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Upper Extremity & Athletic Injuries Protocol

upper-extremity-protocols

Physical Therapy Protocols

Upper Extremity & Athletic Injuries Protocols

Come experience physical therapy in the Redmond area with our therapists experienced in hand, elbow, and shoulder treatments.

Hand and Wrist

1st Dorsal Compartment Release

This surgery involves release of the 1st dorsal compartment. The sheath is not repaired; subcutaneous tissue and skin are closed in separate layers to avoid excessive adhesions to the tendon. The Goals of this protocol are to allow for rapid return to activity while also protection the post-operative incision minimizing effects if immobilization and scar adhesions.

POD #3-14

  • Remove bulky dressing.
  • Fabricate thermoplastic thumb spica splint as needed
  • Ace wrap for edema.
  • Assess neurological function dorsal sensory radial nerve.
  • Ice and elevation
  • Modalities PRN for pain control.
  • Monitor wound status.
  • Initiate gentle AROM in all planes of wrist and hand motion.
  • Scar massage and silicone gel pad to scar 48 hours after suture removal.
  • Splinting should be discontinued by the second week.

POD #14-six weeks

  • Unrestricted AROM.
  • Monitor for loss of ROM. Allow light stretching pain-free.
  • Continue modalities PRN now also for improving tissue elongation.
  • Desensitization
  • Grip and hand strengthening.
  • Patient education to avoid repeated ulnar deviation and resisted radial deviation.

Week four – six

  • Return to prior level of function.

Carpal Tunnel Release

Goals of therapy:

  1. minimize post-op edema
  2. maximize digit and wrist range of motion
  3. prevent early scar adhesions to finger flexor tendons
  4. maximize grip strength

2 Days Post-op:

  • Patient is given post-operative instructions to remove bulky post-op dressings, apply a small dressing to incision site, and begin finger range of motion.

2 Weeks Post-op:

  • First visit with M.D. – sutures are removed
  • Begin scar management with silicone gel pad, scar massage and compressive sleeves
  • Active tendon and nerve glide exercises
  • Begin wrist active range of motion to tolerance
  • Monitor for signs of Complex Regional Pain Syndrome/RSD
  • Begin scar desensitization techniques, as needed

4 Weeks Post-op:

  • Begin strengthening with therapy putty
  • Resume ADL’s and work tasks to patient tolerance. Patient is instructed to use pain as guide for heavy lifting.

Patient is usually seen for one visit only at 2 weeks post-op. They are issued theraputty at that visit and instructed to begin use at 3 weeks post-op.

Distal Radius Fracture

0 – 2 Weeks Post-op:

  • Long-arm post-operative dressings are left intact
  • Begin active digit and shoulder active range of motion
  • Edema reduction techniques, with upper extremity elevation

2 Weeks – 6 Weeks Post-op:

  • 1st post-operative visit with M.D. at 2 weeks post-op
  • Sutures removed
  • Convert to short arm cast or splint
  • Continue finger and shoulder active range of motion
  • May begin active-assistive and passive digit range of motion, if needed
  • Continue edema reduction techniques
  • Begin forearm rotation range of motion
  • If using splint, can begin scar management techniques
  • No heavy lifting, gripping, pinching or pulling

6 Weeks Post-op:

  • 2nd post-op visit with M.D.
  • Cast or splint is removed, based on fracture healing
  • Begin wrist range of motion
  • Continue digit and forearm range of motion

8 Weeks Post-op:

  • Begin strengthening exercises, including forearm rotation
  • Continue range of motion and edema reduction techniques

Dupuytren's Contracture Release (Open)

Goals of therapy:

  1. promote wound healing
  2. minimize edema
  3. prevent recurrent flexion contractures
  4. maximize digit flexion
  5. minimize scar formation

1 to 3 Days Post-op:

  • Remove bulky post-op dressings, including vessel loops/drains from the wound
  • Evaluate digit sensation, documenting any sensory changes
  • Using sterile technique, apply dressings. If wounds are macerated from sanguinous oozing, apply additional gauze sponges to wick moisture from incision sites
  • Fabricate hand-based thermoplastic static extension splint, using perforated splinting material, or perforate with hole-punch, to minimize skin maceration
  • Fabricate dynamic extension splint if patient is unable to demonstrate good extension of affected digits (greater than 30 degree extensor lag).
  • Begin active and active-assistive range of motion to patient tolerance, including “place and hold” exercises to maintain joint mobility and minimize pain
  • Patient education regarding ADL’s:
    • Avoid heavy lifting or gripping, as this may lead to wound dehiscence
    • Maintain upper extremity elevation to minimize edema
    • Avoid activities that apply friction to incision sites, such as opening jar lids, turning door knobs
  • Edema reduction techniques with co-ban wrap to digits, tubigrip sleeves to hand and wrist, or kinesiotape to dorsal surface of hand and digits.
  • Patient education regarding wound care, dressing changes, and signs of infection

2 Weeks Post-op:

  • First follow-up visit with M.D. – sutures are removed, if wounds are well-healed
  • Begin gentle scar massage, if wounds are well-healed
  • Begin silicone gel pad, if wounds are well-healed
  • Continue splinting, as needed to maintain range of motion
  • May convert to Capener splint for PIP joint extension, if palmar wounds are well-healed
  • Begin use of elastomer pad for prolonged palmar edema or early scar formation
  • Begin gentle theraputty to encourage digit flexion, if wounds are well-healed
  • Active and passive range of motion to patient tolerance

3 to 8 Weeks Post-op:

  • Continue aggressive scar management techniques
  • Continue night extension splinting
  • Continue edema reduction techniques, as needed

Extensor Tendon Repair - Thumb EPL

Goals of therapy:

  1. Protect tendon repair
  2. Minimize scar adhesions
  3. Maximize range of motion of right thumb and wrist

3 to 7 Days Post-op:

  • Remove post-op dressings, maintaining thumb and wrist in extended position at all times
  • Cleanse wounds and apply sterile dressings
  • Fabricate thermoplastic forearm-based dynamic extension splint, blocking MP joint at neutral Note: setting outrigger base more proximally will allow you to achieve IP hyperextension with a 90 degree angle of pull
  • Fabricate forearm-based thermoplastic static extension splint, with care given to position the IP joint in hyperextension. Avoid excessive hyperextension with skin blanching.
  • Begin isolated active thumb IP and MP flexion and dynamic-assist IP joint extension. Total arc of motion into flexion: 30 degrees. Note that IP joint may have been positioned in hyperextension, therefore 30 degrees is total arc of motion, not necessarily 30 degrees of IP joint flexion from a neutral position.
  • Therapist-assisted wrist extension may be performed while patient is in therapy only.

