Tendon Reconstruction

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Post-operative patient information for flexor and extensor tendon injuries | Mark Yazid, MD, FACS

Please read this document   in its entirety before your first post-operative visit.

Tendon repair is among the most technically demanding and recovery-sensitive procedures in all of hand   surgery. Your outcome depends not only on the quality of the surgical repair,   but equally — and perhaps even more — on what happens in the weeks and months   after surgery. Your compliance with your splinting protocol and hand therapy   program is not optional. It is the difference between a good result and a   poor one.

The tendons of the hand and wrist are extraordinary structures. They are the cables that transmit force from your forearm muscles to your fingers, enabling you to grip, pinch, type, write, and perform the thousands of fine motor tasks you carry out every day without thinking. When a tendon is cut, crushed, or ruptured, restoring that function requires precise surgical repair — followed by an equally precise rehabilitation process that is unlike recovery from almost any other hand surgery.

Dr. Yazid wants to be direct with you about what lies ahead: tendon repair is one of the most difficult areas in hand surgery in which to achieve consistently excellent results, even in ideal circumstances. The biology of tendon healing is inherently challenging. Tendons heal slowly, scar readily, and exist in an environment — the narrow pulleys and sheaths of the hand and wrist — that is uniquely unforgiving of complications. With meticulous surgical technique, strict protocol adherence, dedicated hand therapy, and your full commitment to the process, excellent outcomes are absolutely achievable. But they require your active participation at every step.

Your specific rehabilitation   protocol will be determined at your post-operative consultation and will   depend on your exact injury, the location and type of repair performed,   whether other structures were involved, and your individual hand anatomy. The   instructions in this document are a framework — your individualized protocol,   provided by Dr. Yazid and your hand therapist, takes precedence over   everything written here.

Understanding Your Tendons: A Brief Anatomy Overview

The tendons of the hand are divided into two systems that work in opposition to one another — flexors and extensors. Injury to either system has distinct characteristics, heals differently, and requires a different rehabilitation approach.

Flexor Tendons

Flexor tendons run along the palm side of the hand and fingers. They originate as muscles in the forearm and travel through a series of tight fibrous tunnels — called the flexor sheath and pulley system — to attach to the bones of each finger. Their job is to bend (flex) the fingers toward the palm.

• There are two flexor tendons to each finger: the Flexor Digitorum Profundus (FDP), which bends the fingertip joint, and the Flexor Digitorum Superficialis (FDS), which bends the middle joint of the finger.

• The thumb has a single flexor tendon: the Flexor Pollicis Longus (FPL), which bends the thumb tip.

• Flexor tendons travel through an extremely tight, enclosed canal along each finger. This anatomy is what makes flexor tendon injuries so challenging — the repair must glide freely within a space that offers very little tolerance for swelling, scarring, or imprecision.

• Flexor tendon injuries are divided into zonesbased on where along the finger or hand the injury occurred. Zone II — from the base of the finger to the middle joint — is historically referred to as "no man's land" because of its notoriously difficult healing environment and high risk of adhesion formation. Your zone of injury significantly influences your rehabilitation protocol and prognosis.

Extensor Tendons

Extensor tendons run along the back (dorsal surface) of the hand and fingers. They straighten (extend) the fingers and thumb. Unlike flexor tendons, extensor tendons are flat and ribbon-like, and they lack an enclosed sheath over much of their course — which affects both their healing characteristics and their rehabilitation approach.

• Extensor tendons are also divided into zonesnumbered from the fingertip (Zone I) to the forearm (Zone VIII). The zone of injury determines the type of repair performed and the rehabilitation protocol that follows.

• Zone I injuries (at the fingertip level) cause a condition called mallet finger — the inability to straighten the last joint of the finger. These are often managed with splinting alone rather than surgery, though surgical repair is sometimes required.

• Zone III injuries (over the middle joint of the finger) can result in a boutonniere deformity — a characteristic posture where the middle joint bends down and the fingertip bends up — if not properly treated and rehabilitated.

• Extensor tendons are generally considered somewhat more forgiving than flexor tendons in terms of healing, but they are equally capable of forming adhesions and losing motion if rehabilitation is neglected.

The location of your tendon   injury — the zone — is one of the most important determinants of your   rehabilitation protocol and realistic outcome. Dr. Yazid will explain your   specific zone of injury at your post-operative visit and what it means for   your recovery.

