and
return- to- work goals.
12-16 weeks - Work conditioning and FCE to facilitate
return to work.
Clinical Pearls: Throughout the rehab process it is extremely important to monitor for signs of tendon adhesion
and modify plan of care accordingly. It is important to remember that the client will continue to improve after
discharge from therapy. Progress will continue for up to 1 year following tendon repair and clients should be
instructed to continue to focus on a HEP until all of their goals are met. Therapy visits are most important during the
first 2- 4 weeks to achieve good motion and prevent tendon adhesion. Both active and passive ROM measurements
should be taken on each visit.

Cannon, Nancy M. “Therapy Management of Flexor Tendon Injuries and Repairs.” Rehabilitation of the Hand and Upper Ex-
tremity, Seventh ed., vol. 1, Elsevier, 2021, pp. 421–431

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 20

PERCUTANEOUS PINNING P1 FRACTURE

Phase I Precautions: Protect healing fracture and percutaneous pins with thermoplastic orthosis, prevent pin tract
infection with daily pin care.
Emphasis on... Orthosis Exercise
Phase I AROM of uninvolved Custom thermoplastic - Initiate AROM of all uninvolved
(0-4 weeks) fingers with expectation hand- based (HB) fingers, wrist, elbow, and shoulder.
of at least 75% AROM by orthosis in safe position - With MD clearance, Gentle DIP
Week 1
the end of phase I. with MP flexion to 60- flexion of involved finger.
70°, PIP and DIP 0°
extension. - Daily pin care to prevent infection.

May use fingers, thumb, - Edema control including: coban,

and unaffected joints to elevation, ice.
hold objects less than 1 - Light ADL’s with protective
lbs. during ADLs/IADLs orthosis.
while in orthosis.

Phase II Precautions: Percutaneous pin removal between 4- 6 weeks depending upon fracture healing.
Continue to perform daily pin care until pins are removed. Once pins have been removed continue to protect
healing fracture with gentle ROM and no forceful manipulations of the injured finger.
Phase II Nearly full AROM of Continue with protective - Initiate gentle AROM of involved
(4-8 weeks) uninvolved fingers. HB orthosis between finger including: PIP and DIP joint
Initiate gentle AROM of exercise sessions and blocks, differential tendon glides,
Week 4
involved finger after pin at night. May need individual tendon glides.
removal. Goal of at least adjustment after pin - Light to moderate ADL activities
75% AROM of involved removal and as edema are permitted.
finger by end of phase II. resolves.

May use affected finger

and hand to hold
objects less than 1 lbs
and perform light ADLs
such as putting on and
taking off loose clothing
and shoes, washing
dinnerware, and folding
clothing.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 21

Emphasis on... Orthosis Exercise

Weeks 5 Monitor for extension lag May discontinue HB - Initiate scar massage once pin
due to extensor tendon orthosis during daytime sites are closed and fully healed.
adhesions along pin site. for static finger orthosis - Differential gliding while
to protect finger and stabilizing scar to free up tendon
maintain IP extension. adhesions.

6 weeks Continue to monitor If client is maintaining - With good fracture healing may
for extension lag while good IP extension, may begin gentle PROM.
maintaining flexion gains. discontinue protective - Reverse blocking for IP extension
orthosis with MD if IP lag is observed.
clearance.
Phase III Precautions: Continue to protect healing fracture, restore normal muscle balance, and focus on gentle
strengthening. Client goals should continue to address ADL’s, IADL’s, and return to work goals.
Emphasis on... Orthosis Exercise
Phase III - Continue with A/PROM for
(8-12 weeks) involved finger.

8 Weeks - May add gentle strengthening

with therapy putty and hand
grippers.
- Continue ADL activities.
10 weeks Focus on increased May add corrective - Progressive resistive exercises
independence with ADL’s, orthosis for finger including: BTE simulator and
IADL’s, and return-to-work flexion limitations, if MD return- to- work goals.
goals. confirms fracture healing:
- Progress toward independence
static progressive
with IADL’s.
composite finger flexion
orthosis.
12-16 weeks - Work conditioning,

- Focus on HEP.
Clinical Pearls: Therapy visits should be preserved until phase II after pin removal. Phase I intervention should
focus primarily with instruction in HEP, pin care, and edema control with weekly to biweekly visits depending upon
patient compliance. It is important to remember that patients will continue to progress for up to 6 months following
injury. Continue to instruct client in the importance of HEP to maximize progress until all of their goals are met.

Skirven, T.M., Osterman, A. L., Fedorczyk, J. M., Amadio, P. C., Feldscher, S. B., & Shin, E. K. (2021). Rehabilitation of the
hand and upper extremity. Philadelphia, PA: Elsevier.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 22

PROXIMAL ROW CARPECTOMY (PRC)

Phase I Precautions: Protect surgical repair, pain control and edema control.
Emphasis on... Orthosis Exercise
Phase I - Wrist is immobilized - Short arm cast for 4 - Finger ROM exercises including:
(0-4 weeks) in 0-10° wrist weeks. Differential Tendon Gliding, Individual
extension for 4 Tendon Gliding, Composite Fist
weeks. - Gentle AROM of forearm, elbow, and
shoulder is initiated.
- Achieve full - All exercises should be performed 4-6
shoulder, elbow, times per day for up to 5-10 minutes.
finger and thumb - Edema Control: Elevation, Ice, Coban
ROM on affected wrapping of fingers.
side within 4 weeks.

