Extensor Tendon Protocols
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[00:00:00] I think challenge is good. Challenge is good. I had a really, um, tough conversation with a patient of mine today and I'm going to share because I think sometimes you have to have tough conversations with your patients. Um, I have a patient who's coming to me and he drives pretty far to see me. He's coming for a stroke, right?
And I always say that every stroke patient is neuro here, but we can become. orthopedic shoulder can become nerve issues, all sorts of stuff. So he had a stroke, but he also suffered sustained burns, um, to his arm when he, um, I guess when he, um, had a stroke, he had a stroke in the shower and the water kept like hitting him.
And for whatever reason, it was just hitting him in very particular places. And so he has like these burns along the dorsum [00:01:00] side and along the bowler side and a lot around his thumb. And so he's coming for like, um, mostly he's coming to me for hand wrist stuff. Mostly he's coming to me for that and, you know, needing a splint, but, um, cause he's going somewhere else.
Um, he's going to another occupational therapist for, um, some of his other stuff and his shoulders and things like that. Um, but I'll tell you what I treat the whole thing because you can't treat, you can't treat one without, you know, consideration of the other. But he is, um, he's had his stroke for like several months now.
I think he had it at the beginning of the year, but does not do what he needs to do. Does not do what he needs to do. And then his family and his caregiver, they're, um, They're supposed to help him. I, I allow them to film, um, you know, certain as like, I don't mind if they film the whole team. Nobody has [00:02:00] space on their phone, but they, I don't mind them filming me when I'm showing them exactly what to do.
And it's because sometimes they can't do it. Sometimes they won't do it. And, and, um, I guess the family member today was like really unhappy because they're like, we're driving all this way. We're spending all this money and he's not making any progress. I'm like, yeah, but you know, you're only coming. I mean, you're literally coming once a week.
I've got one hour with you. Y'all people got to step up and do your shit. It's like, you know, uh, and then I have to get real strict with, with him, but I just get strict with them. I'm like, the man's trying to tell you something he doesn't need to be lectured and worked on. I was like, just work on his hand.
Like, don't lecture him. Why are you working on his hand? He's telling you. So I'm like there and I'm like, you know, telling him shit, telling her stuff. And I'm like, Hey, you, you got to do this. I'm like, you're trying to get back to work. [00:03:00] Come January. I was like, we got three months. We have three months to prepare for that day.
You don't get to that day and then prepare to go to work. If your goal is to go back to work on January, your preparation starts now. You better get your ass up at eight, get dressed, go brush your teeth, get dressed. What you got to do. I was like, you got to do your exercise, go wear your splint. You got to get up, you know, You got to prepare to sit the day, right?
Not just to sit, but you got to, you know, get up and do your therapy and, you know, do your work and stuff like that. Your work is going to take you longer than what it normally, uh, was taking you before. I was like, you haven't, you know, and I explained to them, I was like, you know, a stroke is actually considered a traumatic brain injury.
You know, what happens with traumatic brain injury, people, they, they, They lose a lot of motivation. There's certain amounts of depressions, [00:04:00] you know with with that stuff too, you know Um, and I was like you have to take that into consideration, but you know, you gotta put stuff on the calendar Put it on the calendar You have to work on it Um, otherwise you're not going to get ready for the day that you're trying to get ready for you Can't wait until january to start getting ready.
You got to get ready Now You know, so I was like, let's talk about them and they left better for it. You know, um, see how that story can resonate with you and what you want to do, right? See how that story can resonate with how you can approach some of your patients, um, based on what they want. And where they're at, you know, some of the toughest cases come to hand therapists, certified hand therapists, and you have to [00:05:00] be able to have these tough conversations.
You know what I mean? All right, so type into the chat. Tell me what's good. So that was good today because I think that really set them. Set them up for success in the coming weeks. Um, you know, that's, that's what I hope to do. Cause we're, we're not with our people all the time. I can tell you right now, like in my exam prep, I'm not with those students all the time.