10 Days to 2 Weeks Post-op:

  • First follow-up visit with M.D. Sutures are removed.
  • Continue static and dynamic splinting
  • Begin gentle scar massage
  • Begin desensitization techniques, as needed

3 Weeks Post-op:

  • Increase arc of motion to 40 degrees
  • If early stiffness and dorsal scar adhesions are present, begin place and hold exercises using 50% of muscle strength
  • Continue static and dynamic splinting
  • Begin therapist-assisted passive wrist flexion, with thumb supported in full extension

4 Weeks Post-op:

  • Advance arc of motion to 50 degrees
  • Begin gentle composite thumb flexion
  • If early stiffness and dorsal scar adhesions are not resolving, begin gentle active extension of thumb IP joint.

5 to 6 Weeks Post-op:

  • Begin weaning from dynamic splint
  • Continue use of static extension splint at night
  • Allow full isolated thumb IP and MP joint flexion

6 to 8 Weeks Post-op:

  • Continue use of static extension splint at night, with careful monitoring for extensor lag. If no lag is present, may discontinue splint at night.
  • Begin strengthening program at 8 weeks.

Flexor Tendon Repair

Zone I – Passive Motion

  • 0 to 3 weeks post-op:
    • Remove post-op dressings within 1 to 3 days post-op
    • Wound care and edema reduction techniques as needed
    • Fabricate thermoplastic dorsal blocking splint
      • Wrist at 30 degrees flexion
      • MP joints at 50 degrees flexion
      • IP joints at neutral
    • Begin passive flexion to each digit joint
      • 10 repetitions, every one to two hours
    • Active digit extension within limits of splint
    • Therapist supervised wrist extension only with digits maintained in full passive flexion
    • Begin gentle scar massage when sutures removed at 10 to 14 days
  • 3 weeks post-op:
    • Begin ‘place and hold’ exercises for digit flexion with wrist in 30 degrees extension
    • Patient should be instructed in using 50% of motor power only
    • Adjust splint with wrist to neutral position
  • 4 weeks post-op:
    • Continue place and hold exercises, including hook fist position to encourage FDP tendon glide
    • Advance to active digit flexion if evidence of early scar adhesions
  • 6 weeks post-op:
    • Discontinue use of dorsal blocking splint
    • Advance exercise program to include full active digit flexion
    • Begin blocking exercises
    • Continue hook fist exercises to increase FDP glide
    • Consider PIP joint blocking splint or cast to improve DIP joint flexion if FDP tendon glide is poor
  • 8 weeks post-op:
    • Begin strengthening

Zone II – Passive Motion

  • 0 to 1 week post-op
    • Remove post-op dressings
    • Maintain wrist and digits in protected position at all times
    • No active finger flexion
    • Fabricate thermoplastic dorsal blocking splint
      • Wrist positioned at 30 degrees flexion
      • MP’s positioned at 60 degrees flexion
      • IP’s positioned at 0 degrees
    • Home exercise program:
      • Passive flexion of each individual joint, 10 reps every 1 to 2 hours
      • Active extension of each digit within limits of splint
    • Edema reduction techniques
    • Wound care and dressing changes as needed
    • Thorough patient education regarding need for constant splint use, flexor tendon anatomy, and wound healing/scar adhesion formation
  • 1 to 2 weeks post-op
    • Sutures removed at 10 to 14 days post-op.
    • Begin scar massage following suture removal
    • Continue passive range of motion
  • 3 weeks post-op
    • Begin ‘place and hold’ exercises, with instruction to patient to use 50% of their muscle power
      • If patient is compliant, dorsal blocking splint should be removed for exercises. Wrist is positioned in 30 degrees of extension during ‘place and hold’ exercises.
      • Patient should be specifically instructed to avoid composite wrist and digit extension
    • Continue passive range of motion
    • Continue edema reduction techniques. Be aware that use of co-ban may be creating small amount of resistance with ‘hold’ portion of exercises.
    • Adjust dorsal blocking splint to position wrist at neutral.
  • 4 to 6 weeks post-op
    • Continue home exercise program.
    • If poor flexor tendon glide is evident and patient is unable to ‘hold’ flexed position, early gentle active flexion is initiated.
    • If poor flexor tendon glide is evident and patient is compliant, splint is discontinued at 5 weeks post-op.
      • Patient is specifically instructed to use splint for any risky activities, and is educated regarding avoiding resistive activities
    • If there is no evidence of scar adhesions limiting range of motion, or if patient has history of diabetes, prednisone use, or other conditions which may delay healing, splint is discontinued at 6 weeks post-op.
  • 6 to 8 weeks post-op:
    • Continue active and passive range of motion, advancing to include composite wrist and digit extension at 6 weeks post-op
    • Add tendon glide and blocking exercises
    • Begin strengthening at 8 weeks post-op

Early Active Motion (based on Indiana Hand Center protocol)

