What is the next best step in managing a 29-year-old male patient with persistent right fifth digit pain and limited mobility after a proximal interphalangeal (PIP) joint fracture and a subsequent injury, who has been doing flexion extension exercises twice a day?

Management of Right Fifth Digit Pain and Limited DIP Joint Mobility

The patient should discontinue the finger splint immediately and be referred for hand therapy with a focus on progressive range of motion exercises and strengthening, as prolonged splinting can lead to muscle deconditioning, joint stiffness, and decreased function. 1

Assessment of Current Condition

The patient presents with:

• Right fifth digit pain
• Inability to flex the distal interphalangeal (DIP) joint
• History of proximal interphalangeal (PIP) joint fracture that healed (December 2024)
• Subsequent injury two months ago
• Continuous splint use since the second injury

Treatment Algorithm

Step 1: Discontinue Prolonged Splinting

• Prolonged splinting has likely contributed to the current symptoms
• Guidelines strongly recommend against extended splint use as it can lead to:
  • Muscle deconditioning
  • Joint stiffness
  • Learnt non-use
  • Increased pain 1

Step 2: Implement Structured Exercise Program

1. Frequency: Increase from twice daily to 3-4 times daily
2. Exercise Components:
   • Active range of motion exercises for all finger joints
   • Passive stretching to gradually increase DIP joint mobility
   • Strengthening exercises using putty or grip devices
   • Functional tasks that incorporate finger movement

Step 3: Consider Hand Therapy Referral

• Professional hand therapy is indicated for:
  • Guided progression of exercises
  • Manual therapy techniques
  • Monitoring of progress
  • Prevention of compensatory movements 1

Specific Exercise Recommendations

For DIP Joint Mobility

• Place the PIP joint in slight flexion while attempting to actively flex the DIP joint
• Use the opposite hand to provide gentle passive assistance
• Hold stretches for 15-30 seconds, repeating 5-10 times per session
• Progress from passive to active-assisted to active range of motion

For Strengthening

• Begin with isometric exercises (gentle pressure against resistance without movement)
• Progress to dynamic strengthening with putty or small objects
• Incorporate functional tasks that require precision grip

Monitoring and Progression

• Assess improvement in:

  • Pain levels during and after exercise
  • Active range of motion at the DIP joint
  • Functional use of the digit

• If no improvement after 2-3 weeks of consistent exercise, consider:

  • Radiographic evaluation to rule out bony abnormalities
  • Ultrasound to assess tendon integrity
  • Possible orthopedic consultation 2

Potential Complications to Monitor

• Joint stiffness
• Chronic pain
• Extensor lag
• Post-traumatic arthritis 2

Cautions and Pitfalls

1. Avoid Aggressive Overstretching: This can increase pain and inflammation
2. Prevent Compensatory Movements: Focus on isolated DIP joint motion
3. Monitor for Signs of Overuse: Increased pain lasting more than 1-2 hours after exercise indicates excessive stress 1
4. Beware of Splint Dependency: Patients may become psychologically dependent on splints; emphasize the benefits of controlled movement 1

By implementing this structured approach with progressive exercises and discontinuing the splint, the patient has the best chance of regaining DIP joint mobility and function while minimizing pain and preventing long-term disability.