They have to go home and they, they have to study. And I show up again, I show up once a week, you know, kick everyone's butt. And then I show up for you guys twice a month. Kick your butt. Well, on email as well. So type into the chat what's going well. I have tons of, um, tons of cases to discuss today. I'm going to go over anatomy for extensor tendons today, right?
Because I think [00:06:00] sometimes when we start with anatomy, I'm going to start with anatomy and then I'm going to build in how to use the fast track framework to make your life easier. Now here's the thing, and this is why we want to always talk about this fast. Track framework, right? And it's because if you don't, you can see all these like exercise examples, manual examples, kinesio example, everyone's got an example to share with you.
But what works is when you know when to use what in what order. Right? It is about knowing when to use what in what order and that makes a big difference, right? So if you understand fundamentally taking it [00:07:00] through step by step, is it a bone issue? Is it a muscle or tendon issue? Is a ligament issue? Is it a nerve issue?
Is it a skin fascia? Um, you know, which, which issue is the main issue that then helps to guide your thinking to say, this is safe. This is not safe. This is, I can, you know, move along with this. I can start with this. No, I shouldn't start with this. Right. Um, and it guides your treatment. Now, this helps you, I think.
to better understand if you love protocols, right? So some people just love protocols. I'm not going to talk shit about that. You can love protocols all you want, but what happens the [00:08:00] shortfall with relying on protocols is that you have a really hard time explaining it to your patients and you sometimes have a really hard time knowing when to progress.
Knowing what to use, when to use it, why you are using what you're using. So anytime you're unsure of anything, right? You go back and you check off. If it's like a little checklist for you, you can check it off. Okay? So if we are going to talk specifically about extensor tendons today,
Then we know it's a muscle tendon issue, right? So first and foremost, we want to understand the anatomy of the extensor tendon because when you understand the anatomy of the extensor tendon, [00:09:00] um, it makes it easier to start to think through because extensor tendons from here and here are different from here and all the way down, right?
just like flexors, um, they look and feel a certain way. So if you understand anatomy and then you understand the nature of the tissue, so a Nate, the nature of the tissue, what's the nature of the tissue? Well, um, muscles are attached to tendons and when the muscle moves, the tendon moves. So muscles get long and get short.
Muscles and tendon junctions get long and get short. That's all it does. Right? Um, in its job of getting long and getting short, what it does is because it crosses a joint, it moves the joint, right? That's the nature of the tissue and that's it. That's all there is to it. [00:10:00] Right? So this produces
If you can simplify it, that literally is how I explain it to my patients, right? To make it as easy as possible, not only for you to understand, but also as you are explaining it, you don't have to get specific with them if you don't want to. Right? Um, the other thing to understand about muscles and tendons, right?
Is muscles have blood supply to it, but tendons do not. Do not have blood supply, right? It doesn't have blood supply. So if you cut it, it doesn't heal on its own. If it's torn, it doesn't heal on its own. It relies on the [00:11:00] surrounding tissues to help give it nutrients to potentially in certain areas, help it to scar down.
Right. But usually with tendons, you have to sew it and then use scar tissue to firm it up. Right. So that is the nature of the tissue itself. So now you also, you know, we'll get into, um, the nature of injury.
Everything we talk about, you know, there, there's a nature of injury to it, right? Even in chronic things that are not injury. Like you can have chronic pain, but you didn't have like an accident and an acute incident or anything like that. Um, But it is a form of injury, right? [00:12:00] So when it comes to tendons, how, um, how is it injured?
Right? How is it injured? Well, if we think about tendons in general, right, they can have a rupture. They can have a cut. Sometimes it can be kind of like a, a, a saw. Sawing effect, right? So something, uh, where the structures are, like, let's say around the DRUJ, around this bone, uh, with arthritis, the bone fragments can get really sharp, and as it moves, it, like, saws away at that tendon.