  • 0 to 2 weeks post-op:
    • Remove post-op dressings within first 1 to 2 days
    • Fabricate dorsal blocking splint for night use and between exercise sessions.
      • Splint is fabricated with hinge at wrist, allowing wrist extension.
      • Extension block is included in splint to block wrist extension beyond 30 degrees extension.
      • Thermoplastic cover is fabricated for block, to prevent wrist motion between therapy sessions
    • Begin place and hold exercises for digit flexion, with wrist in tenodesis position of 30 degrees extension
    • Begin scar massage at 10 to 14 days post-op.
  • 2 to 5 weeks post-op
    • Continue place and hold exercises
    • Advance to gentle active digit flexion at 5 weeks, if evidence of early volar scar adhesions
  • 5 to 6 weeks post-op:
    • Remove dorsal blocking/tenodesis splint
    • Advance to full digit active flexion
    • Begin blocking exercises
  • 8 weeks post-op:
    • Begin grip strengthening

ALGORITHM TO ADVANCE RANGE OF MOTION (From: Sueoka SS, LaStayo PC. “Zone II flexor tendon rehabilitation: a proposed algorithm. J Hand Ther. Oct-Dec. 2008)

  • First 3 weeks post-op (beginning at 3-7 days post-op):
    • use either passive (Duran’s), dynamic traction (Kleinert’s) or early active protocols, based on physician preference and patient’s ability to cooperate/comply with program.
  • 3 weeks post-op:
    • Begin place and hold exercises for digit flexion.
    • Assess passive motion – if passive motion is limited, continue passive motion as well.
    • Continue dorsal blocking splint for all patients
  • 3.5 weeks post-op:
    • Evaluate AROM to assess presence or absence of flexor lag.
      • If patient has full active motion, continue place and hold exercises
      • If flexion lag is present, begin active composite digit flexion
    • Continue dorsal blocking splint for all patients
  • 4 weeks post-op:
    • Evaluate AROM to assess presence or absence of flexor lag
      • If patient has full active motion, continue place and hold exercises and gentle active composite fisting, with continued use of dorsal blocking splint up to 8 weeks post-op
      • If flexion lag is present, begin fisting series of full digital flexion, hook fist and straight fist exercises. Include full extension of the digits.
        • Continue place and hold exercises
        • Continue dorsal blocking splint
  • 4.5 weeks post-op:
    • Evaluate AROM to assess presence of flexion lag.
      • If no lag is present:
        • Begin composite wrist and digit flexion and extension exercises
        • Continue dorsal blocking splint
      • If lag persists:
        • Begin blocking or isolated FDS and FDP exercises.
        • Continue dorsal blocking splint
  • 5 weeks post-op:
    • Evaluate AROM to assess presence of flexion lag
      • If no lag is present:
        • Continue to protect repair, with composite wrist and digit range of motion only
        • Continue dorsal blocking splint
      • If lag is present:
        • Begin light resistance exercises with putty
        • Begin ultrasound, e-stim, as needed.
        • Continue dorsal blocking splint
  • 5.5 weeks post-op:
    • Evaluate AROM to assess presence of flexion lag
      • If no lag is present:
        • Continue all active exercises and dorsal blocking splint
      • If lag is present:
        • Discontinue dorsal blocking splint
        • Fabricate composite wrist and digit extension splint, if needed
        • Continue active fisting exercises
  • 6 weeks post-op:
    • Evaluate AROM to assess presence of flexion lag
      • If no lag is present:
        • Discontinue dorsal blocking splint
        • Continue active digit exercises
        • Begin strengthening at 8 weeks post-op

Flexor Tenolysis

Goals of therapy:

  1. minimize post-operative edema
  2. protect surgical incision site, and frayed tendons, if necessary
  3. maximize range of motion and strength
  4. minimize scar adhesions.

1 Day Post-op:

  • Remove post-op dressings
  • Wound care and dressing change, as needed
  • Edema reduction techniques with co-ban wrap
  • Begin active digit flexion and extension on an hourly basis
  • Include isolated flexor tendon glide exercises for FDS and FDP
  • Fabricate static extension splint for protection and for night-use
  • Consider MP blocking ‘exercise’ splint to promote isolated tendon glide and to reduce chance of patient returning to previous motor pattern of intrinsic-plus or superficialis pattern

2 Weeks Post-op:

  • Begin scar management techniques when sutures removed at 10 to 14 days
  • Advance exercise program to minimize scar formation
  • Begin gentle strengthening

Frayed tendon protocol

If flexor tendon is found to be frayed or fragile during tenolysis procedure, early active motion should be delayed for 2 weeks. Place and hold exercises are initiated at first post-op visit. Based on the integrity of the tendon, a dorsal blocking splint may be required.

Strengthening is delayed for 6 weeks.

Metacarpal Fracture

Shaft Fractures with ORIF

Goals of therapy:

  1. minimize dorsal scar adhesion
  2. maintain full digit range of motion
  3. minimize post-operative edema
  4. maximize grip and pinch strength

0 to 2 Weeks Post-op:

  • Remove post-op dressings
  • Sutures removed at 10 to 14 days post-op
  • Fabricate forearm-based ulnar or radial gutter splint with MP joints in 30 to 40 degrees flexion to prevent MP joint extension contracture, if active motion is to be delayed
  • Fabricate forearm-based ulnar or radial gutter splint with MP joints in full extension to prevent MP joint extensor lag, if active motion is initiated at first visit
  • Begin early active motion, including ‘place and hold’ exercises for digit extension if early extensor lag is present
  • Begin scar massage when sutures are removed

2 to 4 Weeks Post-op:

  • Continue active range of motion, including isolated MP joint flexion, straight-fist and extension exercises

4 Weeks Post-op

  • Convert to hand-based splint
  • Continue active range of motion, with careful monitoring for extensor lag

6 Weeks Post-op:

  • Discontinue splint, except with risky activities

8 Weeks Post-op:

  • Begin strengthening program

MP Arthroplasty (Pyrocarbon)

(based on protocols from Ascension Orthopedics, Inc. Note: For most recent updates on product protocol, check website at www.ascensionortho.com)

