What is the best course of treatment for a patient with a previously dropped middle finger that now aligns with the index and fourth fingers during extension, but still exhibits weakness?

Treatment for Recovering Middle Finger with Persistent Weakness

The best course of treatment is intensive task-specific functional training focusing on progressive strengthening activities that engage the middle finger in normal movement patterns, combined with functional electrical stimulation (FES) as an adjunctive therapy to enhance motor control and reduce weakness. 1, 2

Primary Rehabilitation Strategy: Task-Specific Practice

The core intervention should be task-specific practice focusing on finger extension movements and functional activities that progressively challenge the recovering middle finger. 2, 3 This approach promotes neural reorganization and motor recovery through:

• Repetitive, goal-oriented functional activities that require active use of the middle finger in alignment with adjacent digits 1, 3
• Progressive difficulty - gradually increasing resistance and complexity as the finger demonstrates improved control 2
• Normal movement patterns with good alignment and even weight distribution across all fingers during functional tasks 4

The American Heart Association emphasizes that patients demonstrating finger extension ability (which this patient now has) are specifically appropriate candidates for intensive rehabilitation interventions. 1

Adjunctive Therapy: Functional Electrical Stimulation

FES should be applied to the affected hand and forearm muscles to address the persistent weakness. 4, 3 The evidence supports:

• FES for patients with demonstrated impaired muscle contraction and finger motor impairment 4
• FES promotes neural reorganization by providing sensory input and facilitating more complete muscle contractions 3
• Use FES as an adjunct to motor practice, not as standalone treatment 3

Specific Exercise Prescription

Strengthening Protocol

• Begin with low-intensity resistance exercises (40% of 1-RM) with 10-15 repetitions 2
• Progress to moderate intensity (41-60% of 1-RM) with 8-10 repetitions as strength improves 2
• Increase resistance when 15 repetitions become only somewhat difficult (Borg RPE 12-14) 2

Flexibility Component

• Perform flexibility training 2-3 times per week 2
• Static stretches held for 10-30 seconds with 3-4 repetitions for each stretch 2

Functional Task Examples

• Engage in tasks that promote normal movement and good alignment: stabilizing objects with the hand, using the hand during standing kitchen tasks, bilateral activities 4
• Focus on gross rather than fine movements initially (which require less concentration), progressing to more refined motor control 4

Critical Implementation Factors

Avoid prolonged positioning of joints at end ranges (such as full flexion while sitting), as this may exacerbate symptoms or promote abnormal movement patterns. 4, 2

Do not use splinting - splints may prevent restoration of normal movement and function by increasing attention to the area, promoting compensatory strategies, causing muscle deconditioning, and leading to learned non-use. 4, 2, 3 The evidence specifically recommends trying strategies that encourage normal movement patterns before considering any splinting. 4

Discourage "nursing" of the affected limb - instead, promote therapeutic resting postures and active limb use to prevent learned non-use. 4

Duration and Monitoring

• Continue rehabilitation for 9-12 months depending on functional goals 2
• Monitor for unremitting pain during follow-up, which would warrant reevaluation 4
• The presence of voluntary finger extension (which this patient now demonstrates) is a positive prognostic indicator for upper extremity motor recovery 1

Constraint-Induced Movement Therapy Consideration

While the patient now has finger alignment, constraint-induced (CI) movement therapy requires specific criteria: 20 degrees of wrist extension AND 10 degrees of finger extension, with no sensory or cognitive deficits, plus the ability to participate in 6-8 hours of daily training for at least 2 weeks. 4, 1 If these criteria are met, CI therapy may be considered for this select patient population. 4