Phase II Precautions: Avoid composite wrist and digit flexion and extension to prevent overstretching of extrinsic
muscle/tendon length.
Phase II - Full finger ROM - Thermoplastic wrist - Initiate gentle AROM of wrist including:
(4-8 weeks) and initiate gentle hand orthosis (WHO) “Dart thrower’s Motion”.
wrist AROM with with wrist positioned - Initiate scar management and
4 weeks
goal to obtain in neutral, removed desensitization techniques.
approximately 50% only for exercise and
wrist AROM by the hygiene. - Light ADL activities can resume.
end of phase II.

May perform light

ADLs with affected
hand. Light ADLs
include putting on
and taking off loose
clothing and shoes,
washing dinnerware,
and folding clothing.
6 weeks - Initiate wrist AAROM.
- Initiate isometrics.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 23

Phase III Precautions: Forceful manipulations and joint mobilization techniques are not recommended at any
time during the rehab process.
Emphasis on... Orthosis Exercise
Phase III (8-12 Continue to focus - May discontinue - Initiate gentle strengthening with
weeks) on active ROM and the thermoplastic theraputty, hand grippers, isotonic exercise,
begin to focus on orthosis, if client and progressive resistive exercises.
8 Weeks
strengthening for needs a step- down
ADL’s. orthosis can offer
neoprene wrist
support.

10 weeks Focus on increased - Progressive resistive exercises, BTE to

independence with address return- to- work goals.
ADL’s, IADL’s, and
return- to- work goals.
12-16 weeks - Work conditioning and FCE to facilitate
return to work.

Clinical Pearls: The post- operative therapy goal is a pain- free functional wrist. A stable wrist that is pain- free will
provide a better functional outcome. While wrist salvage procedures will likely result in decreased ROM, many of
these restrictions will not limit participation in basic ADL’s. Loss of motion and strength is expected due to relative
shortening of the wrist and lengthening of the extrinsic muscles and tendons.

Shin, Eon Kyu. “Wrist Salvage Procedures: Surgery and Therapy.” Rehabilitation of the Hand and Upper Extremity, Seventh
ed., vol. 1, Elsevier, 2021, pp. 901–910.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 24

THERAPY MANAGEMENT OF TENDON TRANSFERS

Common Tendon Transfers for Radial Nerve Injury

Palsy Loss Transfer Orthosis

Radial Nerve Wrist Extension - Pronator Teres to ECRB - Wrist hand orthosis (WHO) with 45°
wrist extension.

MCP Joint Extension - FCR to EDC II- V - Wrist and MP block with 30° wrist
- FCU to EDC II- V extension and MP’s full extension.

- FDS III to EPL and EIP

- FDS IV to EDC III- V

Thumb Extension - Palmaris Longus to EPL - Wrist and Thumb extension with
- FDS III or IV to EPL wrist in 20° extension, Thumb MP full
extension, IP 10° hyperextension.

Precautions: Avoid simultaneous wrist and digit flexion to prevent over-stretching tendon transfer.
For Radial Nerve Palsy with multiple transfers for absence of wrist, MCP, and thumb extension, Pt should be fitted with
a sugar tong with removable wrist and MP block and thumb extension orthosis.

Feldscher, Sheri B. “Therapy Management of Tendon Transfers.” Rehabilitation of the Hand and Upper Extremity, Seventh ed.,
vol.1, Elsevier, 2021, pp. 621–630.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 25

Common Tendon Transfers for Median Nerve Injury

Palsy Loss Transfer Orthosis

High Median Nerve Thumb IP joint flexion - Brachioradialis to FPL Dorsal Block orthosis (DBO) with 20°
injuries: At or above wrist flexion, Thumb MP and IP 20°
the elbow. flexion, CMC in palmar abduction.

II and III finger flexion - Suture FDP II and III DBO with 20° wrist flexion, MP’s 65°
to functioning FDP IV flexion, IP’s full extension.
and V.

- ECRL to FDP II and III

if additional power is
needed.
Low Median Nerve Opposition - FDS IV to APB - DBO with 20° wrist flexion, Thumb
Injuries: Below the wide palmar abduction.
elbow - Same as above unless dorsal
- EIP to APB approach: Wrist is 15° wrist extension.
- HB splint with thumb in wide palmar
abduction.
- ADM to APB

Thumb Abduction - PL to APB - Thumb Spica 20° wrist flexion, thumb

wide palmar abduct.

Precautions: Avoid simultaneous wrist, thumb, and finger extension.

Feldscher, Sheri B. “Therapy Management of Tendon Transfers.” Rehabilitation of the Hand and Upper Extremity, Seventh
ed., vol. 1, Elsevier, 2021, pp. 621–630.

Common Tendon Transfers for Ulnar Nerve Injury

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 26

Palsy Loss Transfer Orthosis

High Ulnar Nerve FDP IV and V + low ulnar - Suture IV and V to FDP II - DBO with 20°wrist flexion, MP’s
nerve deficits. and III. 65° flexion, IP’s in full extension.