Goals of therapy:

  1. protect surgical reconstruction, including stability of joint replacement
  2. maximize range of motion
  3. prevent extensor lag at PIP joint
  4. minimize dorsal scar adhesions
  5. minimize post-operative edema
  6. maximize grip and pinch strength

TRAUMATIC AND DEGENERATIVE OSTEOARTHRITIS

  • 1 week post-op:
    • Remove post-op dressings
    • Using sterile technique, gently cleanse wounds and apply light dressings
    • Fabricate dynamic extension splint
      • Wrist at 10 degrees extension with slight ulnar deviation
      • MP’s at 0 degrees extension with sligh radial deviation. IP joints and thumb are left free
      • Use as necessary: derotational slings to correct digit rotation; radial outriggers to decrease ulnar drift; IP joint blocking splints (Oval-8 or thermoplastic ulnar gutter splints) to transfer forces to MP joint flexion only
    • Fabricate static resting splint
      • Wrist at 10 degrees extension and slight ulnar deviation
      • MP’s at 0 degrees extension with finger dividers to promote slight radial deviation
      • IP’s in comfortable flexion
      • Thumb included, in resting position
    • Confirm proper implant placement with splints on with x-ray.
    • Begin active MP joint flexion to 60 degrees to protect extensor tendon repair
    • Monitor for full MP joint extension
    • Edema reduction techniques
  • 2 weeks post-op:
    • First follow-up visit with physician
    • Sutures removed
    • Continue to monitor for extensor lag at MP joints
    • Encourage full IP joint motion
    • Continue MP joint flexion to 60 degrees
  • 4 weeks post-op:
    • Increase MP joint flexion to 90 degrees actively
    • If 60 degrees MP joint flexion not achieved, may begin active-assistive exercises and dynamic MP flexion splint may be required
  • 6 weeks post-op:
    • Discontinue use of splints, based on MP joint range of motion
    • Continue use of static night extension splint, if extensor lag at MP joints

RHEUMATOID ARTHRITIS:

  • 2 weeks post-op:
    • Following removal of post-op dressings and sutures at first M.D follow-up visit, begin edema reduction techniques as needed
    • Fabricate dynamic and static extension splints, as noted above in osteoarthritis protocols
    • Check implant position with x-ray with splints on
    • Begin MP joint flexion to 30 degrees
    • Begin radial finger walking (with fingers in dynamic extension slings)
    • Begin full IP joint range of motion
  • 4 weeks post-op:
    • Goal is to achieve 45 degrees of flexion after 4 weeks
    • Use IP blocking splints, as needed, to transfer forces to MP joints, if 45 degrees is not achieved
  • 6 weeks post-op:
    • Increase MP joint flexion to 60 degrees, continue dynamic extension assist
    • Begin weaning from splints, based on digit alignment and implant position
    • Begin light ADL’s.
  • Up to 12 weeks post-op:
    • Continue to wean from splints
    • Advance ADL’s
    • Night resting splint may be continued to maintain alignment of digits

Scapholunate Ligament Repair

Surgeries listed below address different levels of scapholunate ligament tears and carpal instabilities, ranging from isolated tears to advanced carpal collapse as seen in SLAC wrists. Rehabilitation progression is limited by bone/ligament healing and carpal kinematics. The goal of all surgical procedures is to provide a stable, pain-free joint – therefore full range of motion of the wrist is not the therapy goal. Patient education pre-operatively is critical to prepare the patient for decreased wrist mobility and loss of grip strength. Specific education regarding the concept of axial loading across the carpals with resistive gripping is critical to maintaining the stability of the ligament repair.

I. Capsulorrhaphy:

  • First one to two weeks post-op
    • Long-arm (sugar-tong) dressings for 10 to 14 days
    • Sutures removed at 10 to 14 days
    • Finger and shoulder range of motion
  • 2 weeks to 6 weeks post-op
    • Wrist splint at first post-op visit
    • Begin “toggle” exercises for wrist range of motion
    • Modalities PRN
    • Aggressive range of motion contraindicated
    • Scar mobilization
    • Desensitization
  • 6 to 12 weeks post-op
    • Continue active range of motion of wrist
    • Begin grip strengthening at 12 weeks
    • Discontinue wrist splint at 6 weeks

II. Open SLIL Repair/Reconstruction and RASL procedure

  • First one to two weeks post-op
    • Long-arm (sugar-tong) dressings for 10 to 14 days
    • Sutures removed at 10 to 14 days
    • Shoulder and digit active motion
  • 2 weeks to 4 weeks post-op
    • Long-arm thumb spica splint
    • Continue digit, elbow and shoulder range of motion
  • 4 weeks to 8 weeks post-op
    • Short-arm thumb spica cast
    • Continue digit and shoulder range of motion
    • Begin elbow range of motion
  • 8 to 12 weeks post-op
    • Wrist splint
    • Begin gentle active wrist range of motion
    • Joint mobilization techniques contraindicated
    • Begin scar mobilization
    • Desensitization
    • Modalities PRN
  • 12 to 16 weeks post-op
    • Wean from wrist splint
    • Continue wrist range of motion, advancing to gentle passive wrist flexion
  • 16 weeks post-op
    • Begin grip strengthening
    • Continue wrist range of motion

III. Blatt capsulodesis: (dorsal capsule tightening)– expect limited flexion, approximately 50%

  • First one to two weeks post-op
    • Long-arm post-op dressings for 10 to 14 days
    • Sutures removed at 10-14 days
    • Thumb spica cast applied
    • Begin digit, elbow and shoulder range of motion
  • 2 weeks to 6 weeks post-op
    • Continue thumb spica cast
    • Continue active digit and shoulder range of motion
    • Do not test grip strength
  • 6 to 12 weeks post-op
    • Cast may be removed, based on healing and extent of original injury
    • Wrist splint at all times except when exercising
    • Begin gentle active wrist range of motion. “Toggle” exercises, advancing to full active range of motion
    • Advance to gentle passive range of motion. Remember goals of surgical procedure!
    • Modalities PRN
    • Do not test grip strength
    • Desensitization to incision sites
    • Scar mobilization techniques
    • Joint mobilization techniques contraindicated
    • Patient education to avoid weight-bearing and pushing activities
  • 16 weeks post-op
    • Begin grip strengthening exercises.
    • May begin grip strength testing.
    • Joint mobilization techniques contraindicated