Why Tendon Repair Is Uniquely Challenging

Patients are sometimes surprised to learn that a tendon repair — which they may perceive as a straightforward surgical fix — carries one of the most prolonged and demanding recovery processes in hand surgery. Understanding why helps set realistic expectations and underscores why adherence to your protocol is so critical.

The Adhesion Problem

When a tendon is repaired, the body responds to the surgical trauma by forming scar tissue — adhesions — around and within the repair site. This is a normal part of healing. The problem is that these adhesions can tether the tendon to the surrounding tissue, preventing it from gliding freely within its sheath or along surrounding structures. A tendon that cannot glide freely cannot transmit force effectively — meaning the finger cannot bend or straighten fully, regardless of how well the repair was technically performed.

• Adhesion formation is not a surgical complication or an error — it is a biological certainty to varying degrees in every tendon repair. The goal of rehabilitation is to minimize it.

• Early, controlled tendon motion — started in the first days after surgery under precise protocols — is the most powerful tool available to reduce adhesion formation. Moving the tendon through its sheath during the early healing phase stimulates gliding and prevents the scar from becoming restrictive.

• This is why early motion protocols exist — and why starting therapy promptly after surgery is so important. Every day of immobility in the early phase is an opportunity for adhesions to consolidate.

The Rupture Risk

A repaired tendon is at its weakest between days 5 and 21 after surgery — a phase known as the proliferative healing phase when the original repair sutures bear maximum load but the tendon's own biologic strength has not yet recovered. Rupture of the repair during this window is one of the most feared complications of tendon surgery.

• Rupture is irreversible without additional surgery. A re-ruptured flexor tendon is far more difficult to repair than the original injury, often requiring a staged reconstruction using a silicone tendon spacer over many months.

• This is why your splint protocol is non-negotiable during the early healing phase. The splint is not a suggestion — it is structural protection for the repair.

• Activities that generate resistive force through the tendon — gripping, pinching, lifting, opening jars, turning doorknobs — must be completely avoided during the early protected phase.

IF YOU FEEL OR HEAR A 'POP'

Stop all activity immediately.   If you experience a sudden pop, snap, or loss of finger movement at any point   during your recovery — particularly in the first 6 weeks — this may indicate   rupture of your repair. Do not move the finger. Splint it in the position of   comfort and contact our office immediately or go to the emergency room. Time   is critical.

The Stiffness Problem

While rupture and adhesion represent the two poles of the tendon repair problem — too much motion tears the repair; too little motion creates stiffness — the reality is that finding and maintaining the precise middle ground is the central challenge of tendon rehabilitation. It requires a highly skilled certified hand therapist, consistent attendance, and a patient who understands why every instruction matters.

• Joints that are immobilized — even briefly — develop capsular contracture and stiffness that can be extremely difficult to reverse.

• The finger joints adjacent to and distant from the repair site are equally at risk of stiffening if not actively exercised within the parameters of your protocol.

• Swelling is a major driver of stiffness — elevation, compression, and early motion all help manage it.

Flexor Tendon Repair: What to Expect

Your Splint — The Dorsal Blocking Splint

Following flexor tendon repair, you will be placed in a dorsal blocking splint — a splint applied to the back of the hand and wrist that holds the wrist in slight flexion and the fingers in a partially bent position. This posture reduces tension on the repair and protects it while allowing controlled motion within a safe range.

• The splint must be worn at all times — day and night — during the early protected phase. It is not removed for any reason without specific instruction from Dr. Yazid or your hand therapist.

• Do not straighten your fingers against the splint.Extension force is the primary threat to a flexor tendon repair. Even passive straightening of the fingers beyond the limits set by your therapist can rupture the repair.

• Keep the splint clean and dry. Cover it completely during bathing.

• If the splint cracks, loosens, or no longer fits properly — due to swelling changes — contact our office or your hand therapist immediately for adjustment.

Early Motion Protocols

The type of early motion protocol used for your flexor tendon repair will be determined by Dr. Yazid based on the zone and nature of your injury, the strength of the repair, your anatomy, and your reliability as a patient. The three most common approaches are:

• Passive motion protocols (e.g., Kleinert): Your therapist moves the finger passively — using rubber band traction or manual assistance — while your muscles remain relaxed. This glides the tendon without loading the repair.

• Active place-and-hold protocols: You passively position the finger in flexion (with your other hand or with therapist assistance), then gently hold that position with a minimal muscle contraction. This provides slightly more tendon excursion than pure passive motion.

• Early active motion protocols: Cautious, controlled active tendon movement within a protected range. Used selectively for strong repairs and highly compliant patients. Carries higher rupture risk if performed incorrectly.

