HandLab Clinical Pearls

March 2022 No. 72

Treating The Stiff PIP Joint...Why Did You Do It That Way?

Karol S. Young OTD, OTR/L, CHT


When observing treatment to regain both flexion and extension of a stiff proximal interphalangeal (PIP) joint, our student intern asked: “Why did you do it that way?”

Background: K.G., age 72, sustained a avulsion fracture of the volar base of the proximal phalanx of the left long finger during a fall. Osteoarthritis and a pre-existing trigger finger in the injured digit complicated her recovery. Any active interphalangeal (IP) joint flexion created triggering, and active extension was limited by both joint tightness and pain. See Figures 1 & 2. The therapy goal was to improve her range of motion in preparation for trigger finger release.

Figure 1 & 2: Flexion and extension limitations in the long finger

Favoring Weaker Extension

Rationale: Both patients and inexperienced therapists often prioritize flexion because it is functional, but proximal interphalangeal (PIP) joint extension is more difficult to regain as it is the weaker motion.

Treatment: K.G. was fitted with a custom static progressive orthosis to regain passive PIP joint extension which allowed better evaluation of the proximal movement of the dorsal apparatus required for PIP joint extension. The extension orthosis was worn periodically during the day and at night as tolerated. See Figure 3.

Figure 3: Static progressive PIP joint extension orthosis

Why: Since this patient’s avulsion fracture was within the joint capsule, PIP joint extension limitations were created by localized edema, adherence of the newly disorganized (healing) collagen (bone and soft tissue) around the PIP joint, and the triggering that limited lubricated glide of the flexor tendons. Positioning the PIP joint in extension at night created a prolonged stretch to combat the forces limiting PIP joint extension. (1)

Regaining Flexion Without Exacerbating The Trigger Finger

Rationale: Most trigger fingers result from the tendinous nodule “hanging” on the A1 flexor pulley. Triggering is more likely when the metacarpophalangeal (MP) joint is flexed because the tendon approaches the A1 pulley at an angle. When the MP joint is in extension, the tendon is parallel to the pulley opening, minimizing friction.

Treatment: K.G. wore a relative motion orthosis (RMO) during the day when not wearing the extension orthosis (2). See Figure 4. The RMO blocked the long finger MP joint in greater extension than the adjacent fingers, never allowing full MP joint flexion. (2) This orthosis encouraged active IP joint flexion but did not allow triggering or create pain with IP joint flexion.

Figure 4: A relative motion orthosis limits MP joint flexion but facilitates IP joint flexion of the long finger

Why: Since IP flexion is driven by the extrinsic flexors and MP flexion is primarily driven by the interosseous muscles, the blocked active hook exercise eliminates MP joint flexion, demanding maximum excursion of the extrinsic flexors across the IP joints. (3) Active IP joint motion stimulates digital lymphatic flow, normalizes the flexion pattern since finger flexion is initiated with the extrinsic flexors, and promotes the differential tissue glide needed for full IP joint motion. Additionally, the blocked hook exercise promotes maximum elongation of the interosseous and lumbrical muscles which quickly adaptively shortened in the presence of IP joint stiffness.

Regaining Functional Motion After Trigger Finger Release

Rationale: Following surgical release of A1 pulley of the long finger to prevent triggering, K.G. could begin composite finger flexion.

Treatment: Initially, K.G. resumed the blocked active hook exercises with the RMO and use of the night extension orthosis to encourage end range PIP joint motion. As active flexion and extension continued to improve, the RMO was discontinued, and she began to increasingly use her hand for all normal daily activities.

Why: K.G. avoided resisted finger flexion exercises to strengthen her grip because repetitive resistive gripping tends to increase joint pain in those with osteoarthritis and can create triggering in other digits. K. G. finalized her rehabilitation program by gradually increasing her hand use with daily activities, which improved both her strength and range of motion. (4) See Figures 5 & 6.

Figure 5 & 6: Final active flexion and extension

Students’ clinical questions remind us that the nuances of treating hand stiffness require a combined knowledge of anatomy, clinical experience, and understanding of research, all of which guide our treatment. In our busy clinic we often treat without asking ourselves “Why did you do to that way?” We should always be able to answer that question in detail for ourselves and for our students.


1. Flowers KR, LaStayo P. Effect of total end range time on improving passive range of motion. J Hand Ther. 1994;7(3):150-157. doi:10.1016/s0894-1130(12)80056-1

2. Hirth MJ, Howell JW, O'Brien L. Relative motion orthoses in the management of various hand conditions: A scoping review. J Hand Ther. 2016;29(4):405-432. doi:10.1016/j.jht.2016.07.001

3. https://bracelab.com/clinicians-classroom/which-hook-exercise-most-effectively-decreases-finger-stiffness

4. Che Daud AZ, Yau MK, Barnett F, Judd J. Occupation-based intervention in hand injury rehabilitation: Experiences of occupational therapists in Malaysia. Scand J Occup Ther. 2016;23(1):57-66. doi:10.3109/11038128.2015.1062047


Download Clinical Pearl No. 72, Treating The Stiff PIP Joint...Why Did You Do It That Way?, March 2022

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Disclaimer: BraceLab Clinical Pearls are intended to be an informal sharing of practical clinical ideas; not formal evidence-based conclusions of fact.

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