This text based course is a transcript of the live webinar titled, "Flexor Tendon Injuries" presented by Rebecca von der Heyde, PhD, OTR/L, CHT.
>> Rebecca Von der Heyde: I would like to know a little bit about those joining us today. Have you treated a patient with a flexor tendon injury in the past month? Have you ever treated a patient with flexor tendon injury? Today's talk is about tendon injuries. We are going to start at the beginning with healing and move our way all the way through to making good informed choices based on evidence for patients with flexor tendon injuries. Let's look at the objectives for today's talk.
Objectives
The first objective is to describe the benefits of early motion in flexor tendon healing. The second objective is to prioritize interventions based on excursion, and I will explain what excursion is, force and optimal timing, and the third objective is to rationalize immobilization in terms of timing and positioning. We will look at all three of these objectives. I have many articles that I have studied and referenced in this talk, and the reference list is very long. If you are interested or have any specific questions, please do not hesitate to let me know. I really want to encourage you to use the question-and-answer box on the left. Since this is not my rookie attempt, I am hoping to pay better attention to those questions and I will try to keep looking at those throughout the talk.
Part 1: Tendon Healing & Biomechanics
The first part of this talk is going to be about tendon healing and biomechanics. Within tendon healing, I am also going to talk about a concept called work of flexion. I have given talks on flexor tendons in many places, and what I find is that a lot of people still receive orders to immobilize patients with flexor tendon injuries.
If you think about where this conservatism comes from, it comes all the way back from 1941 from Drs. Mason and Allen. Basically what these two doctors did was define the healing phases in exudative and formative. We can call these reparative and remodeling. There are many names for this, but basically they used two separate stages. They thought that during that exudative phase, when all those good tissues are coming in to heal, they really thought that we should be immobilizing patients with flexor tendon injuries; no motion, waiting for healing to occur. In the second part, they thought that we should really look at strength and tendon gliding after that exudative stage was over and the patient was in the formative stage. Whenever I think of the word formative, I think of “forming scar tissue.” This old idea, a 1941 idea, actually still is in practice today. If you think about it, that is 70 years ago, which is a long time. If you are still seeing these patients who are being immobilized, think that this came from way back in 1941. It also continued though all the way through 1963 and 1965.
Dr. Potenza in 1963 continued to advocate for immobilization. His idea was that if you injure a tendon, it is solely dependent on extrinsic processes for healing. I am going to show you a picture to describe that concept.
Peacock in 1965 also agreed with Dr. Potenza saying that there is going to be one wound. There was not going to be a separate tendon from the sheath surrounding it; it was all going to be one wound. We need for that wound to heal before we moved on with rehabilitation. If you look at this picture, this shows this whole one wound concept.
Here in the middle is your tendon and around the outside is the tendon sheath. Drs. Peacock and Potenza, and even Mason and Allen, all thought that this type of scar tissue was necessary. It was necessary for the tendon to actually scar to the sheath. We as therapists know what happens if that tendon scars to the sheath. We achieve no motion. It does not surprise me at all to think that people started to say “Wait a minute. Why would we want all this extrinsic healing to happen?” Those original doctors thought that this was the only way the tendon could heal.