The specific exercises,   frequency, range of motion limits, and progression schedule for your protocol   will be provided by your certified hand therapist at your first therapy   session. Follow these instructions exactly. Do not progress beyond what your   therapist has authorized — more motion is not always better. Pushing beyond   protocol limits is the most common cause of rupture in motivated patients.

Flexor Tendon Healing Phases

• Weeks 0–4 (Inflammatory & Proliferative Phase):Highest rupture risk. Strict splinting. Motion is passive or place-and-hold only within protocol limits. Zero resistive activity.

• Weeks 4–6 (Transition Phase): Repair gains biologic strength. Gradual transition to more active motion under therapist guidance. Splint weaning begins.

• Weeks 6–8 (Active Motion Phase): Progressive active range-of-motion exercises. Light daily activities begin.

• Weeks 8–12 (Strengthening Phase): Progressive grip and pinch strengthening under therapist supervision. Return to work assessment.

• Months 3–6: Full functional recovery for most patients. Some residual stiffness or weakness may persist and continue to improve.

Flexor tendon recovery   timelines are estimates. Your actual progression will be determined by Dr.   Yazid and your therapist based on direct assessment. Do not compare your   progress to someone else's recovery or to timelines found online — every   injury is different.

Extensor Tendon Repair: What to Expect

Extensor tendon repairs vary considerably depending on the zone of injury. Some extensor injuries are managed with splinting alone; others require surgical repair followed by specific immobilization or controlled motion programs. Your protocol will be tailored to your zone of injury and the nature of your repair.

Splinting for Extensor Repairs

• Zones I–II (fingertip and middle joint level): A finger extension splint holds the injured joint straight. It must be worn continuously. The joint must not be allowed to droop — even briefly — during the early healing phase, as this can gap the repair or re-rupture it.

• Zones III–IV (over the middle joint and proximal phalanx): Splinting prevents the boutonniere deformity from developing or worsening. The middle joint is held extended while interphalangeal motion is addressed in therapy.

• Zones V–VIII (hand, wrist, and forearm): A wrist extension splint is typically used, often combined with finger positioning depending on which tendons were involved. Dynamic extension splinting may be used in some protocols.

• For all zones: do not allow the repaired tendon to shorten against resistance during the early phase. Flexion force against an extensor repair is the analog of extension force against a flexor repair — both can rupture the repair.

Mallet Finger — Zone I Injuries

Mallet finger — caused by disruption of the extensor tendon at or near the fingertip — deserves special mention because the treatment requirement is both simple and absolute: the fingertip must be held in full extension continuously for 6–8 weeks without a single episode of flexion. A single moment of the fingertip drooping can reset the healing clock entirely.

• A mallet splint or stack splint is worn on the fingertip at all times — day, night, bathing, and sleeping.

• When changing the splint for cleaning, support the fingertip in extension with your other finger. Do not let it drop even for a second.

• After 6–8 weeks of continuous splinting, a gradual weaning protocol begins under therapist guidance.

• Non-compliance with mallet finger splinting is the most common reason for a poor result in an otherwise straightforward injury.

Extensor Tendon Healing Phases

• Weeks 0–3: Strict immobilization in extension. No active flexion of the repaired zone.

• Weeks 3–5: Controlled early active extension exercises begin under therapist direction. Passive flexion within limits.

• Weeks 5–8: Progressive active range-of-motion. Splint weaning begins for most zones.

• Weeks 8–12: Strengthening phase. Functional activity progression.

• Months 3–4: Most patients approach full or near-full function. Extensor repairs generally recover somewhat faster than flexor repairs, but this is not universal.

Hand Therapy: The Most Important Part of Your Recovery

Surgery repairs the tendon.   Hand therapy determines what you can do with it. In tendon surgery,   rehabilitation is not a supplement to the surgical outcome — it is half of   the procedure. Your compliance with therapy is the single most modifiable   factor in your recovery, and the one most directly under your control.

Dr. Yazid will refer you to a Certified Hand Therapist (CHT) — an occupational or physical therapist with advanced specialized training in the rehabilitation of hand and upper extremity injuries. The CHT works directly with Dr. Yazid, follows a protocol tailored to your specific repair, and will see you frequently — typically multiple times per week — during the critical early phases of recovery.

What Hand Therapy Involves

• Custom splint fabrication and monitoring: Your therapist makes and adjusts your splint throughout recovery to ensure precise positioning as your hand changes with swelling and healing.

