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The Thumb That Stops Lifting, Weeks After the Cast Comes Off
If your thumb suddenly won’t lift off a tabletop 4 to 12 weeks after a wrist fracture, the most likely cause is an EPL rupture: the tendon that lifts your thumb has snapped where it rubs over the healing bone. It won’t heal on its own. The usual fix is a tendon transfer, about 4 weeks in a splint, and most people have good thumb lift back by 3 to 6 months.
It often follows a fracture that was treated in a cast and was healing perfectly well. You may still be able to straighten the thumb tip a little. What you cannot do is lift the whole thumb off a tabletop.
It almost never hurts when it goes, which is precisely why people wait. And waiting is the one thing that costs you the simple version of the repair.
Leave it for months and two things happen. The muscle at the other end of the snapped tendon shrinks back and stiffens. And the thumb joints stiffen from not being used. A transfer still works after that…but the result is capped by whatever movement the joints have left.
What is the EPL tendon?
EPL (extensor pollicis longus) starts in the forearm, runs through a tight bony groove at the back of the wrist, hooks around a small ridge called Lister’s tubercle like a rope over a pulley, and ends on the tip of the thumb. It is the only tendon that lifts the thumb UP and back, off the plane of your palm.
It’s the tendon behind every hitchhiker’s thumb and every Fonzie “Ayyy”. (Lose it and you’ll find out how often you used it.)
Why does EPL rupture after an undisplaced wrist fracture?
This is the part that catches people out. The rupture is MORE common after minimally displaced fractures treated without surgery than after the badly displaced ones that get plated.
Two things happen after a fracture near that groove.
- Pressure. Bleeding and swelling raise the pressure inside that closed compartment, choking the tendon’s already marginal blood supply.
- Friction. The healing callus roughens the floor of the groove, so the tendon saws across a surface that used to be smooth.
A big displaced fracture tends to burst the compartment open, which paradoxically decompresses it. A small crack keeps the lid on.
Incidence is low, under 1 percent of distal radius fractures, but the fracture is so common that every hand clinic sees these. It is also a recognized complication after volar plating, when a screw tip pokes out the back of the bone into the tendon’s path.
Outside fractures, EPL can also rupture in rheumatoid arthritis, where inflamed lining wears the tendon from underneath.
How do I know if my EPL has ruptured?
Put your palm flat on a table.
Lift the thumb straight up off the surface, keeping the palm down.
If it will not lift, EPL is not working. The muscles that spread the thumb sideways are intact, so people can still move the thumb about and assume all is well. This lift-off test (retropulsion, if you want the clinical word) is the one that exposes it.
Sideways is not the same as upwards. Only one of those directions belongs to EPL.
What a clinician adds:
- Feel for the tendon. With the thumb lifting, EPL normally stands out as a cord on the back of the thumb base, forming one edge of the little hollow there. Ruptured, that cord is gone.
- Ultrasound shows the gap and where the tendon ends sit.
- X-ray checks the fracture, the callus, and whether a plate screw is sitting in the tendon’s path.
If ONLY the tip droops and the rest of the thumb lifts fine, that’s a different injury at the end joint, usually a mallet thumb. See the mallet thumb splint.
Are there warning signs before EPL ruptures?
Often, yes. A rupture is frequently preceded by days to weeks of a dull ache and creaking (crepitus) over the back of the wrist, around the thumb side of center. That’s the tendon’s lining inflamed and warning you before the tendon gives. That is the moment worth catching.
Pain and creaking there after a radius fracture, with the thumb still lifting, is an intact tendon in trouble.
Releasing the tendon from its groove at that stage can prevent the rupture. That is a far smaller operation than a transfer.
Once the thumb cannot lift, that option is gone.
(Not every click after a fracture is this. Most are harmless. Clicking after a wrist fracture sorts the worrying ones from the rest.)
Which window are you in?
- OPEN: ache and creaking, thumb still lifts. Act now. Prevention is possible.
- CLOSING: fresh rupture. A transfer works well. Timing isn’t desperate, but it shouldn’t drift past a few weeks while you wait for the next routine review.
- SHUT for the straightforward result: many months of disuse. The thumb joints stiffen, and any transfer is capped by how much passive motion is left. The goal changes: get the joints moving first, then transfer.
A wrist fracture that everyone signed off as fine, and six weeks later the thumb quietly resigns. Recovery has a few plot twists that nobody puts in the discharge letter. The rest of the normal fracture road is in wrist fracture recovery week by week.
Can a ruptured EPL tendon heal without surgery?
No. A ruptured EPL does not heal on its own, and the ends do not stay in reach of each other.
The muscle 100% will retract (and this isn’t a good thing for function).