Intrinsics - FDS to radial lateral - Same as above.

band.
*Interossei
- ECRL to lateral band - Same as above
*Ulnar Lumbricals

- ECRB to lateral band - DBO with 30° wrist extension,

(dorsal approach) MP’s 60° flexion, IP’s in full
extension

- DBO with MP’s in 30° of flexion,

- MCP joint capsulodesis wrist and IP’s are not included.

Thumb Adduction - ECRL + graft to AP - DBO with wrist 20° extension,

- BR + graft to AP thumb 30° palmar abduction.

Precautions: Avoid MCP joint extension and simultaneous finger, thumb, and wrist extension.
Feldscher, Sheri B. “Therapy Management of Tendon Transfers.” Rehabilitation of the Hand and Upper Extremity, Seventh
ed., vol. 1, Elsevier, 2021, pp. 621–630.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 27

Postoperative Management Treatment Guidelines

Phase I: Immobilization 0-4 weeks - Protect Transfer - Protective orthosis
- A/PROM of the uninvolved joints
10-14 days - Post- op bandage and - 25 repetitions every 2 hours.
splint removed in favor of - Edema control; elevation, ice,
custom orthosis. compression.
3 weeks Facilitate tendon gliding - Initiate AROM to recruit tendon
without placing undue transfer.
stress on healing juncture - Scar management
site.

4 weeks - NMES for activation of transfer.

Phase II: Activation of 5-8 weeks Facilitate tendon gliding - Continue Tendon transfer
transfer; active motion without placing undue training
stress on healing juncture - Active Motion
site.
- Initiate Biofeedback
- Facilitation techniques
including: vibration, tapping,
etc.
- Edema Control
- Scar Management
- Initiate light ADL activities
6 weeks - Protective orthosis discontinued
during daytime.

Phase III: 8-12 weeks Increase strength and - Putty exercise, hand grippers
Strengthening and endurance to allow for
- Light hand weights
return to function return to function.
- Increased participation in ADL
activities
8-10 weeks - Night splinting is discontinued.

10-12 weeks - BTE or work simulator

- independent ADL’s.
14-16 weeks - FCE/return to work.

Feldscher, Sheri B. “Therapy Management of Tendon Transfers.” Rehabilitation of the Hand and Upper Extremity, Seventh ed.,
vol. 1, Elsevier, 2021, pp. 621–630.
If you have any questions or concerns, please call 859-562-1980.
 Hand Rehabilitation Protocols | 28

TOTAL WRIST ARTHRODESIS

Phase I Precautions: Protect surgical repair, pain control and edema control. Client will have 5lb lifting restriction
for up to 8 weeks.
Emphasis on Orthosis Exercise
Phase I - Achieve nearly full Short arm cast for 4 - Finger AROM exercises including:
(0-4 weeks) finger and thumb weeks. Differential Tendon Gliding, Individual
ROM of affected Tendon Gliding, Composite Fist
hand within 4 - Gentle AROM of forearm, elbow, and
weeks. - Current literature shoulder is initiated.
positions the wrist
- All exercises should be performed 4-6
in 10-15° wrist
- Expect full elbow times per day for up to 5-10 minutes.
extension.
and shoulder ROM - Edema Control: Elevation, Ice, Coban
within 4 weeks. wrapping of fingers.
Phase II Precautions: With delayed healing or non- union phase I may be delayed. Therapist should continue
to monitor for signs of infection, hematoma, excessive edema and dehiscence at the incision site. Focus on EDC
gliding to prevent scar adhesions.
Phase II Full ROM of elbow, - Forearm based wrist - Initiate scar management and
(4-8 weeks) shoulder, and hand orthosis (WHO) desensitization techniques.
hand by the end of to be worn between - Light ADL activities can resume.
4 weeks
phase II. exercise sessions and
at night. - May begin blocking exercises and PROM
of fingers if any limitations are present.

May perform light

- If MCP lag is present,
ADLs with affected
may attach extension
hand. Light ADLs
support at night.
include putting
on and taking off - If MCP flexion is
loose clothing and limited may add
shoes, washing exercise orthosis to
dinnerware, and promote MCP flexion.
folding clothing.
6 weeks - WHO can be - Continue outlined plan above.
discontinued at 6 - Focus on fine motor tasks and medium
weeks. ADL activities.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 29

Phase III Precautions: Continue to protect healing fusion. 5lb lifting restriction may be removed at 8 weeks but
progression of resistive exercises should be client centered and include MD regarding healing of the fusion.
Emphasis on Orthosis Exercise
Phase III (8-12 weeks) - Begin to focus on - Client can continue - Initiate gentle isometric strengthening
strengthening for with a step- down progress to light theraputty exercise.
8 Weeks
ADL’s. orthosis if needed
for heavy ADL’s to
ease Pt concerns over
injury.

10 weeks - Focus on - Hand grippers, isotonic exercise, and

increased progressive resistive exercises.
independence
with ADL’s, IADL’s,
and return- to-
work goals.
12- 16 weeks - Work conditioning and FCE to facilitate
return to work.

Clinical Pearls: Grip strength will not plateau for up to 1 year following surgery. Client may continue to have
difficulty with ADL’s and IADL’s for up to 6- 12 months following surgery and should receive instruction in adaptive
equipment, ergonomic adjustments, and task modification to meet ongoing ADL goals.

