Sagittal Band Injuries Explained And How To Get Motion Back

We break down why a sagittal band injury causes that painful tendon “pop” over the big knuckles and why getting movement back is the real win. We walk through a safe, step-by-step plan to restore range of motion after healing without re-rupturing the ligament or creating more finger stiffness. 
• what the sagittal band is and how it keeps the extensor tendon centered 
• why the tendon snaps into a trough with a tear and how inflammation builds 
• common causes including trauma and arthritis-related wear 
• why you need clinician clearance before pushing range of motion 
• the progression from flat fist to MCP bending to full fist 
• gentle stretching with light pull and active holds at end range 
• why all fingers move together due to interconnected extensor tendons 
• how often to practice and why frequency beats intensity 
• using cold to settle soreness and reduce irritation 
Please like and subscribe to the channel. 
Check out my website, carlpetito.com.

Transcript

Welcome And Why Motion Matters

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Welcome back to the Hand to Shoulder Solution where Pain Meets Its Match. I'm your host, Carl Petito. I'm an occupational therapist and a board certified hand therapist. I specialize in the rehabilitation of orthopedic conditions that affect the fingertips through the shoulder. Please like and subscribe to the channel. I've been told by a lot of viewers that this is very helpful information and they've been benefiting from it as well as their family and friends that they've been sharing information with, such as how to optimally self-manage arthritis symptoms and pain and reduce discomfort, restore range of motion. We talk about everything from the fingertips to the shoulder. So I've been getting a lot of feedback, which I frankly did not expect regarding the sagittal band. And today I want to recap what is a sagittal band, what does it do, why is it important on the back of your big knuckles? And if it's ruptured, what do we do? And then how do we regain movement after a sagittal band injury? And that's really what people have been writing in about. Well, how do I get my movement back? Because everything can be healed, your pain can go away, but if you don't have your movement, what good is that? You have to have

What The Sagittal Band Does

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your movement, obviously, in order to have full function of your hand. So the sagittal band, the big knuckles, if you look at your palm, the big knuckles bend at that crease in your palm, and let's just go right directly through the hand, and then there's the back of the big knuckles. So on my hand, you can see my tendons pop up, and they go right over the back of that knuckle. On my hand, my my middle knuckle or my central long finger is the largest knuckle. So let's look at that one. In order for that, let's back up. That tendon connects to these muscles back here. When these muscles contract, opens the fingers. It's called extensor digitorum communus or EDC for short. We look at the skeleton, that's the hinge right there, and then when the muscle contracts, it literally just straightens the fingers to simplify it in uh in brief terms. If we add the tendinous material, you can see here if you have that sort of light bluish-white color over the back of the fingers, it goes under a strap of ligamentous material over the back of the wrist, which keeps the tendons down against the bone so you don't get a lot of pulling away or bowstringing of the tendons off of the skeleton. And it travels over the top of this. But you can imagine that when you make a tight fist, that tendon might roll off into this trough. And that's what happens when you have a sagittal band injury, S-A-G-I-T-T-A-L, sagittal band. The actual sagittal band is a paper thin, small ligament that goes over the tendon, over the top, and inserts over here, inserts over there. And its job is to keep that tendon centralized onto over the back of that joint so it doesn't roll into the trough. When it does roll into the trough, when you make a fist, it'll go pop, and eventually it becomes a painful pop, and that tendon is rolling right off. The tendon is living tissue, and that living tissue just gets inflamed and aggravated and it gets very painful. And then when you straighten out, it pops back to where it's supposed to be. Now, once that sagittal band heals, if it pops again during healing, it reruptures that that sagittal band where it's where it's torn. So if the sagittal band tears, and it happens for multiple reasons, fist fight, so with any trauma, or arthritis changes, maybe there's bone spurs which are uh aggravating the uh the actual sagittal band and just wearing it more thin, and then as it takes stress from doing its job, it just ruptures on its own. So it's quite common. In the clinic, I'll make a special splint which I demonstrated on another video. I won't get into great detail about how we treat that conservatively, but let's pretend now we treated it conservatively without surgery, or the patient had surgery and it's fully healed,