That's kind of like a cut, only a cut is clean. And this has jagged, [00:13:00] jagged
edges. Am I spelling that correctly? You know what I mean? Like, like the, the, the fibers, it's not clean. It's all over the place. Alright? You can have, um, in the fingers, in the fingers, we can see crush injuries. Right, so you get crushed. So you, you, you crush the structures, you can crush the, the tendons, right?
So those are the nature of injury. So understanding that and understanding the nature of the tissue, you know, that it needs to move and it doesn't have its own blood supply. So when it gets injured, you know what can happen. We, there's a couple of things that need to be done if, um, [00:14:00] if they happen. So now when I do extensor tendons, I like to draw on my hand.
So if you guys have a pen or a marker, um, draw on your hands as well. All right. Um, cause it can be really helpful, uh, not just to see like you can go and you can see the, um, The images all over the place, but when you put it on to yourself, it can help solidify and help it make sense for you, right? So when it comes to, um, Let me see.
How do I normally like to draw our extensor tendons?[00:15:00]
So this is the MP. This is P1. P two and P three. All right. So this is a lateral,
this is going to be a lateral view. All right.
All right. It's going to be a lateral view. Um,
so we think about all the extensor tendons. Um, We have them in our wrist. So we have wrist extensors, right? And then [00:16:00] we have finger extensors. And then we have the, um, the extensor hood, right? The extensor hood is essentially a list of structures just of, you know, the finger alone. Right, but extensor tendons can happen anywhere along.
If you understand the structures, you know where they originate. And you don't have to be real specific. You know, we're not in school anymore. You know, nobody's questioning you on like, is it on the lateral border of the blah, blah, blah. You know, like no one cares. It starts over here at the elbow. And the important thing is that it crosses the wrist.
Any joint that something crosses now gets affected if it [00:17:00] moves, right? So that's how you can kind of like simplify it. So, um, so you have your risk sensors and knowing, you know, where those are can really help you. So, um, cause if you have any cuts down here, you know, that you might have cut your. extensor carpi radialis longus, extensor carpi radialis brevis.
What else? Those are the two long ones. And then the one on the ulnar side is your extensor carpi ulnaris, right? So those are your wrist extensors. And then the one that moves your finger, right, is your extensor digitorum communis, right? So it's one muscle belly, and then it divides and it becomes You know, four tendons and it inserts at the the base of [00:18:00] P1
Right? And it helps, it extends your MP and you can see it If you curl, the way you isolate that tendon, right? is to curl your fingers Your eyepiece into a hook and then you hyperextend your MPs and you can see the tendons pop out. Alright, now for those, it goes to all fingers, but then you have extra ones that go to your index finger and it goes to your small finger.
Alright. Right? The indexy, the extensor indexy and the extensor digitorum minimi, right? So those are your, your long, uh, finger extensors. [00:19:00] Let's not forget your thumb. Sensor pollicis longus, right? That one starts over here, it crosses, right? Okay, and then inserts right here. the base of that, that, um, that IP, right?
And you can make it pop up. All right. Any muscle that then becomes a tendon that crosses any joint helps the joints that it crosses. That is the same as remember when we're talking about flexor tendons, any joint that it crosses, it helps. Well, the extensor tendons are no exception. If it crossed the wrist, then it helps to extend the wrist as well as its primary job is to [00:20:00] extend the joint that is there for.
But if you know that it crosses, you're now going to know that if you cut that tendon, you need to protect all the following joints, right? So that can help you. Even if you didn't know the protocol exactly, even if you didn't know what the splint was supposed to be exactly, you know, Oh shit, that's a long one.
I got to make a whole forearm one versus just a hand base or just a thumb or just like the finger. Right? Then now when we get to the extensor hood, Right. We get to the extensor hood. Now here's, I'm going to make the list, right? Because it's this list that's going to be a little bit more
extensive. Extensor [00:21:00] hood,
also known as the extensor mechanism, right? So we're going to go in here and What the extensor hood is, it's just a group of little, you know, connective tissues, strands from this, strands from that, that then move and give support to, um, doing, uh, IP extension, PIP extension and DIP extension. All right. So let's list those out first.