Shin, Eon Kyu. “Wrist Salvage Procedures: Surgery and Therapy.” Rehabilitation of the Hand and Upper Extremity, Seventh
ed., vol. 1, Elsevier, 2021, pp. 901–910.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 30

TOTAL WRIST ARTHROPLASTY

Phase I Precautions: Protect surgical repair, pain control and edema control.

Emphasis on Orthosis Exercise

Phase I - Achieve full - Depending upon - Initiate finger and thumb ROM to limits of
(0-6 weeks) AROM of affected MD: short arm cast or orthosis.
fingers, elbow, and cast or removable - Initiate AROM for forearm, elbow, and
shoulder by end thermoplastic wrist shoulder.
of phase I. hand orthosis (WHO)
which is removed only - Edema control techniques including:
for hygiene. elevation, ice, coban wrapping of fingers.

2-3 weeks - Initiate scar management techniques.

4 weeks - Initiate gentle AROM of wrist.

Phase II Precautions: Continue to protect surgical repair. Focus on good tendon glide of extensor tendons to
prevent tendon adhesion.

Emphasis on Orthosis Exercise

Phase II (6-8 weeks) - Obtain full AROM - Client can be weaned - Continue with ROM goals outlined above.
of fingers and from the WHO by end
6 weeks - May add isometric strengthening for hand,
uninvolved joints. of phase II.
wrist, and forearm with progression to
Client should
isotonic exercises at phase III.
obtain 30° flexion
and extension (arc
of 60°).

- May perform light

ADLs with affected
hand. Light ADLs
include putting
on and taking off
loose clothing and
shoes, washing
dinnerware, and
folding clothing.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 31

Phase III Precautions: Continue to protect surgical repair, manipulations and joint mobilization techniques are
not advised at any point in the rehab process. If a static progressive orthosis is ordered by MD be cautious to avoid
overstressing the joint.
Emphasis on Orthosis Exercise
Phase III - Active ROM - If wrist stiffness is - Gentle PROM of wrist may be added.
(8-12 weeks) and begin to present, with MD - Initiate isotonic exercise including: light
focus on light approval, may add theraputty exercise and hand grippers.
8 Weeks
strengthening for static progressive
ADL’s. orthosis.

10 weeks Focus on increased - Progressive resistive exercises working

independence with within 10 lb. lifting restrictions.
ADL’s, IADL’s, and
return- to- work
goals.
12 weeks - Focus on HEP.

Clinical Pearls: It is important to remember this procedure is most appropriate for lower demand patients. Patients
should be instructed to avoid loading and lifting anything greater than 10 lbs. to protect the prosthesis. Maximal
gains in motion may not be expected for up to 6 months following surgery and include: 60° flexion/extension arc,
10° radial deviation, and 25° ulnar deviation. Grip strength can take up to 1 year to reach maximal potential with a
goal of 70% of the unaffected side.

Shin, Eon Kyu. “Wrist Salvage Procedures: Surgery and Therapy.” Rehabilitation of the Hand and Upper Extremity, Seventh
ed., vol. 1, Elsevier, 2021, pp. 901–910.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 32

FLEXOR TENDON REPAIR ZONES IV

AND V-EARLY ACTIVE MOTION
Phase I Precautions: All exercises must be completed while wearing the dorsal blocking orthosis. It is important
to decrease work of flexion and stress on tendon repair from edema by removing bandages during exercise. Patient
compliance and good communication with MD is extremely important. Modalities including NMES and ultrasound
may be added 3- 4 weeks post op however, please check with MD prior to adding modalities the plan of care.
Emphasis on Orthosis Exercise
Phase I Full supple PROM Post-op bandages PROM within restraints of orthosis is
(0-6 weeks) of digits; this must are removed for light performed
be obtained prior to compressive dressing
Week 1 25 repetitions every 2 hours.
initiating early active and custom orthosis.
motion protocol in - passive MCP flexion/extension
week 2.
- passive PIP flexion/extension
Zones IV- V
- passive DIP flexion/extension
- Dorsal Block Orthosis
One-handed ADLs. - composite flexion/extension of entire
Wrist 15- 30° extension, digit in limits of orthosis
MCP 60°- 75° flexion
to intentionally favor
intrinsic shortening, and - Early edema control is critical including:
elevation, coban, ice
IPs at 0°

- With concomitant nerve

repairs, the wrist may
need to be placed in
slight flexion initially,
consult with MD.
Week 2 Must have full supple Continue all exercises - Continue PROM as warm- up.
PROM to initiate early within the confines of the - Initiate early short arc flexion to one
short arc active flexion dorsal blocking orthosis. quarter of fist.
- Initiate short arc place and active hold to
one quarter of fist.
Continue
one-handed ADLs. - All exercises are performed 25
repetitions every 2 hours.
- Continue edema control techniques.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 33

Emphasis on Orthosis Exercise

Week 3 Continue to maintain Continue all exercises - Continue PROM as warm- up.
supple PROM; within the confines of the - Advance early short arc flexion to one
monitor for signs of dorsal blocking orthosis. third of fist.
adhesion formation,
triggering, or - Advance short arc place and active hold
gapping. to one third of fist.
- All exercises are performed 25
repetitions every 2 hours.
Continue one-handed - Continue edema control techniques.
ADLs.
- Initiate scar management techniques.

