FLEXOR TENDON REPAIR PROTOCOLS

Duran Protocol
Uses a splint with wrist - 20 degrees of flexion
3-5 mm glide sufficient to prevent formation of firm tendon adhesions
Exercises performed within the confines of splint
Week Splint Exercises Precautions and
Considerations
0-3 days Dorsal Blocking 6-8 reps twice a day
(Wrist – 20 degrees flex
MCP – 45 to 50 degrees Passive DIP extension (with
IP – Full extension PIP and MCP in flexion)
(neutral) [Movement of FDP away from
FDS]

Passive PIP extension (with

MCP and DIP in flexion)
1 week – Passive DIP extension (with
4.5 weeks PIP and MCP in flexion) 10
reps

Passive PIP extension (with

MCP and DIP in flexion) 10
reps
4.5 weeks – Wrist cuff with elastic Active extension/ Passive
5.5 weeks flexion traction from flexion
fingernail to cuff
5.5 weeks – Wrist cuff discontinued Tendon blocking exercises
7.5 weeks
Tendon gliding exercises
7.5 weeks Splinting to correct Light resistive exercises with
flexor tightness putty

Modified Duran Protocol

No Rubber band traction
Week Splint Exercises Precautions and
Considerations
Day 3 – Zone 1, 2, 3 – Passive DIP flexion & active Reduced blood flow in zone
Week 2 Dorsal Blocking splint extension up to orthosis. 1.
(Wrist – 20 degrees
(Immediate flexion Passive PIP flexion & active Repaired tendon strength
phase) MCP – 30-45 degrees extension to orthosis. reduces as the angle of
flexed tension is increased around
IP – Neutral ) Passively block MCPs in 60̊- the joint axis.
80̊ flexion and active PIP, DIP
Zones 4 & 5 – extension to 0̊ to orthosis. Tendon repair is weakest
Dorsal Blocking splint post-op day 5-21.
(Wrist – Neutral Passive composite fist
MCP - 60̊-75̊ flexed, (composite flexion and
 IP joints – 0̊ ) extension)

(Pulley Ring Orthosis Passive wrist flexion & active

is Pulley is repaired) extension to orthosis.

Therapist removes orthosis.

Passive wrist extension with
fingers flexed passively

Passive wrist flexion with

passive hook fisting to prevent
intrinsic tightness.

Week 2 – Light fine motor Activity NMES can be added (after

Week 4 week 3, FDS and FDP)
Tendon Gliding exercises
(Protective Ultrasound (if adherence
Phase) FDS isolated gliding with starts to develop)
wrist at 0 degrees

Wrist tenodesis/SWM
exercises (fist with extension,
release with flexion)
Week 4 – Gradually wean from Flexor tendon gliding Weight lifting restriction
Week 6 orthosis during day exercises with wrist extended
at 20 degrees Void PIP and DIP joint
(Intermediate blocking to small finger
Phase) PIP and DIP blocking (increased risk of rupture)
exercises (start at week 5)
No composite wrist
Progression to functional movement beyond 20
activities (start at week 6) degrees (uptil 6 weeks)

No combined finger
extension (uptil 6 weeks)
Week 6 – 6 weeks post-op Light-graded strengthening No resisted grip and pinch
Week 12 If IP stiff in flexion, (after week 8) [using smiley exercises (until 8 weeks)
Convert dorsal block to ball, putty, hand exerciser]
(Minimal nighttime No heavy lifting or tight
Protection Volar Hand-based Resisted isolated DIP & PIP sustained grip (uptil 14-16
phase) orthosis (Zone 2) flexion weeks)
Volar – Forearm based
orthosis (Zone 3) Unrestricted participation in
sport and work activities with
Discharge night time surgeon authorization
orthosis when active 0
degrees extension
achieved

Kleinert Protocol
Uses a splint with wrist in 45 degrees flexion and elastic band secured to patient’s nails with the proximal
point of attachment at wrist (IP full active extension, elastic band recoils the IP passively)
Elastic band to resist full active extension
Week Splint Exercises Precautions and
Considerations
0-3 days Dorsal Blocking Hourly exercises
(Wrist – 45 degrees flex
MCP – 10 to 20 degrees Active extension of fingers to
IP – Full extension limit of splint
(neutral)

Elastic traction from

fingernail through
palmar pulley to volar
forearm
1 week – Hourly exercises Wound and Scar management
4 week and education
Active DIP extension (to limits
of splint) 10 reps

Active PIP extension (to limits

of splint) 10 reps

Active MCP extension (to

limits of splint) 10 reps

Passive flexion with elastic

traction only
4 weeks – Dorsal Blocking splint Active fist (gentle flexion)
6 weeks discontinued
Active gentle wrist flexion
Replaced with wrist (start at week 5)
cuff and elastic traction