IV. 4-bone Weave

  • First one to two weeks post-op
    • Long-arm post-op dressings for first 10 to 14 days
    • Sutures removed at 10 to 14 days
    • Placed in thumb spica cast when post-op dressings removed
  • 2 weeks to 8 weeks post-op
    • Focus on shoulder and digit active motion
    • Patient education regarding avoiding strengthening activities or resistive gripping
  • 8 to 12 weeks post-op
    • Cast discontinued
    • Wrist splint
      • Progressively wean from splint
    • Begin active wrist range of motion
    • Modalities PRN for pain control
    • Joint mobilization techniques contraindicated
    • No strengthening exercises
    • Desensitization
    • Scar mobilization techniques
    • Patient education regarding avoiding weight-bearing and pushing activities
  • 12 to 16 weeks post-op
    • Begin strengthening and grip strength testing
    • Add passive wrist range of motion

V. STT Arthrodesis (Partial Fusion): Limits wrist motion – flexion/extension by 30 % and radial/ulnar deviation by 40%

  • First 1 to 2 weeks post-op
    • Post-op dressings, above elbow for first 10 to 14 days
    • Sutures removed at first post-op visit (10-14 days)
  • 2 weeks to 4 weeks post-op
    • Long-arm thumb spica cast
    • Begin digit and shoulder range of motion
    • Patient education regarding avoiding gripping and resistive activities
  • 4 weeks to 8 weeks post-op
    • Short-arm thumb spica cast for additional 4 weeks or until arthrodesis evident on radiographs
    • May be casted up to 12 weeks
    • Begin elbow range of motion
  • 8 to 12 weeks post-op
    • Convert to wrist splint
    • Begin active range of motion of left wrist
    • Scar mobilization
    • Desensitization
    • Modalities PRN
    • Joint mobilization techniques contraindicated
  • 16 weeks post-op
    • May begin grip strengthening

VI. 4-corner Fusion (Partial fusion)

  • First 1 to 2 weeks post-op
    • Post-op dressings, above elbow for first 10 to 14 days
    • Sutures removed at first post-op visit (10-14 days)
  • 2 weeks to 4 weeks post-op
    • Long-arm thumb spica cast
    • Begin digit and shoulder range of motion
    • Patient education regarding avoiding gripping and resistive activities
  • 4 weeks to 8 weeks post-op
    • Short-arm thumb spica cast for additional 4 weeks or until arthrodesis evident on radiographs
    • May be casted up to 12 weeks
    • Begin elbow range of motion
  • 8 to 12 weeks post-op
    • Convert to wrist splint
    • Begin active range of motion of left wrist
    • Scar mobilization
    • Desensitization
    • Modalities PRN
    • Joint mobilization techniques contraindicated
  • 16 weeks
    • May begin grip strengthening

VII. Proximal Row Carpectomy

  • First 1 to 2 weeks post-op
    • Post-operative dressings for 10 to 14 days
    • Sutures removed at 10 to 14 days
    • Begin finger range of motion at first post-op visit
  • 2 to 4 weeks post-op
    • Short-arm cast or clam-shell dorsal and volar splint
    • No active range of motion of wrist
    • Continue finger and elbow range of motion
  • 4 weeks post-op
    • Begin wrist range of motion
    • Begin scar mobilization
    • Desensitization
    • Modalities PRN
  • 6 weeks post-op
    • Advance exercise program to include grip strengthening
    • Advance strengthening program to wrist flexion and extension when pain allows and range of motion has plateaued.

VIII. Total Wrist Arthrodesis

  • First one to two weeks post-op
    • Post-op dressings for 10 to 14 days
    • Sutures removed at 10 to 14 days, at first post-op visit
    • Short-arm cast applied at first post-op visit
    • Fabrication of dynamic extension splint over cast, if extensor lag present at digits
    • Begin digit, shoulder and elbow active range of motion.
  • 2 to 8 weeks post-op
    • Continue casting
    • Continue dynamic extension splinting, as needed
    • Continue shoulder, elbow and digit range of motion
  • 8 to 12 weeks post-op
    • Based on radiographic evidence, cast may be removed
    • Convert to wrist splint
    • Begin gentle strengthening to digits and elbow
    • Scar mobilization techniques
    • Modalities PRN

Thumb CMC Joint Arthroplasty

This surgical procedure is performed for isolated trapeziometacarpal joint osteoarthritis. A costochondral allograft procedure or Silastic implant is performed.

Goals of treatment:

  1. protect joint replacement and soft tissue reconstruction
  2. provide a pain-free functional thumb
  3. patient education regarding changes in grip and pinch strength
  4. provide adaptive equipment, as needed

0-2 Weeks Post-op:

  • Post-op dressings are removed at the first post-op visit with M.D.
  • Sutures are removed at this visit
  • Short-arm thumb spica cast is applied
  • Begin thumb IP, index through small finger, elbow and shoulder active range of motion

2 – 5 Weeks Post-op:

  • Continue active range of motion, as above
  • Continue short-arm thumb spica cast

6 Weeks Post-op:

  • 2nd follow-up visit with M.D.
  • Short arm cast is removed
  • Fabricate thermoplastic thumb spica splint – MP joint is positioned in 30 degrees of flexion
  • Splint may be removed for hygiene and exercises for the first 2 weeks, then gradually wean from splint, with use for risky activities and pain relief. Splint should be worn at night until 12 weeks post-op.
  • May also be fitted with a neoprene hand-based support. Patient may alternate between use of thermoplastic splint and neoprene support based on activity level, MP joint hyperextension, and pain level.
  • Begin gentle thumb and wrist range of motion
  • Avoid thin lateral pinch activities with affected hand
  • Monitor MP joint for hyperextension.
  • Begin scar massage, silicone gel pad, as needed
  • Desensitization techniques, as needed

6 to 11 Weeks Post-op:

  • Continue active wrist and thumb range of motion

12 Weeks Post-op:

  • 3rd follow-up visit with M.D.
  • May begin gentle strengthening
  • Advance range of motion, as needed
  • Discontinue all splints, based on patient’s pain level. May continue to use neoprene support, as needed, for risky or provocative activities.