• Exercise instruction and progression: You will be taught specific exercises for each phase of recovery, shown how to perform them correctly, and progressed on a schedule determined by Dr. Yazid and your therapist — not by how you feel on a given day.

• Edema management: Manual lymphatic drainage, compression wrapping, and elevation strategies to control swelling that drives stiffness.

• Scar management: Scar massage, silicone gel application, and desensitization techniques to reduce the adhesion of the repair site to surrounding tissue.

• Sensory re-education: If nerves were also injured, your therapist will guide the recovery of sensation alongside tendon function.

• Functional activity grading: Careful, stepwise reintroduction of daily activities as the repair gains strength — so that you recover function without putting the repair at risk.

Your Responsibilities in Therapy

• Attend every session. Tendon rehabilitation cannot be compressed or caught up — each session builds on the last, and missed appointments during critical windows cannot be recovered.

• Perform your home exercise program exactly as instructed — the correct number of repetitions, at the correct frequency, within the correct range of motion. More is not better. Deviation from the protocol — in either direction — carries consequences.

• Communicate openly with your therapist. If an exercise causes unusual pain, if your splint is uncomfortable, if you accidentally moved your hand outside of protocol, or if you have any concern — say so. Your therapist needs accurate information to keep you safe.

• Do not look up exercises online or follow advice from friends, family, or other patients. Tendon rehabilitation protocols are highly specific to the injury and the individual. Generic exercises found online are not appropriate substitutes and can cause rupture or permanent stiffness.

• Be patient. Progress in tendon rehabilitation is nonlinear. There will be days that feel like setbacks. This is normal. Trust the protocol.

Insurance authorization for   hand therapy should be obtained as promptly as possible after surgery. Delays   in starting therapy — particularly beyond the first week — have measurable   negative effects on outcomes. If you encounter insurance difficulties, contact   our office immediately so we can assist with documentation and advocacy.

Tenolysis: When Additional Surgery May Be Needed

Even with excellent surgical technique and dedicated rehabilitation, some patients develop significant adhesion formation that limits their tendon gliding and finger motion despite completing their full therapy program. When this occurs and conservative measures have been exhausted, a procedure called tenolysis may be recommended.

What Is Tenolysis?

Tenolysis is a surgical procedure in which the scar tissue (adhesions) that has formed around the repaired tendon is carefully released, freeing the tendon to glide normally again. It is performed under local or regional anesthesia — and often with the patient awake — so that the surgeon can ask the patient to actively move the tendon during the procedure to confirm that full gliding has been restored.

• Tenolysis is not a sign of failure — it is a recognized and planned-for possibility in tendon surgery, particularly after Zone II flexor tendon repairs and complex injuries involving multiple structures.

• It is performed only after the tendon repair has fully matured — typically no earlier than 4–6 months after the original repair — and only after a full course of hand therapy has been completed and motion has plateaued.

• The procedure releases adhesions but does not repair the tendon again — the original repair must be fully healed and intact for tenolysis to be appropriate.

• Immediate post-operative motion is critical after tenolysis. The patient must begin active tendon exercises the same day or the day after surgery to prevent adhesions from re-forming while the tendon is still mobile from the surgical release.

• Hand therapy is equally — if not more — intensive after tenolysis than after the original repair.

Who May Need Tenolysis?

Not every patient will need tenolysis, and it is impossible to predict at the time of the original repair who will and who will not. Factors that increase the likelihood of tenolysis include:

• Zone II flexor tendon injuries — the most common site requiring tenolysis.

• Complex injuries involving multiple tendons, nerves, bones, or pulleys repaired at the same time.

• Injuries requiring staged reconstruction — where a silicone tendon rod is placed first, followed by a tendon graft — which inherently carries higher adhesion risk.

• Delayed repair — injuries treated more than 72 hours after the initial injury, where scar tissue has already begun to form.

• Crush injuries, contaminated wounds, or injuries requiring prolonged immobilization due to associated fractures.

• Patients who, despite their best efforts, were unable to complete the full therapy program due to pain, insurance barriers, or other circumstances.

If Dr. Yazid recommends   tenolysis, it means your repair is healed and intact — and that there is a   clear surgical opportunity to improve your motion and function. It is a   hopeful procedure, not a setback. He will discuss timing, expectations,   anesthesia, and the intensive therapy program that follows at your   consultation.

General Post-Operative Instructions

Elevation — Your Most Important Early Job

• Keep your hand elevated above heart levelcontinuously for the first 72 hours. This is the single most effective thing you can do to reduce swelling.

