Winston Folkes Jr., MS, OTR/L
One of the most frequent questions I receive as a hand therapist is, “When can I go back to [my activity]?”. This question can bring some of the best or worst news for our clients. As therapists, it is imperative that we provide a response that is both considerate of our clients’ lifestyles and intrinsic values and knowledgeable in safe return to occupations without risking re-injury. In my experience, clients are most often inquiring about when they can return to their vocation, sport, and fitness routines. I will take a few minutes to discuss our role as therapists, in patient education and intervention.
When beginning this conversation with a client I consider the nature of the injury, what is needed to protect the healing process, and the physical demands of the activity in question. Let’s now take a deeper dive into each of these areas.
What Is The injury?
Understanding the course of healing and nature of injuries will do most of the guiding of these conversations. For example, if the client is experiencing a tendinous injury, we want to make sure that we are classifying the injury appropriately. In some cases, I will receive a specific diagnosis from an orthopedic specialist, making things simpler and clearer. At other times, I will receive the infamous “pain” diagnosis on a script, leading to less defined parameters. However, in both cases it is vital to understand the course of healing while also trying to identify the root cause of their impairments.
Healing timelines vary based upon the type of tissue: bone, tendon, nerve. In the case of a tendon injury, you want to first consider whether you are you dealing with post-opertive rehab, such as a tendon repair or a more chronic problem such as tendinopathy. (Skirven, Osterman, Fedorczyk., et al 2021). Each scenario gives way to a different approach. A tendon repair has strict tendon healing timelines with defined protocols based on the phase of healing. The general tissue healing phases include:
Hemostasis, the initial injury response (Minutes to Hours)
Inflammatory Phase (Hours to Days)
Reparative Phase (Days to Weeks)
Remodeling Phase (Weeks to Months to Years)
(Skirven, Osterman, Fedorczyk., et al 2021)
For chronic presentations we will be primarily influencing the latter stages of healing: reparative and remodeling. Take note if patient’s signs and symptoms are severe, and/or frequent, if so, the inflammation phase may be restarting. Once a client has arrived to a later stage of tissue healing we can encourage a graded and gradual return to activity.
What Is Safest For My Client?
When determining what is most safe for our clients, this again can be guided by the healing timeline. In the event of a more recent injury, all pain-provoking activity may trigger an inflammatory response, thus prolonging healing and stalling return to activity. Therefore, what is most safe boils down to: how can I protect and promote healing, preventing exacerbation or further injury. Patient education plays a big role with safety.
Dialogue with the patient regarding what is at risk and what are the potential means of intervention, allows for “better patient outcomes” and “improved patient satisfaction” (Feiler 2022). This dialogue, alongside patient education ensures client collaboration in care planning, compliance and acknowledgment of what is “safe” for their corresponding injury. Things that are “unsafe” lead to the next part of conversation.
What Exactly Is My Client Doing in His or Her Activity?
Occupational and physical therapists are skilled in observing movement. We need to utilize this skill when connecting causes of injury to potentially exacerbating activities or tasks. For example, if I have a client with dorsal forearm and wrist pain. I need to be able to communicate to my client that his or her wrist pain was potentially caused from repetitive motions in sport. From there, I need to connect that forceful gripping and wrist motions with limited rest can create damage to specific structures. This is where open dialogue with the patient can shed light to specific “unsafe” tasks, such as ball throwing or some other sport-specific motion.
From here discussing healing timelines can bring clarity and guidance to our clients as to why rest is needed and when return to sport can be feasible. Although therapists are not diagnostic, we do need to be able to identify probable root cause of impairments and identify probable causes of injury so that patients can appropriately return to daily activity, recreation, hobbies, and leisure without exacerbation or re-injury.
When Can I Go Back?
Even after all of the time spent with the evaluative process, patient education, identification of injury, and establishing a plan to facilitate healing, some patients need to return to their activities sooner and do not have arrangements to rest. Be mindful that 4-6 weeks of rest may be most beneficial for soft tissues injuries (Wallace, Basehore, Zito, 2023), yet if there is expressed urgency to return sooner, hand therapists can assist through education to activity modification and potentially with the use of orthotics.
Referring to Halim & Weiss (2016), with orthopedic and ligamentous injuries return to sport can be initiated “immediately”. “Return to play can be allowed for both contact and non-contact sports during immobilization. Most athletes can safely return to play 4 weeks after injury in a playing cast (Halim & Weiss, 2016). Again, this is pertaining to nonoperative scenarios and lower grade “manageable” injuries. Post-operative injuries should defer to applicable protocols.
The next time you have a patient with an injury that is non-operative and is onset from overuse, be sure to have open dialogue about onset and causation of pain. From this, therapists must accept the challenge in identifying potential at risk structures, and providing methods to promote healing. Rest is vital, as well as promoting quality of life! Avoid painful tasks to limit inflammatory responses and utilize relative rest with activity modification and the use of orthoses if needed to support more timely return to activity.
Feiler, C. (2022, February). 3 benefits of patient education: Improving safety and quality of care. Healthwise. https://www.healthwise.org/blog/3-ways-patient-ed-improves-care.aspx#:~:text=Patient%20education%20can%20improve%20patient,and%20how%20to%20take%20medicines.
Google Images. 2023.
Halim, A., & Weiss, A.-P. C. (2016). Return to play after hand and wrist fractures. Clinics in Sports Medicine, 35(4), 597–608. https://doi.org/10.1016/j.csm.2016.05.005
Skirven, T. M., Osterman, A. L., Fedorczyk, J. M., Amadio, P. C., Feldscher, S. B., & Shin, E. K. (2021, p. 12 & 51). Rehabilitation of the hand and upper extremity (7th ed.). Elsevier.
Wallace HA, Basehore BM, Zito PM. Wound Healing Phases. [Updated 2023 Jun 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www