What a Hand Therapist Actually Does (and When You Need One)

What Does a Hand Therapist Do? Splints, Sessions, and When You Need One

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Written by Nigel Chua, hand occupational therapist · 21 years treating fingers, hands, wrists, forearms and elbows · Singapore

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Splints From Flat Sheet. Angles in Degrees. Protocols Counted in Days.

A hand therapist is an occupational therapist or physiotherapist who has specialized in the hand, wrist, forearm and elbow. You need one after any tendon or nerve repair, for a stiff finger, hand or elbow, when a splint IS the treatment, and when a hand is going backwards after week 3. And the job is less about exercise sheets than almost anyone expects.

A large part of it is:

  • Making custom splints from scratch, molded on your hand, in the room.
  • Measuring things precisely enough to detect change week to week.
  • Knowing exactly which day of which protocol you are on.

The single most valuable thing a hand therapist does is know what should be happening by when, and tell you when it isn’t, while there is still time to do something about it.

That matters because hands run on clocks. A repaired flexor tendon is at its weakest around week three, right when the hand starts feeling normal. A finger held bent for a few months shortens into that bend. The window for changing stiffness is measured in weeks to a few months, not years.

Get the timing wrong and the goal quietly changes. From “full movement” to “the best we can get”… and nobody tells you the day it happened.

That’s the Closing Window Method in one line: name the window your condition runs on, find where you are in it, and act while it’s still open. A good hand therapist does exactly that, every session.

This page covers what actually happens in the room, what the qualification means, how a course of treatment runs, when it is genuinely worth the money, and when it honestly is not.

Is a hand therapist an OT or a physio?

Either. Hand therapy is a post-qualification specialism, not a separate degree. You start as an occupational therapist or a physiotherapist, then spend years working specifically with hands, usually alongside hand surgeons, before you are any good at it. A lot of it is learned on the job.

  • Occupational therapists come at it from function and activity: what you need your hand to do, and how to get it back. Splinting has traditionally sat with OT.
  • Physiotherapists come at it from movement and tissue: range, strength, loading.
  • In practice the two converge. An experienced hand therapist from either background does the same job.

In some countries there is a formal credential: Certified Hand Therapist (CHT) in the US and several other regions, which requires several thousand hours of direct hand therapy practice plus an examination. Elsewhere the title is less regulated, which means the useful question when choosing someone is not what letters they hold but how much of their week is hands.

Ask what proportion of their caseload is hand, wrist and elbow. Anything under about half and you are seeing a generalist who also sees hands.

What happens at your first hand therapy appointment?

Typically about 45 minutes is enough. Longer if there’s more than one problem, e.g. a finger and a wrist at the same time, or an elbow and a hand. And most of a hand therapy session is treatment, not paperwork.

The history, which is longer than you expect

Exactly what happened and exactly when.

In hand injuries the date is not background information. It is the whole plan. A repaired flexor tendon at day 12 and the same tendon at day 30 are two completely different clinical situations with opposite instructions.

Then: which hand is dominant, what you do for work, what you do for sport or hobbies, what you cannot currently do that matters to you. That last one becomes the goal, and it should be specific. “Get my hand back” is not a target.

“Hold a coffee cup with the handle, do up my own buttons, and get back on the bike by March” is.

The examination

  • Looking first. Swelling, color, scars, posture of the hand at rest, wasting compared with the other side. A resting hand tells you which tendons are working before anyone touches it.
  • Feeling. Where exactly is tender, to a couple of millimeters. In a hand that is most of the diagnosis.
  • Moving. What you can do actively, and what the joint will allow passively. The gap between those two answers separates a stiff joint from a tendon that is not pulling.
  • Specific tests for the structures in question: stability, tendon integrity, nerve function.

The measurements

This is where hand therapy differs most visibly from general physiotherapy. Everything gets a number, recorded, so that progress is a fact rather than an impression.