Direct repair is usually impossible because the tendon frays over a long segment rather than cutting cleanly. A clean cut from a wound is a different story, repaired end to end. See extensor tendon repair.
Some people with light demands choose not to have surgery. The thumb still pinches and grips, it just can’t lift back. That’s a reasonable choice for some, but it’s one to make with your surgeon, not one to slide into by default.
What does EPL tendon transfer surgery involve?
Tendon transfer is the standard solution. The EIP tendon, the one that lets your index finger point on its own, is rerouted to do EPL’s job. You still have a second tendon that straightens the index, so the finger keeps working.
Losing fully independent index pointing is the trade, and it is a small one. Most people never notice.
The re-education is the part that decides the result, and it is hand therapy work, not surgeon work. Your brain has spent your whole life using that tendon to point a finger. Now it has to learn that the same signal lifts the thumb.
EPL tendon transfer recovery week by week
Your surgeon’s protocol wins if it differs. This is the conservative version.
- Weeks 0 to 4: protect. Thumb splinted in extension full time, usually a forearm-based splint with the wrist tilted slightly back and the thumb lifted. Fingers move freely. Hand above heart for the first days. Stitches out around day 10 to 14. Some surgeons start protected active movement within the first week. If yours does, follow theirs.
- Weeks 4 to 6: re-educate. Protected active movement begins, retraining the new tendon to fire on thumb command. Splint on between exercises and at night.
- Weeks 6 to 12: wean and build. Splint weaned for light tasks. Gentle strengthening from about week 8. Still no forceful thumb bending with the wrist bent forward.
- Months 3 to 6: full function. Heavy gripping and sport return. Most people regain near-normal thumb extension.
If the thumb or wrist is going stiff during this, deal with it early. See stiff hand after a cast or surgery.
Exercises after EPL tendon transfer
Only once your surgeon or hand therapist has cleared active movement, usually around week 4. Slow, controlled, no pain above a mild pull.
- Point and lift. Forearm resting on a table, palm down. Think “point the index finger” and let the thumb lift with it. 10 slow repetitions, 4 to 5 times a day. This is the bridge your brain needs.
- Thumb lift alone. Palm flat on the table. Lift only the thumb, hold 3 seconds, lower slowly. 10 repetitions, 4 to 5 times a day.
- Gentle thumb bending. Bend the thumb toward the base of the little finger with the wrist kept straight or tilted back, never bent forward. 10 repetitions. Bending the thumb with the wrist flexed stretches the new join before it’s strong enough.
- From about week 8, strength. A rubber band around thumb and fingers, open against it, 3 sets of 10. Putty pinches, 3 sets of 10, once a day.
When can I drive, work and use my hand normally?
- Desk work: one-handed in the splint, often 1 to 2 weeks after surgery.
- Driving: not in the splint. Usually around 6 to 8 weeks, once you can grip the wheel firmly and control the car in an emergency. See driving after a hand injury.
- Light manual work: around 8 to 10 weeks.
- Heavy gripping work, gym, racquet and climbing: around 3 months, sometimes longer.
What a hand therapist does differently
- Catches the warning phase. Tests the thumb lift at every post-fracture review, not just the wrist.
- Molds the splint to hold the transfer at the right tension, and adjusts it as swelling drops.
- Runs the re-education, from “point to lift” to the thumb firing on its own.
- Protects the other joints, so the thumb and wrist don’t stiffen while the tendon heals.
Get it checked today if
- Your thumb suddenly can’t lift off a tabletop during or after wrist fracture recovery, or after plate surgery.
- Ache and creaking over the back of the wrist on the thumb side, and the thumb lift is getting weaker.
- Fingers going numb, or the cast feels too tight. See numb fingers after a wrist fracture or in a cast.
Call your surgeon today if
- After a transfer, the thumb stops lifting when it had started to. The join may have given way.
- Increasing redness, heat, throbbing, discharge or a fever.
- New numbness on the back of the thumb or hand.
- Pain escalating after the first week, with a shiny, swollen, color-changed, very sensitive hand. See CRPS.
Get it checked if
- By week 6 after surgery you still can’t lift the thumb without pointing the finger.
- The thumb won’t bend into a fist by week 8 to 10.
- The scar is thick and the tendon feels stuck to it when you move.
Sideways is easy. Up is the test. A thumb that won’t lift isn’t stiff, it’s disconnected.
Written by Nigel Chua, hand occupational therapist in practice since 2005. Thousands of hands, wrists and elbows assessed and treated. My credentials are here. This article explains; it doesn’t examine. A thumb that stops lifting after a wrist fracture deserves a look this week, not at the next routine review.
Every article on this site is written using the Closing Window Method: name the window your condition runs on, find where you are in it, and act while it’s still open.