The Pesky Pip Joint: Webinar Q&A with Nicola Goldsmith, MSc, SROT

Join Nicola Goldsmith, MSc, SROT in this Performance Health webinar as we explore the different techniques we can use to address the problem of the swollen and stiff PIP joint. All therapists are faced with troublesome PIP joints, and we will look at ways to measure and then treat the swollen joint. We will then look at ideas for treating stiffness. One of the most successful ways to manage loss of extension is splinting. We will look at the pros and cons of thermoplastic circumferential, volar, and dorsal splints in this context and when neoprene might provide a solution. Devices to gain end-of-range flexion will also be explored. Plus, don't miss a look at our NEW Rolyan Smart Splint Bath.

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Q&A with Nicola Goldsmith, MSc, SROT

1. What is the name of those oedema gloves we saw?

Those are the Over-the-Wrist Edema Gloves - Open Finger Gloves.

2. Do you measure the MCPs with a tape for gloves at all?

For the Edema Gloves shown, to find the appropriate size, measure the circumference of your hand through the thumb webbing. X-Small: 7" (17.8 cm), Small: 8" (20.3 cm), Medium: 9" (22.9 cm), Large: 10" (25.4 cm).

3. Do you have any details on supplier of the self-cleaning splinting pan?

It's from Performance Health. The Rolyan Smart Splint Bath item #7028738. Please reach out to your account manager or UKCustomerSupport@performancehealth.com for more information!

4. What was the splint material called?

I used three materials: Polyflex II was the white one for the volar splint. It differs from Polyform, as it remains flexible. Then, the circumferential one was the red Aquaplast Watercolours. Finally, the relative motion blue splint was Ezeform.

5. How do you reduce stiffness in the PIP joint without the tape? Does mobilisation help?

If you are confident that the joint surfaces are fine, accessory mobilisations are good. Otherwise, you need to carefully select active, passive, resisted, and place and hold exercises to encourage movement. Isolated first, always, and then combined.

6. How would you best gain PIP flexion when stuck in extension following splinting for central slip repair? (Consultant requested splinting in extension for 6 weeks and now it won’t bend.) Is a dynamic splint best thing to do?

That's a difficult one. The ideal is to treat these with a short arc motion regime after 2 to 3 weeks immobilisation and then with graded motion. However, now you have a super stiff joint with all the structures tethered, so masses of isolated active flexion exercises, place and hold exercises, gentle passive (if over 8 weeks post-injury) and as much DIP flexion as possible, too. If the joint is also stiff, then maitland mobilisations. Use wax for heating prior to movement. Masses of soft tissue massage over the central slip area. Static progressive splinting at night to gently nudge towards flexion. It's hardest if it's a little finger, as the FDS is often not a prime mover and therefore isolated PIPJ flexion is not that strong.

7. What is the most effective approach you recommend for PIP extension deficit after a proximal phalanx fracture post-op?

Firstly, establish what is causing the deficit. If there is was an intraarticular fracture, then the joints may not enable full extension. If not, you need to establish whether the issue is stiffness at the joint or tendons tethered and reduced in action. If the joint can passively extend but not actively extend, then the figure of eight splint I showed you (with the blue Ezeform) is ideal to be worn all day, encouraging isolated extension all the time during movement and function in the day. If there is a passive loss of movement but the joints are okay, then a low load, prolonged stretch splint (such as the white or red ones I made) is the best.

8. How long would you expect a moderate PIP joint soft tissue injury to take to heal if there is significant swelling?

Oh, months. This depends on the tissues damaged and the treatment given, but it is common for the swelling and pain to persist for 8 to 9 months.

9. What are your thoughts on using the Relative Motion Splint to gain active extension on the PIP?

Excellent! I have been using this for decades.

10. Do you use oval 8 splints?

Yes, but not for stiff joints, hence not covering their use in this session!

11. Can you tape a flexed swollen PIPJ?

Taping for swelling as I showed - yes, for sure. Otherwise, I am not sure what you would be taping for? Lateral stability, perhaps, which I do with collateral ligament injuries.

12. For re-assessment, any additional considerations for PIP gout?

Yes - be very careful with any passive or accessory movements. Active motion is your primary aim.

13. What is your opinion on the use of serial PIP casting for stiff PIP joints?

I think it is great. I have recently done this with a patient, but only use it as a last resort, as it affects daily life so much. It works very well and is the ultimate low load prolonged stretch.

14. When ordering these splints, what are the brand names, and what are we asking for?

The materials were white Polyflex II 1.6, red Aquaplast T Watercolours 1.6, and blue Ezeform 3.2. The off the shelf splints were the Rolyan Sof-Stretch finger extension splint, Rolyan Sof-Stretch short extension splint, and Rolyan Sof-Stretch coil extension splint. The flexion straps I showed at the end were the 3PP Final Flexion Wraps.

15. Are these methods okay for Rheumatology patients?

Not necessarily. You need to assess carefully and primarily promote active exercises. Nothing that might set off a flare-up.

16. Where can you get those sponges?

I love them and use them for so many things. You can get them from Performance Health. They are the Rolyan Temper Foam R-Lite Foam Blocks.

17. Can you use any sponge, or do they have to be therapeutic?

The great thing about these sponges is that they are completely standardised with four different resistances according to colour. This will not be the same with a normal sponge.

18. The sponges with flexion- can this help with patients with RA ulna deviated digits? Would this help to maintain radial deviation of the digits?

No, this would not work. You can do active and then resisted radial walking of the fingers. Use a yellow sponge or just a finger from the other hand. A purpose-made MUD splint works well. Perhaps I should do a rheumatoid splinting webinar! Watch this space!

19. Would you ever use low load prolonged stretching to improve flexion after PIPJ arthroplasty?

Yes, I would after eight weeks, if the joint is stable. Probably dynamic splinting to allow the tissues to respond appropriately. These do tend to lose range after a few years, so I like to aim to get a little more than functionally necessary in the initial six months.

20. Is there any contraindications to be cautious about while prescribing these splints or materials used?

Yes, there are always contraindications. Careful clinical reasoning is vital with every patient and every situation.

21. Can you suggest a splint for an A3 and A4 pulley injury, and its wearing schedule?

Circumferential "ring-style" splints are good for these pulley injuries. 24/7 when acute and then according to symptoms and functional load.

22. Can you say the name of the researchers again?

I think I mentioned two authors. Celeste Glasgow and Rosemary Prosser. Glasgow wrote about tissue elongation principles and how to determine whether to use static progressive, serial static, or dynamic splinting. It is excellent. Then Rosemary Prosser wrote about TERT (total end range time), i.e., the time a joint needs to be held at end of range for effective splinting of contracture. Also excellent and on PIPJs.

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