Understanding PIP joint stiffness and its treatment, the Benzema´s Finger Injury

The proximal interphalangeal joint stiffness (PIP stiffness), is one of the finger injuries or pathologies that cause the most headaches for surgeons and hand therapists. Without going any further, the best known case is the fracture of the 5th finger of the Real Madrid player, Karim Benzema. The stiffness appearance, as in his case, can be associated with finger fractures with poor consolidation or recent hand surgeries.

Due to some unforeseen events in his rehabilitation process (he suffered a new fracture in the same finger, during a training session) his finger has acquired this deformed position in flexion. This is why he always appears at matches with his finger bandaged.

The only solution for his situation is surgery, but so far it has not influenced his sporting performance and is therefore not an emergency.

Benzema with his finger taped during a match

In addition to this case, there are many other injuries that require surgery, such as phalangeal dislocations, carpal instabilities, finger tendon injuries or radius fractures, among others. These surgical interventions require a more or less prolonged period of immobilisation, which can sometimes lead to loss of mobility or joint stiffness.

In this new blog entry, we take a closer look at one of the most prevalent joint stiffness in the population, PIP joint stiffness, what causes it, how it originates and how we can treat it through physiotherapy, hand therapy and hand surgery itself.

👌Introduction to Joint Stiffness ¿Joint Contracture or Lag?

Before discussing the treatment of a PIP Joint Stiffness, it is important to differentiate between the terms contracture and lag. In a joint contracture there is a deficit in passive mobility, while in a “Lag” in movement the passive movement is intact but there is a deficit in active movement. Different anatomical structures will cause each of these situations.

There are two main types of joint contracture: flexion contracture (limited passive mobility in extension) and extension contracture (limited passive mobility in flexion). In these cases, the involvement of a single structure (skin, tendon, etc.) usually has a better prognosis. However, sometimes the involvement of this structure can secondarily trigger dysfunction of other structures (joint changes, soft tissue contractures, etc.).

An example of a flexion contracture is shortening of the volar plate and collateral ligaments of the proximal interphalangeal joint, which keeps the joint in flexion.

Picture from Green´s Operative Hand Surgery (Wolffe SW et al 2010)
Picture from Green´s Operative Hand Surgery (Wolffe SW et al 2010)

An example of an extension contracture could be the shortening of the dorsal region of the dorsal collateral ligaments and the dorsal joint capsule when the joint is held in extension.

As you can see, there are many possible causes of these movement limitations. For this reason, we have organised some of the aetiologies that most frequently appear in the consultation room.

1️⃣ 0️⃣ causes of Proximal Joint Stiffness

The first point to take into account in order to correctly treat joint stiffness is to know exactly WHAT is causing this situation in the joint. In addition, the prognosis will depend on the level of shortening, structure or how long it has been affected.

The proximal interphalangeal joint is a hinge-type joint, with a primary flexion-extension mobility, which has some structures that limit its mobility. Thus, some of these structures can eventually lead to stiffness:

💭 Retracted volar plate: The volar or palmar plate is a fibrocartilaginous structure that reinforces the joint capsule. It has no elasticity and is capable of proximal sliding in flexion movements.
💭 Checkrein ligaments: stabilise the volar plates of the fingers, and allow them to glide smoothly.
💭 Collateral ligaments: these ligaments tend to tighten in flexion and relax in extension, which explains their tendency to retract in flexion. They originate in the dorsal region of the proximal phalanx, and insert at the palmar level of the middle phalanx.
💭 Shortened accessory collateral ligament: They are located between the collateral ligaments and the volar plate, and have a similar action to the collateral ligaments but of lesser importance.
💭 Cruciate ligaments of the flexor tendon sheath over the IFP joints (C1 and C2 pulleys)
💭 Landsmeer’s transverse and oblique ligaments
💭 Deformity of the IFP articular surfaces
💭 Anterior capsule or volar plate
💭 Adhesions of extensor tendon to skin or proximal phalanx
Palmar or dorsal skin shortening

Contractures of the volar plate, check-rein ligaments and shortening of the collateral accessory ligaments are the most common causes of proximal interphalangeal stiffness in flexion.