Night splint to prevent

flexion contracture
6 weeks – Dorsal blocking splint Tendon blocking exercises
8 weeks only extends upto PIP
joint to allow PIP Tendon gliding exercises
extension
Progressive resistive exercises
Nighttime – elastic
band detached and (Four-finger method)
Volar component added - Wrist – 30-45 degrees
to hold IP joint in flexion
extension - MCP – 50-70 degrees
flexion
- IP - Full extension
Manual pressure applied to all
4 fingers to attain final degrees
of passive flexion
Belfast and Sheffield Protocol
Kumar D, Sundaram MS, Selvam PS, Chettinad School of Physiotherapy. Effectiveness of early passive
Mobilisation (EPM) versus Early Active Mobilisation (EAM) Protocols on total Active Motion and grip
strength in flexor tendon Zone II repair – a pilot study. Vol. Vol. 6, Journal of Positive School
Psychology. 2022 p. 2160–7. – This pilot study suggested that total active motion and grip strength
following FTI zone 2 repair was better in the early active mobilization group (Belfast and Sheffield
protocol) than by early passive mobilization (Modified Duran Protocol)

Week Splint Exercises Precautions and

Considerations
0 – 1 week Dorsal blocking splint Every 4 hourly within the
Wrist 0-20 degrees orthosis
flexion
MCP – 80-90 degrees Zone 2 – Initiate exercises after
flexion 48 hours (allow inflammation
IP – full extension to subside)

Cast extends 2 cm Zone 3 – Initiated within 24

beyond fingertips hours after repair

2 reps of passive flexion,

2 reps of active flexion
2 reps of active extension

1st week goals –

Full passive flexion
Full active extension
Active PIP flexion to 30
degrees
Active DIP Flexion to 5-10
degrees
1 week – Goal uptil week 4 –
4 weeks Active PIP flexion to 80-90
degrees
Active DIP flexion to 50-60
degrees

4 weeks – Orthosis discontinued at Passive IP extension (MCP Do’s

6 weeks week 5 held in flexion) (in presence of - Start using your hand
flexion contracture) for light activities
Orthosis discontinued at - Careful while washing
4 weeks, if tendon glide Active finger extension on and drying your hand
is poor supported surface - Continue shoulder and
elbow movements
Orthosis discontinued at Passive finger flexion - Massage and
6 weeks, if tendon glide Active finger flexion moisturise scar
is good Wrist flexion Don’ts
Wrist extension - Don’t force fingers
out straight
Thumb movements - Don’t force wrist to
bend backwards
- Don’t grip any object
tightly
 - Don-t drive
6 weeks – After 3 weeks of Tendon blocking exercises at
8 weeks orthotic removal
Finger based dynamic
extension orthosis for
flexion contracture
correction
8 weeks – Progressive resisted exercises
12 weeks
Heavier hand use

At 12 week,
Regain full function

Strickland/ Canon Protocol

Active hold OR Place hold active mobilization program
Digits are passively placed in flexion, and the patient then maintains the flexion with a gentle muscle
contraction.
Patients learn to use only minimal force by practicing with the uninjured hand
Week Splint Exercises Precautions and
Considerations
0-4 weeks Dorsal Blocking Every hourly
(Wrist – 20 degrees flex
MCP – 50 degrees flex Modified Duran protocol in
IP – Full extension Dorsal blocking orthosis
(neutral) Passive DIP flexion & active
extension up to orthosis.
Exercise orthosis –
Hinged wrist orthosis Passive PIP flexion & active
(Allows full wrist extension to orthosis.
flexion and wrist
extension limited to 30 Passively block MCPs in 60̊-
degrees 80̊ flexion and active PIP, DIP
MCP extension limited extension to 0̊ to orthosis.
to 60 degrees
Full IP flexion and Passive composite fist
extension allowed ) (composite flexion and
extension)

Passive wrist flexion & active

extension to orthosis.

Therapist removes orthosis.

Passive wrist extension with
fingers flexed passively

Passive wrist flexion with

passive hook fisting to prevent
 intrinsic tightness.

Place and hold digit flexion in

exercising orthosis –

Active wrist extension with

passive finger flexion and then
actively maintain digit flexion
for 5 seconds
Followed by relaxation (wrist
allowed to flex and fingers
allowed to extend to limits of
orthosis

4 week – Exercise Orthosis 2 hourly exercises Avoid simultaneous wrist and

7 weeks discontinued finger extension
Place and hold digit flexion –
Dorsal blocking splint
used except during Active wrist extension with
active flexion exercises active finger flexion and then
actively maintain digit flexion
for 5 seconds
Followed by relaxation (wrist
allowed to flex and fingers
allowed to extend to limits of
orthosis

At 5-6 weeks,
Tendon blocking exercises
Hook fists
Maybe added

7 weeks – Orthosis discontinued Progressive wrist exercises

14 weeks
Resume ADLs

FPL moved aggressively

Little finger flexors moved
least aggressively

Week 14, no restrictions

Evans and Thompson Protocol

Flexion forces increase dramatically
- At the end of flexion range(full fist) and
- During finger flexion combined with wrist flexion
Early passive mobilization program at home (with dorsal blocking orthosis without rubber band traction)
MAMTT (minimal active muscle-tendon tension) exercises:
- (Only performed under therapist supervision)
- Orthosis removed and exercises performed
- Passive wrist extension to 20 degrees
Passive MCP flexion to 83 degrees
Passive PIP flexion at 75 degrees
Passive DIP flexion at 40 degrees
Maintain the position with gentle muscle contraction

Sandow and McMahon Protocol

Position –
- Wrist at 20-degree extension
- MCP at 90 degrees flexion
- IP full extension
Assisted Active flexion initiated in the operating room
Exercises performed hourly
Orthosis discontinued at 6 weeks