  • Goniometry. Joint angles measured with a small protractor, joint by joint, in degrees. Total active motion across the finger gets calculated and tracked.
  • Grip strength with a dynamometer, usually three attempts averaged, compared with the other hand.
  • Pinch strength: tip, key and three-point, with a pinch gauge. Pinch often fails before grip and tells you different things.
  • Swelling by tape measure at fixed landmarks, or by volumeter, which measures water displaced by the hand.
  • Sensation with monofilaments (calibrated fibers of known force) and two-point discrimination, the smallest distance at which you can tell two touches apart. After a nerve repair this is the number that tracks recovery.
  • Function scores, usually a standard questionnaire, so the hand’s performance in real life is tracked alongside the joint angles.

Four weeks later those numbers get repeated. That is how you know whether a plan is working, rather than relying on whether the hand feels a bit better today.

Custom splinting: the skill that defines the profession

A hand therapist makes splints, in the room, from flat sheet.

Low-temperature thermoplastic is heated in a water bath until it goes soft and translucent, cut roughly to a pattern, molded directly onto your hand, then trimmed, flared, riveted and strapped while it cools and hardens. Live, on the spot.

(Kinda like when you see your chefs making your dish for you on the spot…)

It takes twenty minutes to an hour depending on the design, and it is a genuine craft skill: the difference between a splint that works and one that sits in a drawer is fit.

Why custom rather than the pharmacy

  • Exact joints, exact positions. A trigger finger splint needs to hold the big knuckle straight while leaving the other two joints completely free. Almost nothing off the shelf does that.
  • Exact angles. A wrist that needs to sit at neutral, or at fifteen degrees of extension, or in a safe position after a burn, gets that angle and holds it.
  • It fits your hand. Pressure points cause skin breakdown and get the splint abandoned. Custom means no pressure points.
  • It can be changed. As a joint gains range, the splint gets reheated and remolded to the new position. That progressive process is how a stiff joint is actually recovered.

The main families of splint

  • Static: holds a position. Protects a repair, rests an irritated tendon, prevents a deformity.
  • Static progressive: holds a position at the current end of range, then gets adjusted further as range improves. The workhorse for stiffness.
  • Dynamic: has an elastic or spring component that applies gentle continuous force, or that assists a movement a paralyzed muscle cannot make.
  • Relative motion: small, elegant splints that change one finger’s position relative to its neighbors, used for tendon injuries and sagittal band problems, and often allowing near-normal hand use.

How long will I have to wear a splint?

Anywhere from a few weeks of nights to months of full-time wear. Some typical examples, with your own therapist’s or surgeon’s instructions taking precedence:

  • Mallet finger: day and night, never off with the tip allowed to drop, usually 6 to 8 weeks. Then often nights for a few weeks more.
  • Trigger finger (MCP blocking splint): worn most of the day or at night, commonly 6 to 10 weeks.
  • Carpal tunnel night splint: nights, usually a trial of 6 to 12 weeks.
  • Flexor tendon repair (dorsal blocking splint): full-time, around 6 weeks, exercises done inside it to the protocol.
  • Stiff joint (static progressive or serial casting): built up to several hours a day of end-range time, adjusted at each visit, often over 6 to 12 weeks.

Splints Hand Therapy Does

This is the working list. Most are molded from thermoplastic in clinic. A few are prefabricated and then adjusted to fit.

The name matters less than the JOB: which joint it holds, at what angle, and which joints it leaves free. Looking for the right finger splint? Finger splints: which one for which injury matches them up.

Fingertip and finger

Thumb

Hand and knuckles

Wrist and forearm

Elbow

Upper arm and shoulder

  • Humeral fracture brace: a clamshell sleeve around the upper arm that holds a shaft fracture while the elbow and shoulder keep moving.
  • Shoulder abduction splint: holds the arm out from the body. Burns in the armpit, some shoulder surgery.

Across every region

  • Serial casting: plaster or fiberglass changed every few days to gain range in a stiff joint, including casting motion to mobilize stiffness.
  • Playing splints and casts: padded or silicone splints that let an athlete return to sport while a fracture or ligament heals, where the rules allow.
  • Neurological positioning splints: mainly for positioning a hand with high tone after stroke, brain injury or cerebral palsy, including thumb-in-palm designs for children.

For the wear schedules and when to stop, see wrist splints: which type, when to wear it, when to stop and what to buy and what to skip.

What hands-on treatment does a hand therapist do?