♻️ Pathogenesis of Proximal Interphalangeal Joint Stiffness

Joint structures can be affected by direct trauma to the joint or indirectly through injury to surrounding structures resulting in oedema and immobilisation. According to a meta-analysis by Strickland et al. (1982), the critical duration of finger joint immobilisation to produce some stiffness after a phalangeal fracture is 3 weeks. Continued immobilisation of the injured finger beyond this period leads to contracture.

Trauma causes direct tissue injury, intra-articular effusions or effusions. Following tissue injury, there is an increase in vascular supply due to the inflammatory process that can lead to adhesions and the growth of scar tissue, associated with the contraction of the collagen fibres it contains.

In the proximal interphalangeal joint, an intra-articular effusion forces the joint into flexion, as seen in Karim Benzema’s finger injury. In addition, swelling of the injured hand tightens the normally lax dorsal soft tissues and skin, driving the metacarpophalangeal (MCP) joints into extension. Consequently, resting muscle tone of the forearm and hand pushes the IFP joints into flexion.

The natural processes of tissue turnover are controlled by the tensile and compressive forces acting on the tissue. The loss of these natural tensions due to immobilisation after an injury causes an alteration of tissue homeostasis. This situation of tissue abnormality can trigger various processes:

🔺 loss of lubricity of collagen fibres
🔺 Proliferation of intra-articular connective tissue
🔺 adhesions between synovial folds
🔺 Capsulo-cartilaginous adhesions
🔺 Cartilage atrophy
🔺 Osteoporosis.

The end result of these processes is contracture. To prevent the formation of this contracture, immobilisation of the hand should be carried out in the so-called “safe position”, with the MCP joints flexed and the PIP joints in the extended position. This position combats the tendency associated with inflammatory processes in this region.

👐The Role of Hand Therapy in Joint Stiffness: The TERT Theory

Hand therapists employ a range of techniques to address joint stiffness effectively. This includes techniques as joint mobilisations, stretching, thermotherapy with hot/cold water baths, bandages, splints, Total End Range Time (TERT) techniques, electrotherapy, etc.

Total End Range Time (TERT) in Hand Stiffness

One of the few interventions that has been shown to be effective at a conservative level to combat joint stiffness is the use of prolonged stretching over time, known as TERT methodology. TERT (Total End Range Time) theory involves the application of a moderate stress or load in end range of motion (ROM) for prolonged periods of time, in order to improve joint mobility and elongate tissues.

These techniques are usually used by means of active or passive splints (depending on the type of action), which make it possible to maintain small stress loads on the tissue for prolonged periods of time in a comfortable and simple way.

Picture from Glasgow C et al 2012

In this way, controlled loads are provided to the tissues during a long period of time, which promotes tissue “growth” (as the authors prefer to call it), and thus mobility gain (Flowers & LaStayo 2012).

It is algo possible to self-apply a TERT manually using their own hands. Here an example in a PIP joint:

Manual TERT on the 4th PIP joint
Manual TERT on the 4th PIP joint

Variables to be taken into account in the use of TERT:

💪  Intensity, we will always look for a maximum ROM in which the patient is comfortable at low load. In the work of Flowers KR et al 2012, this technique was applied with forces between 0-800gr. This prevents possible tissue injury.
⏰ Times: usually refers to the number of hours per day that the patient maintains that position of elongation. In this way we can obtain 1 hour of daily TERT by dividing its application into 3 sessions of 20 minutes of maintained stretching.

Some authors state that the ideal session time is 20 minutes, with the addition of local heat to promote tissue relaxation (McClure P et al 1994). They suggest starting initially with 1 hour of TERT daily, using 4 sessions of 15 minutes, 3 sessions of 20 minutes or 2 sessions of half an hour.