When Healing Is Solid Enough

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it's solid. Now you're cleared to begin range of motion to get your it your flexibility back so you can make a full fist or have a full grip. Okay, and this is why it's very important to be seen by your clinician, your healthcare practitioner, your hand therapist, especially, to make sure that you are solid, enough time has gone by for healing, it's been protected, now you're weaned off of your splint. So, usually while a patient is in their custom splint that I fabricated for the patient, I will have them perform active motion in what's called a flat fist, like this. And the IP joints, these small joints of the fingers, can fully flex if the big knuckles are being are being held straight. So that does not put pressure on the sagittal band. Then from that point, the next motion is to keep the small joints straight and bend just the big the big knuckles. So that puts less pressure. So this is a continuum. The most pressure is position of a full fist. So we start out with active motion and do the get that that flat fist like this, and then let's pretend like if that's if that's stiff right there, what I have my patients do is just lay the back of their hand on the table or on their lap, and they can they can get underneath that first bone of the finger and then get on the back of the fingernail and push that in. So they're pushing literally pushing themselves into this

Stepwise Return To A Full Fist

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position and going each finger 10 seconds. Okay, so now once this is obtained, it might take a few days. Once that's obtained, then we can work on this, and then when we work on this, and let's well, maybe that's as far as I can go. Or that one that healed, maybe it's up like this, right? Then they can start stretching gently, only until they feel a light pull, and you hold that for 20 seconds and then let go do active hold one, two, three, and relax, and then one more time, 20 seconds, light pull, no pain. 20 seconds, active hold, one and two and three, and relax. Why the active hold? Because it's really nice to activate the muscle at your new end range of flexibility, at your increased flexibility, to retrain the muscle to move to its maximum flex flexibility so that way as you're regaining your flexibility, also regaining your muscle control at the same time. So once that's obtained, now we can go start doing the full fist. So maybe a couple of weeks has have gone by. Okay, so now they're going to the full fist. This position, what's really nice here, is to push on the end of that first bone, so that pig knuckle is bent. Normal flexion here is 90 degrees. So you're looking for that right angle of this bone on this bone, and then I'm gonna get on the end of the second bone, so that's there, and maybe I'm feeling a little bit of a stretch at that point. Okay, now I'm gonna go right down to the very tip of my fingernail, and I'm gonna get that right in there. It's important that all the fingers go together because guess what? Those extensor tendons that I just told you about, EDC, they're all interconnected. So if you're trying to do this one and you're holding other ones out of the way, guess what? That's resisting the stretch. They all have to go down as a team, okay? That's a very common thing. People want to keep their fingers out of the way and just focus on that one. No, they have to all go down together, okay? And then so here, here, and then slide down to the tip. Now, eventually, the end point is to get this down with the full fist. Now, should we just force it there and do it real quick? No, never. Never on the small fingers, on the small joints of the fingers, because that increases stiffness. It really undoes everything you're trying to do. And moreover, you run the risk of re-rupturing that ligament. You want to we want a gentle, slow progression, gentle, slow tissue lengthening. Tissue lengthening

Frequency Not Intensity Plus Icing

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happens gently over time, so you want frequency, not intensity, which leads to the next next idea is how often should I do this? You should do this every one to two hours. Every two hours is roughly six times per day. And I have patients set their alarm on their phone. Every two hours they're gonna do 20 seconds, two repetitions, active hold, one, two, three, relax again, 20 seconds. Active hold, one, two, three, and relax. And over a period of a couple of weeks, they should get all of their range of motion back. Now, as it gets irritated, if it gets irritated and flame is sore, I have patients either just hold the ice cube and glide it over directly over the skin or stick under cold running water. We're gonna talk about that in a little more detail in the next video about how to decrease inflammation and pain. So that's a slow progression of restoring the range of motion. Really important not to force it quickly, your risk injury, other severe, very complications, and at a minimum, you're just going to make your fingers more stiff. You know, some other joints like a knee or a hip, the larger joints, they can handle more forceful range of motion. The fingers cannot. And I, by the way, um I get patients in the office where they were seen at other locations and they were just forced, and um, and they're having a lot of inflammation and pain, and even sometimes uh tissue ruptures where they end up with a mallet finger or a retorn sagittal band. So let's just avoid all that. It's frequency, not intensity. Thank you for watching. Thank you for subscribing. Check out my website, carlpetito.com. Thank you.