Week 4 Continue to maintainExercises can be - Continue PROM as warm- up.

supple PROM; performed outside of - Advance early short arc flexion to half a
monitor for signs ofdorsal blocking orthosis. fist.
adhesion formation, Continue with Dorsal
triggering, or Block Orthosis between - Advance short arc place and active hold
gapping. exercise sessions and to half fist.
at night. If there is an - Initiate hook fist exercise, passive.
associated nerve repair - Gentle blocking exercises of PIP and DIP
Continue one-handed at wrist level, exercises may be added.
ADLs. are continued within the
dorsal blocking splint. - All exercises are performed 25
repetitions every 2 hours.
- Continue edema control techniques.
- Continue scar management techniques.
Week 5 Continue to maintain - Advance early short arc flexion to full fist.
supple PROM; - Advance to full arc place and active hold.
monitor for signs of
adhesion formation, - Continue hook fist exercise, active.
triggering, or - Initiate wrist ROM exercises.
gapping.

Continue
one- handed ADLs.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 34

Phase II Precautions: Continue to monitor for signs of adhesion formation, triggering, or gapping. Never perform
blocking exercises to small finger due to increased chance of tendon rupture to the small finger. Continue to have
communication with MD prior to progressing the protocol.
Emphasis on Orthosis Exercise
Phase II Focus on unassisted Dorsal Blocking Orthosis - Initiate differential tendon glides,
(6-10 weeks) active flexion and is discontinued at 6 individual tendon glides.
extension. weeks. Full extension - Initiate passive extension of wrist and
Week 6
resting pan splint or a digits.
long dorsal outrigger
with lumbrical bar may - Light ADL activities are permitted.
May perform light
ADL activities with be initiated if extrinsic
affected hand such as flexor tightness is
folding clothes, lightly present.
squeezing washcloth,
passively stabilizing
light objects less than
1- 2 lbs.
Week 8 Continue to focus - Gentle resistive exercise with soft therapy
on active ROM and putty in cylinder shape to encourage DIP
begin to focus on flexion.
strengthening for
ADL’s.

Continue to gradually
advance ADL/IADL
performance with
affected hand.
Week 9 - Add light resistive hand grippers for
exercise.
Phase III Precautions: Client may need to be evaluated for return to work through a formal work conditioning
program and/or FCE.
Emphasis on Orthosis Exercise
Phase III Focus shifts - Progressive resistive exercises, BTE to
(10-12 weeks) to increased address return- to- work goals.
independence with
ADL’s, IADL’s, and
return- to- work goals.

12- 16 weeks - Work conditioning and FCE to facilitate

return to work.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 35

Clinical Pearls: Throughout the rehab process it is extremely important to monitor for signs of tendon adhesion
and modify plan of care accordingly. It is important to remember that the client will continue to improve after
discharge from therapy. Progress will continue for up to 1 year following tendon repair and clients should be
instructed to continue to focus on a HEP until all of their goals are met. Therapy visits are most important during the
first 2- 4 weeks to achieve good motion and prevent tendon adhesion. Both active and passive ROM measurements
should be taken on each visit with a goal of 5- 10° gains in flexion each visit. With combined median and ulnar nerve
repairs may require MP blocking orthosis to prevent clawing. You may also consider a web spacer orthosis at night if
the patient begins to develop a web space contracture following median nerve repair.

Cannon, Nancy M. “Therapy Management of Flexor Tendon Injuries and Repairs.” Rehabilitation of the Hand and Upper
Extremity, Seventh ed., vol. 1, Elsevier, 2021, pp. 421–431.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 36

FOUR CORNER FUSION

Phase I Precautions: There are a variety of techniques described in the literature to secure the arthrodesis, the
chosen method of fixation will determine the post- operative care. In general, protect surgical repair, assist in pain
and edema control techniques.
Emphasis on... Orthosis Exercise
Phase I - Wrist and thumb - Thumb Spica cast for - Finger ROM exercises including:
(0-4 weeks) immobilization for 4 4 weeks. Differential Tendon Gliding, Individual
weeks. Tendon Gliding, Composite Fist
- Gentle AROM of forearm, elbow, and
- Goal is to achieve full shoulder is initiated.
finger ROM within 4 - All exercises should be performed 4- 6
weeks. times per day for up to 5- 10 minutes.
- Edema Control: Elevation, Ice, Coban
- Expect full elbow and wrapping of fingers.
shoulder ROM within 4
weeks.

- Primarily one- handed

ADLs with assistance of
fingers and thumb of
affected limb
Phase II Precautions: Avoid undue stress at the repair site such as grip strengthening exercises or tasks that
significantly load the carpus until physician has indicated fusion can tolerate resistive activities.
Emphasis on... Orthosis Exercise
Phase II
(4-8 weeks) - Initiate gentle AROM - Thermoplastic thumb - Initiate gentle AROM of wrist and thumb.
4 weeks of wrist and thumb. spica with wrist - Initiate scar management and
Goal of 50% ROM by positioned in neutral, desensitization techniques.
the end of phase II. removed only for
exercise and hygiene. - Light ADL activities can resume.

- Initiate light ADL

activities that require
less than 1- 2 lbs of
strength

6 weeks - Initiate wrist AAROM.

