Zone II Flexor Tendon Repair at 3.5 Weeks: A Patient Who Is Stretching Himself
Mr. T is a 34-year-old chef, 3.5 weeks after a zone II repair of the right ring finger (FDP and FDS, 4-strand core with epitendinous suture). He is in a dorsal blocking splint with the wrist at 20° extension and MCPs at 70° flexion, and has been started on place-and-hold tenodesis. His insurance authorizes 10 visits total; he has used 4. Today: PIP active flexion 35°, passive 70°; DIP active 20°, passive 40°; mild diffuse swelling; the repair site and pulley area are nontender. During the session he demonstrates his home stretch - he pushes the PIP into flexion with his other hand "a few times a day, because it feels tight."
1. Identify the most important risk in this presentation and state exactly what you would do and say in this visit.
Read the worked answer
The risk is rupture, and it is driven by behavior rather than by tissue quality. He is performing forceful passive PIP flexion at 3.5 weeks, when repair-site tensile strength is at its weakest relative to the loads he is generating. The nontender repair site and diffuse (not focal) swelling are mildly reassuring but do not offset the mechanical risk of his home stretch.
Immediate actions:
- Stop the stretch today. Replace it with the prescribed place-and-hold, performed with the splint on, at a frequency you can verify (for example 8–10 repetitions hourly while awake rather than "a few times a day").
- Explain the mechanism, not just the rule: passive force is concentrated at the repair while the sheath and pulleys resist excursion, so his "tightness" is the repair and edema, not a muscle that needs lengthening.
- Have him demonstrate his home program back to you before he leaves, and give written cues.
- Contact the referring surgeon the same day to report the passive stretching and the active-passive discrepancy, so the plan is shared.
Reasoning: the active–passive gap (35°/70° at PIP) is expected at this stage from edema and early adhesion formation; it is not an indication for stretching, and treating it as one is the classic route to rupture in zone II.
2. With 6 authorized visits remaining across the next 8 weeks, design the visit schedule and justify the distribution.
Read the worked answer
Front-load the visits into weeks 4–6, then space them out. Suggested pattern: weekly for the next 3 weeks (weeks 4, 5, 6), then one visit at week 8, one at week 10, one at week 12 for progression and discharge testing.
Justification: risk and change are concentrated early. Weeks 4–6 cover the transition to active flexion and the first resisted work, which are the highest-consequence decision points and the hardest to supervise remotely. After week 6 the trajectory is more predictable, so visits can shift to milestone checks with a well-specified home program in between. Front-loading also means that if he plateaus, you still have visits left to address it rather than having spent the authorization on maintenance.
What each gap requires: a written home program with explicit dosage, a self-monitoring rule (stop if he feels a sharp pop or loses active flexion), and a way to check in - a photo or brief message at the midpoint of each gap, so a loss of flexion is caught before the next visit.
Reasoning: visit allocation should follow where clinical decisions change, not a fixed weekly habit.
3. State the criteria you would use around week 6 to progress to active flexion and light resistance, and what you would do if he does not meet them.
Read the worked answer
Criteria to progress: (1) no loss of active flexion compared with the previous week - a drop is the earliest rupture signal; (2) active PIP flexion at least 50–60° with the splint off, and active DIP flexion present; (3) minimal swelling and no focal tenderness over the repair; (4) he can correctly demonstrate the home program and reports no passive stretching; (5) full passive extension is not required, but the dorsal blocking splint should still be protecting against combined extension.
If he does not meet them: do not progress. Hold the current phase, re-check the splint for fit and wear time, treat edema, review the home program with a return demonstration, and speak with the surgeon about the plateau. Consider whether the limiting factor is adhesion-related (active flexion much less than passive, with a soft end-feel on passive) versus protective guarding, and treat accordingly - tendon gliding and edema control for the former, reassurance and graded confidence for the latter.
Reasoning: progression after flexor tendon repair is earned by demonstrating controlled motion and safe behavior, not by the calendar. The week-6 date is a checkpoint, not an entitlement.