Alright,
so from here, we have the [00:22:00] sagittal bands, then we have, sagittal bands, we have the central, uh, tendon,
alright, actually I'm going to go step by step. here. All right. So the EDC, the EDC, right? This long, big one, then sends a slip out to cross P1. So here, um, is the EDC, right? And then it's gonna send a slip out. This is your central tendon and it The central tendon initiates PIP extension, right? So if you think about, I always describe extensor [00:23:00] tendons like, like a ponytail that then gets a piece here and a piece there, right?
So here you see how your tendon just like, if you just play around with your tendon a You see that that that tendon as you make a fist that tendon slips Like over the knuckle, right? Yeah, you guys see that so don't make a hard fist. Just make like a light You see? Oh, yeah, you see right there my My um look at my My middle finger right when I go to make a light fist Let me open it And it slides a little bit more radial.
And then when I go, it slips over, right? Um, that is a tendon just moving and the sagittal bands, right? There's this thin little [00:24:00] netting and what it does is it stabilizes
the EDC. Over that knuckle over the MP. So those that's the sagittal bands. They're very very thin, you know, and it's supposed to move right? It's supposed to move when It's torn on one side or due to arthritis, let's say, uh, overstretched on one side, then it doesn't hold it where it's supposed to be and it slips too far to the other side and then it hurts, right?
Okay. Um, I always give like some time. This might not be appropriate, but when have I ever been that appropriate? Um, So if you think about the sagittal band, it's like an underwear, right? If you cut covering both your [00:25:00] cheeks, you're good, but you got that one ripped on one side It's all up your butt crack It's not going to be comfortable, right?
And so that's like what it is to miss something You know, to not have both sagittal bands giving you like holding everything in place and it's just wonky to one side. It causes pain, right? Once it causes, it, it causes pain because it shifts the balance of how the finger is supposed to work, not because it just causes pain, right?
It causes an imbalance of how that, Finger is supposed to move and then it's from that that the pain comes, right? So here's a central, here's a central tendon, right? And then from that piece, right? From that piece comes divided into another piece that then is the terminal, terminal [00:26:00] tendon, right?
Central.
They call it a central tendon. Sometimes they call it central slip, same thing, right? So those two,
right. And the terminal tendon, um, it extends the DIP, right? It's not the only one, but it's the one that helps extend the DIP. All right. And as you can see, they're really, really small. Right, so that's what happens if you can imagine What happens to it if it gets injured, right? So if you know exactly where it is You don't need a doctor's note to tell you [00:27:00] exactly where it is because you'll see it on the hand So from here it comes and if you bend it Then that is where The terminal tendon is, right?
So in order to extend the flexors have to give and then the extensor has to extend. Make sense? All right. Flicking us off Wong. I know. I know. You know I love that. I can't find my flicking off earrings. It makes me sad. All right. So, um, those are the key things. Now, one thing I forgot to mention is the way I remember So, um, zones is I always remember odd numbers, one, three, and five.
The odd numbers are at the joints, right? The odd numbers, the zones are at the [00:28:00] joints. And then you just fill it in two, four, and six, right? So just from looking at, because you understand your anatomy. You know, anytime you cut or crush at the PIP, you might have a central tendon, right? If you do anything and you crush or you jam the finger really hard, right?
Jam the finger really hard. Then you might have ruptured at zone one, which is the terminal tendon. If someone comes in and they have a cut right here, you know, well, this is zone five. Could they have injured their sagittal band or is it just the EDC that I'm worried about? Right. If they cut right here and smack in the middle, this is four.
So you're right on the central tendon, but it's like right in the middle. Uh, I'm a little confused. Is the central tendon is slipped two different things? No, [00:29:00] it's the same. So sometimes they say central tendon, AKA. Slip. Right? The words get interchanged. But it's the same exact structure.
