Duran Protocol: Controlled Passive Motion and Splinting for Flexor Repairs
In short
Learn the Duran and Houser passive motion protocol for flexor tendon repairs. Understand how controlled passive gliding stops adhesions without suture risk.
In this guide (4 sections)
First described by Robert Duran and Ray Houser in 1975, the Duran protocol established that minimal tendon excursion is required to prevent restrictive peritendinous adhesions following flexor tendon repair. Through experimental and clinical studies, Duran demonstrated that only 3 to 5 millimetres of passive longitudinal tendon displacement is necessary to prevent scar bridges from freezing the repair to the surrounding digital sheath. Unlike dynamic traction protocols that require complex pulleys and rubber bands, the Duran protocol relies on structured, manual passive mobilization executed strictly within the protective boundaries of a custom dorsal blocking orthosis.
Traditional Kitchen Knife Trauma, Industrial Machine Injuries, and Fine Motor Dining Dexterity
In India, the simplicity and reliability of the Duran protocol make it an exceptionally practical choice, particularly in semi-urban and rural settings where dynamic splint hardware may be difficult to maintain. A farm laborer in Punjab recovering from a sickle laceration or a textile weaver in Varanasi recovering from a power-loom injury can easily perform Duran passive glides using their uninjured hand. Because there are no rubber bands or external pulleys to snag on loose garments like a dhoti or dupatta, patient adherence is often superior. However, clinicians must reinforce that passive motion means zero active muscle firing in the operated forearm.
Zone II No Mans Land Pulley Biomechanics, Tendon Healing Biology, and Adhesion Dynamics
The biological efficacy of the Duran protocol rests on fluid mechanics and collagen physiology. When an injured digit is completely immobilized, edema fluid accumulates within the digital sheath, rich in inflammatory cytokines and fibronectin. Fibroblasts from both the extrinsic sheath and the intrinsic endotenon proliferate rapidly, laying down a dense mesh of randomized Type III collagen fibers that unite the repaired tendon to the sheath wall. By introducing controlled passive DIP and PIP joint extension within the splint, the clinician slides the repaired tendon back and forth across the annular pulleys. This mechanical shearing breaks nascent fibrinous attachments, stimulates tenocyte metabolism, and promotes organized, longitudinal collagen alignment without generating core suture tension.
Kleinert and Duran Splinting, Differential Gliding Drills, and Staged Active Motion
The classic Duran protocol employs a rigid thermoplastic dorsal blocking splint holding the wrist in 20 degrees of flexion and the MCP joints in 50 degrees of flexion. The patient or therapist performs two distinct passive maneuvers twice to three times daily. In the first maneuver, the MCP and PIP joints are maintained in flexion while the DIP joint is passively extended to its splint limit, producing isolated distal excursion of the FDP tendon. In the second maneuver, the MCP and DIP joints are held flexed while the PIP joint is passively extended, producing differential gliding of both the FDS and FDP tendons. At 4 to 5 weeks post-surgery, treatment transitions toward active-assisted motion.
Isolated Passive DIP Extension Glide (Duran Maneuver 1)
Objective: Achieve 3 to 5 mm of isolated FDP tendon excursion through the Camper chiasm and A4 pulley
- 1Sit comfortably with your operated forearm resting flat on a table within your dorsal blocking orthosis.
- 2Use the fingers of your opposite healthy hand to support and maintain the middle joint (PIP) in comfortable flexion.
- 3With your thumb and index finger, gently lift the tip of your operated finger (DIP joint) upward toward straight extension.
- 4Stop immediately when you feel mild stretch or contact the dorsal splint ceiling, holding for 3 seconds.
- 5Gently push the fingertip back down into full flexion, ensuring the forearm muscles of the injured arm remain completely soft and limp throughout.
| Duran Maneuver | Joint Positioning and Manual Technique | Tendon Excursion and Biomechanical Action |
|---|---|---|
| Maneuver 1: Isolated DIP Extension | Maintain MCP and PIP joints in full passive flexion; passively extend the DIP joint to splint limits | Produces 3 to 5 mm of isolated FDP excursion relative to FDS and middle phalanx |
| Maneuver 2: Isolated PIP Extension | Maintain MCP and DIP joints in full passive flexion; passively extend the PIP joint to splint limits | Produces composite gliding of both FDS and FDP tendons relative to the proximal phalanx and A2 pulley |
| Composite Passive Flexion | Passively curl all three finger joints simultaneously into the distal palmar crease | Maximizes proximal translation of the entire flexor apparatus within the synovial sheath |
| Splint Boundary Maintenance | Wrist maintained at 20 degrees flexion; MCP joints at 50 degrees flexion throughout exercises | Safeguards against accidental active stretch on the repair while permitting essential passive motion |
Never allow the patient to assist the passive movement by trying to help with the muscles of the injured hand. Even a minor involuntary muscle flicker during passive stretching generates antagonistic tensile load that can pull the suture through softened tendon tissue.
Frequently Asked Questions
How does the Duran protocol differ from the Kleinert protocol?
The Duran protocol uses manual passive motion guided by the patients healthy hand without any rubber bands or pulleys. The Kleinert protocol uses dynamic elastic bands that actively resist finger extension and passively pull the finger into flexion. Both achieve safe tendon gliding when administered correctly.
Do I need a doctor referral to see a hand flexor tendon physiotherapist on BookPhysio.in?
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