- Initiate isometrics.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 37

Phase III Precautions: Forceful manipulations and joint mobilization techniques are not advised.
Emphasis on... Orthosis Exercise
Phase III Continue to focus on - May discontinue - Initiate gentle strengthening with
(8-12 weeks) active ROM and begin the thermoplastic theraputty, hand grippers, isotonic exercise,
strengthening for ADL’s. orthosis, if client and progressive resistive exercises.
8 Weeks
needs a step- down
orthosis can offer
neoprene thumb and
wrist support.

10 weeks Focus on increased - Progressive resistive exercises, BTE to

independence with address return- to- work goals.
ADL’s, IADL’s, and
return- to- work goals.
12- 16 weeks - Work conditioning and FCE to facilitate
return to work.
Clinical Pearls: The post- operative therapy goal is a pain- free functional wrist. A stable wrist that is pain- free will
provide a better functional outcome. While wrist salvage procedures will likely result in decreased ROM, many of
these restrictions will not limit participation in basic ADL’s. Return to work for high physical demand jobs may take
up to 6 months. Outcome studies show on average return of 50% wrist ROM in flexion and extension and 40% wrist
radial/ulnar ROM, along with 50% grip strength compared to contralateral side.

Shin, Eon Kyu. “Wrist Salvage Procedures: Surgery and Therapy.” Rehabilitation of the Hand and Upper Extremity, Seventh
ed., vol. 1, Elsevier, 2021, pp. 901–910.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 38

MALLET FINGER ZONE I-II EXTENSOR TENDON INJURY

Emphasis on Orthosis Exercise
Phase I Full AROM of uninvolved Custom fabricated AROM/PROM of uninvolved fingers
fingers and restricted AROM and MP and PIP joints of involved
0-6 weeks mallet orthosis
of involved finger: finger. Light ADL activities are
fitted with 15°
permitted.
MP’s 80-90° flexion and hyperextension for
continual wear.
PIP’s 80-90° flexion.

May use affected hand for

light ADLs.

Phase II Precautions: Monitor skin integrity for maceration or signs of skin breakdown. Orthosis may be removed
1 time per day for skin care and hygiene, but DIP must be maintained in extension while out of orthosis with finger
supported on tabletop. Avoid extreme hyperextension with orthosis as to not jeopardize circulation to the dorsal
skin causing skin breakdown.

Emphasis on Orthosis Exercise

Phase II DIP Extension 0-5° (Lag Mallet orthosis is AROM of DIP outside of orthosis:
6-8 weeks should be no greater than 5°) continued between 4 times per day for up to 5 minutes
exercise sessions and including:
DIP Flexion 20-25° after week
at night.
first week of mobilization. differential tendon glides, individual
35-40° flexion by end of tendon glides. Light ADL activities
second week of mobilization. are permitted.

Phase III Precautions: Monitor for signs of extension lag. If lag develops may limit number of exercise sessions
and/or return to continuous wearing of orthosis for 2 additional weeks.

Emphasis on Orthosis Exercise

Phase III Full AROM Mallet orthosis is Begin gentle strengthening with
8- 10 weeks worn at night only. putty. Return to normal ADL activities.

Clinical Pearls: Mallet orthosis is discontinued at 10 weeks and client should return to normal ADL activities. For
residual DIP joint stiffness in extension due to ORL tightness may add manual passive assistance at 10 weeks, with
the PIP joint at 0° extension while the DIP joint is actively or passively flexed.

Evans, Roslyn B. “Rehabilitation Following Extensor Tendon Injury and Repair.” Rehabilitation of the Hand and Upper Extremity,
Seventh ed., vol. 1, Elsevier, 2021, pp. 476–478.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 39

ORIF DISTAL RADIUS

Phase I Precautions: MD will determine if fracture is stable and ready to initiate therapy. Early goals are to obtain
excellent finger ROM, edema control, and protect healing fracture.
Emphasis on Orthosis Exercise
Phase I Initiate early unrestricted Remove post- op - Finger ROM including: gentle fist and
(0-4 weeks) motion of fingers to the bandage and apply thumb ROM.
limits of post- op bandage - Edema control: elevation, ice, coban.
Week 1 short arm cast.
or wrist hand orthosis
(WHO).

May use fingers, thumb, and

unaffected joints to stabilize
object during ADLs/IADLs
while in cast.
Week 2 Goal is to have good finger Custom - Finger ROM including:
ROM by end of phase I. thermoplastic WHO Differential tendon glide, individual tendon
with slight wrist glide, joint blocks.
extension.
- Initiate gentle wrist ROM including: wrist
May use fingers, thumb,
blocks, pronation/supination.
and unaffected joints to
hold objects less than 1 lbs. - Continue edema control
during ADLs/IADLs while in - Initiate gentle scar management
orthosis. techniques including: scar massage,
elastomer.