In the event that the ROM increases positively, we will maintain this daily TERT, but if this is not the case, we will increase the daily time by increasing the number of sessions (McClure P et al 1994). The appearance of pain should also be taken into account, as if it is counterproductive we should stop the technique.

Along these lines, McClure P et al 1994 outlined a decision algorithm for the application of TERT techniques in the approach to joint stiffness in order to prevent injury or complications:

The Modified Week Test in Joint Stiffness

Connective tissue is “viscoelastic” in nature, where collagen and elastin fibres constitute the mechanical factor, while the extracellular matrix and oedema form the viscous component. Both components act under external stress applied to a joint. The Modified Week Test is used to determine the viscous component of joint stiffness.

Using the Modified Week Test Test, the joint is placed in a constantly stretched position for an extended period of time, allowing the collagen fibres to slide and “relax tension”. This technique is usually applied before treatment begins, in order to determine which intervention will be most beneficial.

Thus, joints that show a greater change in ROM after 30 minutes of application may have a higher percentage of viscous component, which could indicate that the joint is more likely to respond favourably to TERT therapy.

On the other hand, joints that experience little change in ROM may be composed of a higher percentage of elastic stiffness associated with changes in the collagen matrix (crosslinking, shortening of fibres, etc.). If these changes are minimal over a long period of time, the ability of collagen to remodel and allow functional ROM to be gained may be limited (Glasgow C et al., 2011).

Flowers et al. (2002) proposed a Guideline distribution of the technique to be used according to the improvement in passive ROM after performing the Modified Test of the Week. In cases where a considerable improvement is observed (more than 20°), it is recommended that an exercise programme be implemented directly. However, in cases where the improvement is less than 5°, more invasive interventions such as surgery are used.

🟢 Applicability of TERT and Exercise Therapy with ReHand on Joint Stiffness

We can apply TERT with an active mobility work with ReHand. In this way, the proposal consist of ask the patient to distribute his exercise programme over 3-4 times a day and associate it with the application of TERT techniques.

The TERT work on maximum and maintained joint stretching will be for 15-20 minutes (we can ask them to play 3-4 long songs so that they have a reference) in each of the sessions necessary to reach this TERT of 1 hour per day. If possible, it will be beneficial to apply local heat (hot water bottles, etc.) at the same time.

After those 15-20 minutes of joint stretching, in which we will increase your passive ROM, we will take the opportunity to work actively on that ROM with ReHand, in order to favour the maintenance of what has been gained and achieve an increase in mobility or active joint ROM.

Here is the case of a patient who, following fasciectomy release surgery for Dupuytren’s disease, started early active mobility work to prevent the onset of stiffness in his fifth finger.

Everything you need to know about Dupuytren Disease!

🩸The Role of Hand Surgery in PIP stiffness – what options are available to Benzema?

In those cases in which treatment with Hand Therapy does not have an effect, it will be necessary to resort to a more direct intervention such as surgery. This is the case of Karim Benzema, who has had a finger deformity for three years and is waiting for finger surgery.

What options are supported by scientific evidence to restore joint mobility in a finger?

1️⃣ Mid-lateral surgery for simple contracture

Simple periarticular contracture of a proximal interphalangeal joint is best treated using a mid-lateral approach. The use of this type of surgery allows immediate mobilisation after arthrolysis and avoids stressing the surgical wound itself. This would not be possible if an anterior approach were used.

Imagen de Richter M. The stiff proximal interphalangeal joint – an unsolved problem? J Hand Surg Eur Vol. 2023;

An advantage of this surgical technique is that it simplifies the management of potentially complex periarticular flexion contractures with superficial flexor tendon tenotomy, rather than using a wider palmar approach with flexor tendon tenolysis. Bruser et al. (1999) compared medio-lateral with palmar approaches for arthrolysis of the PIP joint and showed a significant difference in favour of the mid-lateral incision.

Imagen de Richter M. The stiff proximal interphalangeal joint – an unsolved problem? J Hand Surg Eur Vol. 2023;

However, the results of different studies cannot be easily compared due to the small number of cases and the variation in preoperative characteristics. However, there is a tendency for simple periarticular contracture arthrolysis to show better results than complex cases that required more extensive tenolysis and soft tissue reconstruction.

