What is the best course of treatment for a 27-year-old male patient with a stable flexion deformity at the Proximal Interphalangeal (PIP) joint of the fifth finger of the right hand, possibly representing a chronic tendon injury, without signs of acute fracture or pain?

Management of Stable Flexion Deformity at the PIP Joint of the Fifth Finger

Physical therapy combined with splinting/orthoses is the recommended first-line treatment for a stable flexion deformity at the PIP joint of the fifth finger, especially in a young patient with no pain or acute fracture.

Assessment and Diagnosis

The patient presents with:

• 27-year-old male
• Stable flexion deformity at the PIP joint of the fifth finger
• X-ray showing preserved joint spacing without acute fracture
• Possible chronic tendon injury
• No current pain
• No functional complaints documented

Treatment Algorithm

First-Line Treatment

1. Physical Therapy

   • Range of motion exercises to prevent further stiffness 1
   • Eccentric strengthening exercises to stimulate collagen production and promote healing 1, 2
   • Gentle stretching exercises holding for 30 seconds, 3-5 repetitions 2
   • Progressive resistance training as function improves 2

2. Splinting/Orthoses

   • Orthoses to prevent/correct lateral angulation and flexion deformity 1
   • Extension block splint to gradually improve joint alignment 3
   • Consider static and/or dynamic splints based on severity 4
   • Splinting should be worn consistently but removed for exercise sessions

Second-Line Treatment (if no improvement after 6-8 weeks)

1. Topical Treatments

   • Topical NSAIDs for localized pain if it develops 1
   • Local application of heat before exercise sessions 1

2. Oral Medications (if pain develops)

   • Acetaminophen (up to 4g/day) as first-line analgesic 1
   • NSAIDs at lowest effective dose for shortest duration if acetaminophen is inadequate 1

Third-Line Treatment (for persistent deformity after 3-6 months)

1. Surgical Consultation
   • Consider surgical release for chronic flexion contractures that don't respond to conservative treatment 4, 5
   • Surgical options may include capsuloligamentous release 6 or FDS tenodesis 3

Important Considerations

Prognosis

• Most patients with overuse tendinopathies (about 80%) fully recover within three to six months with appropriate conservative treatment 1
• Residual extension deficit of 10-15 degrees may remain even after surgical intervention 4

Potential Pitfalls

1. Avoid complete immobilization as it can lead to muscular atrophy and deconditioning 1
2. Avoid aggressive early rehabilitation which may worsen the condition 2
3. Avoid corticosteroid injections directly into the tendon as they may inhibit healing and reduce tensile strength 1
4. Don't return to full activities too quickly before adequate healing 2

Follow-up Recommendations

• Regular assessment of range of motion and function to guide progression 2
• Follow-up should be adapted to the patient's individual needs based on severity and progression 1
• Consider referral to hand specialist if no improvement after 3 months of conservative therapy

Patient Education

• Explain that tensile loading of the tendon stimulates collagen production and guides normal alignment of newly formed collagen fibers 1
• Emphasize the importance of consistent adherence to the exercise and splinting regimen
• Inform that some stiffness in the DIP joint is not a major functional limitation if the joint is painless and properly aligned 7

This treatment approach prioritizes functional restoration while minimizing pain and preventing progression of the deformity, which will optimize the patient's quality of life and long-term hand function.