Phase II Precautions: Continue to focus on edema control, scar management and desensitization techniques.
Common pitfalls to avoid include: extrinsic flexor compartment tightness, intrinsic tightness. Gentle manipulations
may be added with caution.
Emphasis on Orthosis Exercise
Phase II Full finger ROM and obtain Continue to remove - Add gentle wrist PROM including prayer
(4-8 weeks) approximately 50% wrist thermoplastic WHO stretch, pronation/supination.
AROM. for exercise and - AAROM for extrinsic compartment length
Week 4
short periods of
time during the day. - intrinsic stretches
May perform light ADLs - continue edema control and scar
with affected hand. Light management.
ADLs include putting on and - Light ADL’s are permitted.
taking off loose clothing and
shoes, washing dinnerware,
and folding clothing.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 40

Emphasis on Orthosis Exercise

Week 6 Client should focus on Thermoplastic - Continue to focus on muscle balance with
achieving 75% of wrist ROM. orthosis can be A/PROM
discontinued. Step - Focus on extrinsic and intrinsic length
down orthosis can stretches.
be provided if client
requests soft wrist - May initiate gentle grip strengthening with
support. therapy putty and hand grippers.

Phase III Precautions: Continue to protect healing fracture, restore normal muscle balance, and focus on gentle
strengthening. Client goals should continue to address ADL’s, IADL’s, and return- to- work goals.
Emphasis on Orthosis Exercise
Phase III Client should have nearly full If needed, may add - Begin gentle wrist and forearm
(8-12 weeks) wrist and finger ROM within intrinsic stretch strengthening including: hand weights and
8 weeks. orthosis. theraband.
Week 8
- initiate scapula stabilization exercises.
- initiate gentle weightbearing activities
including: table top dusting, modified wall
push- ups.
Week 10 Focus on increased May add any - Progressive resistive exercises including:
independence with ADL’s, required corrective BTE simulator and return- to- work goals.
IADL’s, and return- to- work orthosis, if MD - Progress toward independence with
goals. confirms fracture IADL’s.
healing: static
progressive wrist
flexion/extension,
pronation/
supination.
Week 12- 16 - Work conditioning,
- Focus on HEP.
Clinical Pearls: It is important to remember that the client will continue to improve after discharge from therapy.
Progress will continue for up to 1 year after surgery and clients should be instructed to continue to focus on a HEP
until all of their goals are met.
Naughton, Nancy. “Therapy Management of Distal Radius Fractures.” Rehabilitation of the Hand and Upper Extremity,
Seventh ed., vol. 1, Elsevier, 2021, pp. 833–848.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 41

TRAPEZIECTOMY WITH LRTI

Phase I Precautions: No heavy lifting greater than 2 lbs. Monitor for signs of skin breakdown from orthosis. CMC
joint should be supported during range of motion exercises and avoid thumb opposition for 8 weeks to prevent
stretching suspensionplasty.
Emphasis on Orthosis Exercise
Phase I Gentle finger ROM Post- Op Bandage - Gentle finger AROM to the limits of
(0-4 Weeks) to limits of post- op the post- op bandage.
bandage. - Edema control techniques.
1- 14 days post- op

10-14 days Thumb Spica Cast Initiate A/PROM of fingers including:

post-op to differential tendon glides, individual
4 weeks tendon glides.
4 Weeks Initiate gentle thumb ROM Custom HB thumb - AROM/PROM of thumb MCP and
with CMC supported. spica orthosis midway IP joint with supported CMC joint. 3
between palmar and times per day for 5 minutes
radial abduction. - AROM/PROM of wrist.
Remove only for ADL’s
and exercise. - Continue edema control.
- Initiate scar management techniques.

Phase II Precautions: Continue to avoid thumb opposition until 8 weeks post- surgery.
Emphasis on Orthosis Exercise
Phase II 50% of thumb ROM for - Continue HB Thumb Initiate gentle AROM of thumb CMC
(4-8 Weeks) MCP and IP joints Spica for repetitious joint including: abduction, adduction,
activities, lifting, or flexion, and extension.
6 Weeks
pinch.
May perform light ADLs
with affected hand. Light Light ADL’s permitted
ADLs include putting
on and taking off loose
clothing and shoes,
washing dinnerware, and
folding clothing

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 42

Phase III Precautions: If client experiences increased pain or swelling with strengthening program, delay
strengthening for 2 weeks. Important to remember healing process can take up to a full year. Continue with HEP
until all goals have been met.
Emphasis on Orthosis Exercise
Phase III Full AROM for MCP and IP - Discontinue HB - Initiate progressive strengthening
(8-12 Weeks) joints by 8 weeks. Thumb Spica by 8 program.
weeks.
8 weeks
10 weeks Full A/PROM of thumb - Continue with HEP for ROM and
MCP, IP, and CMC joints. strengthening.

12 weeks - Client may resume normal ADL

activities as tolerated.
- Client may return to work full duty if
job requirements have been met.

Valdes, Kristen. “Therapist’s Management of the Thumb Carpometacarpal Joint with Osteoarthritis.” Rehabilitation of the
Hand and Upper Extremity, Seventh ed., vol. 2, Elsevier, 2021, pp. 1261–1277.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 43

TRAPEZIECTOMY WITH TIGHTROPE SUSPENSION

Phase I Precautions: No heavy lifting greater than 2 lbs. Monitor for signs of skin breakdown from orthosis. CMC
joint should be supported during range of motion exercises and avoid thumb opposition for 8 weeks to prevent
stretching suspensionplasty.
Emphasis on... Orthosis Exercise

Phase I Full AROM of Post- Op Bandage - AROM/PROM of uninvolved fingers

(0-4 Weeks) uninvolved fingers. - Edema control techniques.
1-14 days post-
op

10-14 days Initiate gentle thumb Custom FB thumb spica - AROM/PROM of thumb MCP and IP joint
post-op ROM with CMC orthosis midway between with supported CMC joint. 3 times per
supported. palmar and radial day for 5 minutes
abduction. Remove only - AROM/PROM of wrist.
for ADL’s and exercise.
- Continue edema control.