 2️⃣Mid-lateral incision after proximal phalanx fracture

After a proximal phalanx fracture, complex periarticular contractures occur if the finger is immobilised incorrectly for too long. Recall the importance of the “Safe Position” of the hand to avoid this situation, and the critical immobilisation time (3 weeks). The risk of adhesions of the extensor tendons in the dorsal 3-5 areas and of the FDS tendon on the palmar side increases if a surgical intervention, in particular a dorsal plate, is performed for complicated fractures of the proximal phalanx.

Thus, a lateral incision over the proximal phalanx, curved dorsally over the distal part of the middle phalanx and proximal part of the metacarpophalangeal is usually recommended. In these stiff PIP joints, reconstructive surgery should address the following structures: the extensor tendons, the dorsal PIP capsule, the flexor tendon sheath, the volar plate, the collateral ligaments and possibly the FDS tendon.

Picture from Richter M. The stiff proximal interphalangeal joint – an unsolved problem? J Hand Surg Eur Vol. 2023;

Even when a correct active movement of the interphalangeal joint is observed in the first few days after surgery, it is not uncommon to find function declining between weeks 3 and 4 after surgery, even with adequate hand therapy.

An example of function deterioration after surgery. Picture from Richter M. The stiff proximal interphalangeal joint – an unsolved problem? J Hand Surg Eur Vol. 2023;

It is interesting to highlight this interview about: Why is it important to go to a Hand Therapist?

🟠 Postoperative rehabilitation in hand stiffness

For both simple and complex periarticular contractures, postoperative care and patient treatment compliance are of utmost importance. Close monitoring is necessary, especially in the first few days, to find the right balance between early mobilisation and inflammation or impaired wound healing.

Over-agressive mobilisation can lead to excessive swelling, which in turn mechanically impedes movement. Wound infection can also be associated with swelling, wound dehiscence and necrosis of the wound margin, leading to increased fibrosis even after healing, with a corresponding poor outcome.

Therefore, the main principle of postoperative treatment is to immobilise the osteoarthritic joints in a favourable position and to gradually increase active and passive exercises from this position avoiding an excessive swelling or interruption of wound healing.

Active flexion and extension exercises should be started on the first postoperative day.

⭕ Clinical Case in Hand Surgery: Patient Post-Finger Surgery

Close monitoring of the patient’s surgery recovery is essential to avoid complications and adhesions appearance. Here we show you a clinical case of a patient we treated in the Hand Surgery area of the Hospital.

This patient was referred to the traumatology department due to joint stiffness of the 5th finger caused by Dupuytren’s disease, which significantly affected his daily activities. Due to the situation, we proceeded to perform a common technique to free the palmar level: Palmar Fasciectomy. You can see the surgical scar below.

After the immobilisation time stipulated with the surgeons, our patient was referred to the Hand Therapy department in order to start rehabilitation as soon as possible, and to avoid associated stiffness. An initial assessment of the functional status of the hand was carried out with the following tests:

🔸  Hand Grip strength with a grip dynamometer.
🔸  Hand dexterity with the Nine Hole Peg Test. We have previously discussed this test in a previous blog, do you know how to correctly perform the Nine Hole Peg Test?
🔸  The Joint Position Sense Test to assess the action of the Wrist Sensorimotor System. Do you know how to perform the Wrist Joint Position Test?
🔸  The QuickDASH Function Questionnaire. Do you know what the QuickDASH scale is? Get it for FREE!

Once the patient had been assessed, he was prescribed the ReHand telerehabilitation tool so that he could work at home as soon and as often as possible. Thanks to its monitoring system, we were able to monitor the patient’s clinical evolution and adherence to the prescribed exercise programme at all times.