Trigger Finger Release

This surgery is performed to release the A-1 pulley in the palm. A small transverse incision is performed at the base of the affected digit, at the distal palmar crease.

The goals of therapy are to:

  1. increase digit range of motion
  2. prevent scar adhesions
  3. increase strength
  4. minimize post-operative edema.

2 to 3 days post-op:

  • Patient is instructed to remove their post-operative dressings independently. A small band-aid is applied over the incision.
  • Patient is instructed to begin gentle range of motion of the fingers. Heavy lifting should be avoided.

10-14 days post-op:

  • First follow-up visit is scheduled with physician. Sutures are removed at this visit.
  • Scar management techniques, including scar massage and silicone gel pad are initiated at this time, if wound is well-healed.
  • Continue with active range of motion exercises. Emphasis should be on composite digit flexion and “hook fist” position. Intrinsic stretches should be added to home program, as needed. If trigger finger was present for prolonged period of time prior to surgical intervention, careful attention should be paid to MP joint extension.
  • Begin strengthening with theraputty, if wounds are well-healed.
  • One therapy visit for instruction in home program is usually adequate. Patient’s with diabetes or prolonged trigger finger may require additional therapy visits to regain full range of motion.

Elbow

Radial Head Fracture: ORIF/Arthroplasty

Goals of therapy:

  1. protect surgical repair of fracture and soft tissue reconstruction, if needed
  2. maximize elbow range of motion, including forearm rotation
  3. minimize edema
  4. increase upper extremity strength

1 to 3 days post-op:

  • Remove post-op dressings
  • Carefully inspect wound
  • Using sterile technique, apply light dressings
  • Begin edema reduction techniques with compressive sleeve
  • Fabricate protective long-arm splint
  • Elbow at 90 degrees
  • Forearm in neutral rotation
  • If collateral ligaments have been repaired, surgeon may specify forearm in pronation
  • Include wrist for comfort
  • Begin active range of motion of elbow: flexion, extension, pronation, supination
  • Instruct in active shoulder range of motion to prevent shoulder stiffness
  • Instruct patient in signs of infection and precautions for heavy lifting

2 weeks post-op:

  • First follow-up visit with M.D. – sutures are removed
  • Begin scar management techniques, if wounds are well-healed
  • Continue edema reduction techniques
  • Continue active and active-assistive range of motion of elbow
  • If given clearance by M.D., may begin gentle weighted stretch to achieve elbow extension
  • Continue use of splint at night
  • Begin light ADL’s
  • Non-compliant patients may need to use splint during the day, as well

4 weeks post-op:

  • Begin passive range of motion to patient tolerance
  • Continue night splinting, as needed, for protection

6 to 8 weeks post-op:

  • Advance range of motion to patient tolerance
  • Begin strengthening to elbow

Tendon Transfer: EIP to EPL

0 to 7 days post-op:

  • Post-op dressings removed, wounds cleansed and sterile dressings applied.
  • Fabricate 2 splints: forearm-based dynamic thumb IP joint extension splint for day use (wrist in 30 degrees extension, thumb in extension. Apply outrigger more proximally to allow hyperextension of the IP joint) and forearm-based static extension splint for night use.
  • Begin protected thumb IP joint flexion to 30 degrees, with dynamic assist for IP joint flexion.
  • Protected wrist and thumb passive range of motion in therapy sessions only.
  • Edema reduction techniques, as needed.

10 to 14 days post-op:

  • First follow-up appointment with M.D.
  • Sutures removed. Begin gentle scar massage
  • Advance thumb IP joint flexion to 45 degrees (2 weeks post-op)
  • Continue protected wrist and thumb passive range of motion in therapy sessions only.
  • Continue dynamic assist thumb extension within splint

3 weeks post-op:

  • Begin “place and hold” exercises for thumb IP joint extension
  • Continue dynamic extension splint between exercise sessions
  • Advance IP joint active flexion to 60 degrees
  • Begin active wrist range of motion in all exercise sessions

4 weeks post-op:

  • Begin active thumb IP extension.
  • Wean from dynamic extension splint.
  • Continue static extension splint at night
  • Monitor for extensor lag.

5 to 6 weeks post-op:

  • Begin full composite thumb flexion and extension
  • Advance to strengthening program
  • Discontinue static extension splint, if no extensor lag present

Subcutaneous Transposition of Ulnar Nerve

This surgery involves transposition of the neurovascular bundle subcutaneously. The flexor origin is preserved. Rehabilitation progression is limited by the postoperative soft tissue healing and comfort.

The Goals of this protocol are to limit the effects of immobilization while allowing for soft tissue healing. Initiation of early range of motion to facilitate return to prior level of function.

POD #3-20

  • Remove bulky dressing and posterior splint.
  • Fabricate thermoplastic splint with elbow at 45 degrees flexion and forearm neutral rotation and wrist free.
  • Ace wrap for edema.
  • Assess neurological function of ulnar nerve.
  • Ice and elevation
  • Modalities PRN for pain control.
  • Monitor wound status.
  • Initiate gentle AAROM elbow, AROM to hand and wrist and elbow.
  • Scar massage and silicone gel pad to scar 48 hours after suture removal.
  • Splinting should be discontinued by the second week.