Right? Now, um, After that, We have
lateral bands. Right? Now lateral bands are really important. They come from the side. Right?
And then insert pretty much, um, at P3 as well right next to the terminal tendon. [00:30:00] Now, the lateral bands,
I'm saying this,
so, and we have lateral bands on both sides, lateral bands on both sides, lateral bands on both sides. The job of the lateral band is actually to extend the D. I. P. Right? The job of the lateral band is to extend the D. I. P.
But because it comes on the side, it gives a lot of support to the P. I. P. and also it [00:31:00] crosses that joint so it can affect how the P. I. P. is, um, like moves or doesn't move well, right? Now the lateral bands are really important because the lateral bands are held down They're held down by two structures, right?
Um, and this is how I like to remember it. One is called the transverse, uh, retinacular ligament. And the other one, ah, is called the triangular.
Right, retinacular ligament. And the way I like to remember is,
right, the way I like to remember it is, um, [00:32:00] the triangular is on top
because it makes like a triangle. Right on top of the finger All right It's like a triangle this is like Connective tissue right a ligament the triangular and it's job Right you see because it's on the dorsal side of the finger. It's job is to prevent the lateral band from moving to volar Right? So it's job is to keep that, um, lateral band in line.
So, prevents
what they call, um, [00:33:00] volar displacement. Right? See, because it's a triangle. So I tend to remember that one first. And because I remember that one, then the transverse is On the bottom, right? So here's the transverse ligaments
on the bottom. The transverse retinacular ligament holds the lateral bands from being dorsally.
Prevents dorsal displacement. All right.
That makes sense. The [00:34:00] structures in an extensor tendon. These structures are the most important thing to understand so that you could understand, um, how to treat. Right. That's all it is. If you understand, Oh, my patient came in and had a PIP injury. Oh, my, my patient came in and I saw they had a pin and they did something here at the term, like at this dorsal DIP, you can start to use your fast track framework and say, well, based on anatomy, right?
Based on anatomy. Tell me, tell me what happened with that. You know, did they do something with the tendon? It just makes you come off knowing and understanding when you say something first, right? Can you clarify one thing for me, please? Yes. [00:35:00] So if you were to rupture your, the transverse retinacular ligament, that's the one that leads to swan neck?
So what it does is if, if it gets, um, uh, I don't, is it swan neck? It, dorsally? Um, so no, because No, it's not. Um, hold on. So if it's ruptured, usually I'm think the lateral bands are going dorsally, the lateral bands are going to go dorsal. Because it's supposed to prevent it. So then, um, you can get, yeah, yeah.
Okay. If you, if it's one, if it's, if it's, um, if it's one or [00:36:00] two, right? So you have two on each side. So if you only rupture one, right? So it's supposed to hold the lateral bands down. It's supposed to hold the lateral bands down. All right, so see how I'm using my finger? It's supposed to hold the lateral band.
So if you rupture, um, it's usually if you rupture one, but usually it's not ruptured by itself. It's usually ruptured with something else. And that's the central slip. or the central tendon. So now if it's ruptured with the central tendon, the central tendon then is the main player to it. So then it's going to fall this way.
The PIP will fall and then the lateral band, well, [00:37:00] the, the retinacular, uh, the transverse, right? We're talking about transverse. Won't be able to hold. But it's not because of the transverse that causes one or the other. It's more the, the, the central isn't. So yeah, this is where my confusion comes in.
Wouldn't that be then the triangular ligament with the central split? That would give you the boutonniere because you just did this one. Yeah. So usually it's, it's one, it's one or the other, right? So if you have a central slip rupture, and if you have a central slips, um, rupture, you sometimes can injure this, but sometimes it can injure like the lateral bands and it'll tear one of the triangular, not sorry, not the triangle, the transverse.[00:38:00]
So it depends on the injury. But it's usually because it's usually because it's it tears one.
It usually one side versus both sides. Yeah. So that's the difference between, um, doing surgery versus trying conservative.
Right.