Here are a couple of examples of exercises that the patient worked on at home:

ReHand demonstrated to reduce the number of rehabilitation referrals and improve function early in patients with soft tissue and bone injuries of the wrist, hand and finger! Find out the results of the latest study published with more than 660 patients recruited!📚 

❓FAQs in hand therapy and surgery for Joint Stiffness

In which cases can I apply TERT techniques to Hand Therapy patients with joint stiffness?

The physiotherapist, occupational therapist or surgeon assessing the patient must be sure that the cause of the limitation is of ligament, capsular, muscle-tendon or adhesion origin.

These patients usually have a previous history of relatively recent trauma, associated with a period of immobilisation. They usually have a history of mobility restriction of more than 3 weeks, and there is a loss of passive mobility.

In which cases should I NOT apply the TERT technique to my patient with joint stiffness in the hand and fingers?

In those cases in which these conditions are not met due to the presence of Pain, Active Inflammation and a muscular defence contraction. In these cases it is not recommended, as the inflammatory and contraction process could worsen the situation.

When should I stop using the TERT technique and consider Hand Surgery?

The literature is clear on this point. In cases where the technique has been routinely applied for 2 weeks, and no significant changes in passive joint mobility have occurred. It is important that the intensities and times of use have been appropriate.

Which factors can predict that my TERT technique will be effective on stiffness?

There are some factors that have been correlated with the success of the therapy (Glasgow C et al 2011). These are:

1. Change in Mobility after applying the Modified Week Pre-Treatment Test. For every 1° change in this test, there is an associated change in the patient’s active mobility of 1.09° in any joint of the hand, and 1.02° in the mobility of the proximal interphalangeal joint.
2. The time elapsed since the injury.
3. The patient’s diagnosis: an intra-articular fracture has a worse prognosis than an extra-articular fracture,
Diagnoses such as extra-articular fractures, volar plate injuries and soft tissue injuries are associated with better results in active mobility. BUT soft tissue injuries should not be underestimated. Hand therapy should be started as early as possible, as a delay in the start of rehabilitation can lead to a worse outcome.
4. Types of Mobility deficits (Flexion VS Extension): in the IFP joint of the finger, flexion contracture leads to BETTER results than flexion contracture.
5. Early start of Hand Therapy with Splints and TERT Techniques: They favour the recovery of mobility.

Do you treat patients with Fingers Injuries or Pathologies? LEARN how to Prescribe Exercise Programmes!
Write to us and our clinical team will show you how to do it!🖥️ 

Richter M. The stiff proximal interphalangeal joint – an unsolved problem? J Hand Surg Eur Vol. 2023;
Glasgow C, Fleming J, Tooth LR, Peters S. Randomized controlled trial of daily total end range time (TERT) for Capener splinting of the stiff proximal interphalangeal joint. Am J Occup Ther. 2012;66(2):243–8.
Flowers KR, Lastayo PC. Effect of total end range time on improving passive range of motion. J Hand Ther. 2012;25(1):48–55. Available from: http://dx.doi.org/10.1016/j.jht.2011.12.003
Philip W McClure, Lisa G Blackburn, Carol Dusold, The Use of Splints in the Treatment of Joint Stiffness: Biologic Rationale and an Algorithm for Making Clinical Decisions, Physical Therapy, Volume 74, Issue 12, 1 December 1994, Pages 1101–1107, https://doi.org/10.1093/ptj/74.12.1101
Glasgow C, Tooth LR, Fleming J, Peters S. Dynamic splinting for the stiff hand after trauma: predictors of contracture resolution. J Hand Ther. 2011 Jul-Sep;24(3):195-205; quiz 206. doi: 10.1016/j.jht.2011.03.001. Epub 2011 May 19. PMID: 21600732.
Flowers KR. A proposed decision hierarchy for splinting the stiff joint, with an emphasis on force application parameters. J Hand Ther. 2002 Apr-Jun;15(2):158-62. doi: 10.1053/hanthe.2002.v15.015015. PMID: 12086026.

Pablo Rodríguez Sánchez-Laulhé
PhD Candidate | PT, Hand Therapy & eHealth Researcher