POD #21-six weeks

  • Unrestricted AROM to elbow wrist and hand.
  • Monitor for loss of ROM. Allow light stretching pain-free.
  • Continue modalities PRN now also for improving tissue elongation.
  • If motor or sensory loss to ulnar hand initiate sensory stimulation and intrinsic strengthening, consider NMES to 1st dorsal interosseous and thumb adductor muscles.
  • Grip strengthening with putty.
  • Whole arm strengthening.
  • Work conditioning and sport specific training.

Week six

  • Return to prior level of function.

Sub-Muscular Transposition of Ulnar Nerve

This surgery involves elevation of the flexor pronator mass of the medial epicondyle and reattachment. Rehabilitation progression is limited by the bone tendon healing at the medial epicondyle.

The goals of this protocol are:

  1. Protect the repaired flexor tendon attachment while minimizing the effects of immobilization.
  2. Full range of motion and strength of the arm.
  3. Full return to prior level of function by three months post-operatively.

POD #3-20

  • Remove bulky dressing and posterior splint.
  • Fabricate thermoplastic splint with elbow at 70 degrees flexion and forearm slightly pronated, wrist in neutral extension.
  • Ace wrap for edema.
  • Assess neurological function of ulnar nerve.
  • Ice and elevation
  • Modalities PRN for pain control.
  • Monitor wound status.
  • Initiate gentle AAROM elbow, AROM to hand and wrist.
  • Scar massage and silicone gel pad to scar 48 hours after suture removal.

POD #21-six weeks

  • Unrestricted AROM to elbow wrist and hand.
  • Monitor for loss of ROM. Allow light stretching pain-free.
  • Wean from splint.
  • Continue modalities PRN now also for improving tissue elongation.
  • If motor or sensory loss to ulnar hand initiate sensory stimulation and intrinsic strengthening, consider NMES to 1st dorsal interosseous and thumb adductor muscles.
  • Grip strengthening with putty.

Week six – twelve

  • Continue stretching, consider dynamic or static progressive splints if developing flexion contracture.
  • Initiate progressive arm strengthening
  • Work conditioning or sport specific exercises.

Shoulder

Rotator Cuff Repair

This protocol gives treatment guidelines for a typical attritional tears of the rotator cuff. It is based on well established and accepted principles of healing soft tissue. The expected time of supervised therapy is 1 to three times per week for twelve weeks. Patient compliance, stiffness or post operative goals usually will dictate frequency and duration of supervised therapy. Heavy emphasis is on a home program that the patients should continue up to a year after surgery.

The guiding principles of this protocol are:

  1. Minimize effects of immobilization.
  2. Protect healing tissue by avoiding early active ROM.
  3. Maximize function.
  4. Progression through the phases are based on patient response to treatment, not just time contingent.
  5. Protocol is based on current research.

Immediate post operative phase: (Prior to discharge from hospital)

  • Teach patient proper use of sling, donning doffing and correct position of abductor wedge.
  • Instruct patient in passive shoulder pendulum exercises.
  • Wand assisted external rotation to tolerance.
  • Review post operative restrictions;
    • No active range of motion of shoulder.
    • Sling at all times except when exercising.
    • Cryo cuff for pain control.
    • Button up shirts only for first month after surgery.

Maximal Protection Phase (weeks one through three)

Goals:

  1. Protect repair.
  2. Regain functional passive ROM.
  3. Minimize patient discomfort.
  4. Minimize muscle atrophy and weakness.
  • Sling for four weeks.
  • Passive ROM in plane of scapula to tolerance, never push through pain or muscle guarding. Do not stretch into internal rotation for eight weeks post-op.
  • Exercise program at home and in clinic;
    • Passive pendulum.
    • Passive table slides into flexion and scaption.
    • Assisted to active elbow ROM.
    • Grip with putty or ball.
    • Passive IR/ER with cane in supine.
    • Modalities PRN (heat prior to ROM, ice and stim post therapy).

Assisted Range of Motion Phase (weeks four through eight)

Goals:

  1. Regain normal active assisted ROM.
  2. Protect repair.
  3. Minimize patient discomfort.
  4. Minimize atrophy and weakness.
  • Discontinue Sling.
  • PROM as needed, joint mobilizations, posterior capsule stretching.
  • Submaximal isometrics.
  • Assisted ROM. “Free ride” UBE.
  • Resisted IR/ER with arm in 30 degrees scaption and scapular retraction at six weeks.
  • Active scaption to 90 degrees at six weeks if pain free.
  • Modalities PRN for pain or stiffness.

Light strengthening Phase (weeks eight through twelve)

Goals:

  1. Full pain free ROM.
  2. Gradual restoration of strength.
  3. No pain or limitation with ADLs.
  • Passive stretching if residual tightness.
  • Progressive resistive exercise program to the rotator cuff.
  • Whole arm strengthening.
  • Scapular PRE’s.
  • Dynamic stabilization exercises to shoulder.

Progressive Strengthening Phase (weeks 12 +)

Goals: Return to prior level of function

  • Work or sport specific exercises.
  • Plyometrics.
  • Avoid working muscles to failure for at least six months post op.
  • Return to strenuous work or recreational activity 6+ months post op.
  • Teach activity modification to avoid re-injury or to comply with permanent post-op restrictions.

Rotator Cuff Repair - Massive Tear or Poor Tissue Integrity

This protocol gives treatment guidelines for repair of severe tears of the rotator cuff. It is based on well established and accepted principles of healing soft tissue. The expected time of supervised therapy is one to three times per week for twelve weeks. Patient compliance, stiffness or post operative goals usually will dictate frequency and duration of supervised therapy. Heavy emphasis is on a home program that the patients should continue up to a year after surgery.