• When lying down, prop the arm on pillows from shoulder to fingertips. When sitting, rest the arm on a pillow at chest height. When walking, hold the hand up — do not let it hang at your side.

• Gravity causes blood and fluid to pool in the fingers and hand, dramatically increasing swelling, pain, and stiffness. Do not underestimate the importance of elevation.

Wound & Dressing Care

• Keep dressings clean and dry until your first post-operative visit.

• Cover the hand completely when bathing. Do not submerge the hand in water.

• Do not adjust, loosen, or remove your splint or dressings for any reason before your first visit.

• If the dressing becomes soaked through with blood or falls off, contact our office promptly.

• Sutures are typically removed at 10–14 days.

Pain Management

• Take prescribed pain medications as directed. Staying ahead of pain in the first 48–72 hours is more effective than chasing it after it has escalated.

• Elevation significantly reduces pain — often more effectively than medication.

• Avoid NSAIDs (ibuprofen, naproxen, aspirin) unless specifically approved — they increase bleeding risk in the early post-operative period.

• Acetaminophen (Tylenol) is safe for mild pain.

Activity Restrictions

ZERO RESISTIVE HAND   ACTIVITY

No gripping, pinching,   lifting, twisting, or any use of the injured hand for functional tasks until   specifically cleared by Dr. Yazid and your hand therapist. This applies to   activities you may not think of as strenuous: opening a jar, turning a   doorknob, carrying a bag, using a computer mouse, or shaking hands. When in   doubt — do not do it.

• You may use the uninjured hand normally.

• Driving is not permitted while wearing a splint on the dominant hand, while taking narcotic pain medications, or until cleared by Dr. Yazid.

• Return to work depends entirely on your occupation and your specific protocol. Desk work with the uninjured hand may be possible within 1–2 weeks. Manual or physical work may require 3–6 months or longer.

Warning Signs — Call Our Office

• Fever over 101.4°F (38.5°C)

• Rapidly spreading redness, warmth, or red streaking from the wound

• Sudden loss of finger movement — possible rupture (call immediately)

• Numbness or tingling in the fingers that is new or worsening

• Increasing — not improving — pain after the first 48–72 hours

• Wound drainage that is thick, cloudy, or foul-smelling

• Fingers that appear blue, pale, or unusually cold

Contact Our Office

• Advanced Reconstruction — Hand & Upper Extremity: (732) 210-9234 | 485 Route 35, Shrewsbury, NJ 07702 | 3499 US Route 9, Building 2, Suite 2C-2, Freehold, NJ 07728 | www.advancedreconstruction.com

• The Plastic Surgery Center: (732) 380-1666 | 107 Monmouth Road, Suite 202, West Long Branch, NJ 07764 | www.looknatural.com

Email and patient portal   messages may take 48-72 business hours to receive a response. For urgent   concerns — including suspected tendon rupture, signs of infection, or any   sudden change in finger movement — call our office directly or go to the   emergency room immediately. Do not use email for urgent issues.

A Final Word from Dr. Yazid

Tendon surgery asks a great deal of you. The procedure itself is just the beginning. The weeks and months of therapy, splinting, patience, and discipline that follow are what ultimately determine your outcome — and that part is yours to own. The patients who achieve the best results are not necessarily those with the most straightforward injuries. They are the ones who understand what is at stake, follow their protocol without exception, attend every therapy session, and communicate openly with their care team when something does not feel right.

Dr. Yazid and his team are committed to guiding you through every phase of this process. You will not be handed a sheet of exercises and left to figure it out alone. You will have a personalized protocol, regular follow-up with Dr. Yazid, close collaboration with your hand therapist, and a team that is accessible to you when questions or concerns arise.

Excellent outcomes after tendon repair are absolutely possible. They take time, trust, and teamwork — and we are honored to be your partner in that process.

Mark Yazid, MD, FACS

Board-Certified Plastic & Reconstructive Surgeon | Hand & Upper Extremity Surgery

Advanced Reconstruction | The Plastic Surgery Center | New Jersey

Medical Disclaimer

The information provided in this document is for general patient education purposes by Mark Yazid, MD, FACS. It does not constitute individualized medical advice and does not replace the specific post-operative instructions and rehabilitation protocol provided to you directly by Dr. Yazid and your certified hand therapist. Tendon repair protocols are highly individualized — your specific instructions govern your care. If you have any question about your protocol, contact our office or your hand therapist before deviating from your instructions.