3 weeks 50% of thumb ROM for - Initiate scar management techniques.

MCP and IP joints
Phase II Precautions: Continue to avoid thumb opposition until 8 weeks post- surgery.

Emphasis on... Orthosis Exercise

Phase II Full AROM for MCP and - FB Thumb Spica may be Initiate gentle AROM of thumb CMC joint
(4-8 Weeks) IP joints by 8 weeks. removed at 4 weeks for including: abduction, adduction, flexion,
light ADL’s and worn at and extension.
night only.
- Light ADL activities are permitted.
- HB Thumb Spica should
be worn for repetitious
activities, lifting, or
pinch.
6 weeks - FB Thumb Spica
discontinued at night.
- HB Thumb Spica should
be continued with
repetitious activities,
lifting, or pinch.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 44

Phase III Precautions: If client experiences increased pain or swelling with strengthening program, delay
strengthening for 2 weeks. Important to remember healing process can take up to a full year. Continue with HEP
until all goals have been met.
Emphasis on... Orthosis Exercise
Phase III

(8-12 weeks) Full A/PROM of thumb - Discontinue HB Thumb - 8 weeks initiate progressive
MCP, IP, and CMC Spica by 8 weeks. strengthening program.
joints.

10 weeks - Continue with HEP for ROM and

strengthening.

12 weeks - Client may resume normal ADL activities

as tolerated.
- Client may return to work full duty if job
requirements have been met.

Valdes, Kristen. “Therapist’s Management of the Thumb Carpometacarpal Joint with Osteoarthritis.” Rehabilitation of the
Hand and Upper Extremity, Seventh ed., vol. 2, Elsevier, 2021, pp. 1261–1277.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 45

FLEXOR TENDON RECONSTRUCTION STAGE I

Phase I Precautions: This procedure results from a failed primary repair or due to delayed repair. All exercises
may be performed out of the custom orthosis. Compliance from the client is critical and good communication with
MD is vital.
Emphasis on... Orthosis Exercise
Phase I Initiate PROM and Post-op bandages PROM is performed to the involved
(0-4 weeks) edema control are removed for light finger:
techniques with a goal compressive dressing and
Week 1 25 repetitions every 2 hours.
of supple passive ROM custom orthosis.
for the involved finger. - passive MCP flexion/extension
- passive PIP flexion/extension
Dorsal Blocking Orthosis
Avoid overuse fitted with - passive DIP flexion/extension
and aggressive - passive composite flexion/extension
Wrist 15-30° extension
manipulation of of entire digit
MCP 45° flexion
affected finger to - AROM/PROM for uninvolved fingers is
prevent synovitis along IP 0° to be worn between unrestricted.
the implant. exercise sessions and at
- Early edema control is critical
night.
including: elevation, coban, ice.

If A2 or A4 pulley’s have
been reconstructed, will
require pulley rings for 6-8
weeks, clarify with MD.
Weeks 2-3 Continue to focus Continue with orthosis - May initiate scar management
on supple PROM of between exercise sessions techniques once wound is fully closed.
involved finger. Should and night.
have nearly full AROM
of uninvolved fingers.
Phase II Precautions: Continue to monitor for edema control, scar management techniques, and prevent PIP
flexion contractures.
Emphasis on... Orthosis Exercise
Phase II Nearly full PROM of Begin to decrease time - Initiate light ADL activities.
(4-8 weeks) involved finger and full in protective orthosis - Continue edema control and scar
AROM of uninvolved with goal of being management.
4 weeks
fingers. discontinued at 6 weeks.

If you have any questions or concerns, please call 859-562-1980.

 Hand Rehabilitation Protocols | 46

6 weeks Expectation is full Discontinue protective - Advance to moderate ADL activities

supple PROM of orthosis. May add buddy (no heavier than 5 lbs). Such activities
involved finger and full straps to increase function. may include carrying ½ gallon of milk,
AROM of uninvolved If using pulley rings may light housework, light community level
fingers. continue up to 8 weeks. activities.
- Initiate light strengthening tasks with
therapy putty and hand grippers.
Phase III Precautions: Continue to focus on protection of pulley repairs, resolve any contractures, intrinsic and
extrinsic compartment length.
Emphasis on... Orthosis Exercise
Phase III Focus shifts Discontinue pulley rings. - Initiate progressive resistive exercises
(8-12 weeks) to increased May add corrective to increase strength and ADL
independence with splinting options for performance.
8 Weeks
ADL’s, IADL’s unresolved flexion
contractures.

10-12 weeks Focus on HEP for PROM, strengthening,

and ADL’s.

Clinical Pearls: Stage II of the reconstruction will occur around 6 months following stage I depending upon
MD preference. It is important that the client achieves full PROM of the affected finger, maximum strength of the
involved hand, and trace levels of edema.

Culp, Randall W. “Secondary and Reconstructive Tendon Procedures.” Rehabilitation of the Hand and Upper Extremity,
Seventh ed., vol. 1, Elsevier, 2021, pp. 488–492.

If you have any questions or concerns, please call 859-562-1980.