The guiding principles of this protocol are:

  1. Minimize effects of immobilization.
  2. Protect healing tissue by avoiding early active ROM.
  3. Maximize function.
  4. Progression through the phases are based on patient response to treatment, not just time contingent.
  5. Protocol is based on current research.

Immediate post operative phase: (Prior to discharge from hospital)

  • Teach patient proper use of sling, donning doffing and correct position of abductor wedge.
  • Instruct patient in passive shoulder pendulum exercises.
  • Wand assisted external rotation to tolerance.
  • Review post operative restrictions
    • No active range of motion of shoulder.
    • Sling at all times except when exercising.
    • Cryo cuff for pain control.
    • Button up shirts only for first month after surgery.

Maximal Protection Phase (weeks one through six)

Goals:

  1. Protect repair.
  2. Regain functional passive ROM.
  3. Minimize patient discomfort.
  4. Minimize muscle atrophy and weakness.
  • Sling for six weeks at all times except when exercising.
  • Passive ROM in plane of scapula to tolerance, never push through pain or muscle guarding. Do not stretch into internal rotation for ten weeks post-op.
  • Exercise program at home and in clinic;
    • Passive pendulum.
    • Passive table slides into flexion and scaption.
    • Assisted to active elbow ROM.
    • Grip with putty or ball.
    • Passive IR/ER with cane in supine.
    • Modalities PRN (heat prior to ROM, ice and stim post therapy).

Assisted Range of Motion Phase (six through ten)

Goals:

  1. Regain normal active assisted ROM.
  2. Protect repair.
  3. Minimize patient discomfort.
  4. Minimize atrophy and weakness.
  • Discontinue Sling.
  • PROM as needed, joint mobilizations, posterior capsule stretching.
  • Submaximal isometrics.
  • Assisted ROM. “Free ride” UBE.
  • Resisted IR/ER with arm in 30 degrees scaption and scapular retraction at eight weeks.
  • Active scaption to 90 degrees at eight weeks if pain free.
  • Modalities PRN for pain or stiffness.

Light strengthening Phase (weeks ten through twenty)

Goals:

  1. Full pain free ROM.
  2. Gradual restoration of strength.
  3. No pain or limitation with ADLs.
  • Passive stretching if residual tightness.
  • Progressive resistive exercise program to the rotator cuff.
  • Whole arm strengthening.
  • Scapular PRE’s.
  • Dynamic stabilization exercises to shoulder.

Progressive Strengthening Phase (weeks 20 +)

Goals: Return to prior level of function

  • Work or sport specific exercises.
  • Plyometrics.
  • Return to strenuous work or recreational activity 8 months post op. Permanent activity restrictions likely.
  • Teach activity modification to avoid re-injury to the cuff.

Rotator Cuff Repair - Acute Tear in the Athletic Population

This protocol gives treatment guidelines for repair for acute tears of the rotator cuff. It is based on well established and accepted principles of healing soft tissue. The expected time of supervised therapy is 1 to three times per week for twelve weeks. Patient compliance, stiffness or post operative goals usually will dictate frequency and duration of supervised therapy. Heavy emphasis is on a home program that the patients should continue up to a year after surgery.

The guiding principles of this protocol are:

  1. Minimize effects of immobilization.
  2. Protect healing tissue by avoiding early active ROM.
  3. Maximize function.
  4. Progression through the phases are based on patient response to treatment, not just time contingent.
  5. Protocol is based on current research.

Immediate post operative phase: (Prior to discharge from hospital)

  • Teach patient proper use of sling, donning doffing and correct position of abductor wedge.
  • Instruct patient in passive shoulder pendulum exercises.
  • Wand assisted external rotation to tolerance.
  • Review post operative restrictions;
    • No active range of motion of shoulder.
    • Sling at all times except when exercising.
    • Cryo cuff for pain control.
    • Button up shirts only for first month after surgery.

Maximal Protection Phase (weeks one through three)

Goals:

  1. Protect repair.
  2. Regain functional passive ROM.
  3. Minimize patient discomfort.
  4. Minimize muscle atrophy and weakness.
  • Sling for two weeks at all times, sling with activity two more weeks.
  • Passive ROM in plane of scapula to tolerance, never push through pain or muscle guarding. Do not stretch into internal rotation for eight weeks post-op.
  • Exercise program at home and in clinic;
    • Passive pendulum.
    • Passive table slides into flexion and scaption.
    • Assisted to active elbow ROM.
    • Grip with putty or ball.
    • Passive IR/ER with cane in supine.
    • Modalities PRN (heat prior to ROM, ice and stim post therapy).

Assisted Range of Motion Phase (weeks three through six)

Goals:

  1. Regain normal active assisted ROM.
  2. Protect repair.
  3. Minimize patient discomfort.
  4. Minimize atrophy and weakness.
  • Discontinue Sling.
  • PROM as needed, joint mobilizations, posterior capsule stretching.
  • Submaximal isometrics.
  • Assisted ROM. “Free ride” UBE.
  • Resisted IR/ER with arm in 30 degrees scaption and scapular retraction at six weeks.
  • Active scaption to 90 degrees at four weeks if pain free.
  • Modalities PRN for pain or stiffness.

Light strengthening Phase (weeks six through twelve)

Goals:

  1. Full pain free ROM.
  2. Gradual restoration of strength.
  3. No pain or limitation with ADLs.
  • Passive stretching if residual tightness.
  • Progressive resistive exercise program to the rotator cuff.
  • Whole arm strengthening.
  • Scapular PRE’s.
  • Dynamic stabilization exercises to shoulder.

Progressive Strengthening Phase (weeks 12 +) ’* Goals:*’ Return to prior level of function

  • Work or sport specific exercises.
  • Plyometrics.
  • Avoid working muscles to failure for at least six months post op.
  • Return to strenuous work or recreational activity 4-6 months post op.
  • Teach activity modification to avoid re-injury or to comply with permanent post-op restrictions.