  • Joint mobilization. Specific, graded pressure applied to a stiff joint to restore its accessory movement. Small joints, small forces, precise application.
  • Scar management. Massage to soften and mobilize, silicone gel or sheeting, and pressure. A scar is at its most changeable in roughly the first six months, then keeps slowly maturing for a year or more. See scar management after hand surgery.
  • Adhesion work. After surgery, tendons stick to what is around them. Specific gliding techniques and blocked exercises separate them, and the timing of this is protocol-driven.
  • Edema management. Retrograde massage, compression garments or wraps, elevation strategy. Swelling is what turns a recovering hand into a stiff one, so this is not cosmetic. See swelling and edema.
  • Desensitization. Graded exposure to textures for a hypersensitive scar or nerve territory, working from what you can tolerate toward what you cannot.
  • Sensory re-education. After a nerve repair, the wiring reconnects imperfectly and the brain has to relearn what the signals mean. Structured retraining with eyes closed, identifying textures and objects. This is a genuinely underused treatment.
  • Mirror therapy and graded motor imagery, used in CRPS and some persistent pain presentations.

Protocol management, which is the part nobody sees

After a tendon repair, a nerve repair, a joint replacement or a complex fracture fixation, there is a written protocol that dictates what movement is allowed, in which direction, with how much force, on which day. Getting ahead of it ruptures the repair.

Falling behind it produces adhesions and a stiff, functionless finger. And that is NOT acceptable.

The classic example is the repaired flexor tendon. The repair is at its weakest around week three, exactly when the hand starts to feel normal and people begin using it. A moment of ordinary use at the wrong moment snaps it. Knowing that, and managing the person through it, is most of the value of the appointment.

The exercises are homework. The appointment is for deciding which homework, and knowing the exact week it changes.

Getting you back to work and the actual activity

The occupational therapy half of the profession.

Turning “I need to get back to bricklaying” or “I have to be able to hold a scalpel” into a graded plan, with specific task practice, tool modification, and a staged return. See returning to work after a hand injury.

It also covers the workarounds that make life livable meanwhile: how to dress one-handed, how to protect a joint doing daily tasks, which adaptive equipment is worth buying.

For an arthritic thumb, this joint protection work does more than any exercise. See thumb base arthritis exercises and joint protection.

How many hand therapy sessions will I need?

Highly variable, but the shapes are recognizable.

  • A simple tendon or overuse problem: often two to four sessions. Splint made, plan given, reviewed at six weeks.
  • A stiff hand or a wrist fracture rehab: weekly or every other week for six to twelve weeks, tapering as you take over.
  • A repaired flexor tendon: the heaviest. Often twice weekly early, then weekly, across twelve weeks, because the protocol has to be supervised.
  • A complex or crush injury: months, with the schedule set by what the hand is doing rather than by a plan written at the start.

Between sessions, the home program does the heavy lifting. A typical stiff-hand program is short and frequent: tendon glides, 10 slow reps of each position, plus the specific joint exercises for your injury, 5 to 10 minutes at a time, 4 to 6 times a day.

A good therapist is trying to discharge you. The aim is a self-managing hand with a home program, not an indefinite appointment.

When do you need a hand therapist?

Hand therapy makes the biggest difference where a timeline is in play.

  • After any tendon or nerve repair. Not optional. The protocols exist because there is a real strength trough and a real adhesion risk.
  • A stiff hand or elbow. The window for changing stiffness is measured in weeks to a few months, and a splint that gets progressively remolded is the main tool. See the stiff hand.
  • Any injury where a splint is the treatment: mallet finger, central slip, sagittal band, trigger finger.
  • After a wrist fracture, particularly in the weeks after the cast comes off, which is where the outcome is actually decided. See wrist fracture exercises.
  • A hand getting worse rather than better after week three. That pattern needs eyes on it, not more time.
  • Complex or crushing injuries, where the fight is against swelling and stiffness rather than the fracture.
  • Suspected CRPS. Early, specialized management matters enormously here.

When you probably don’t need one

Honest answer, because not everything does.

A mild injury clearly improving inside the 3 to 7 day window. A settled, stable arthritic hand you are managing well. A simple overuse problem that is responding to the load changes you have already made. A tendon problem where you understand the loading program and are doing it consistently.

Save the appointment for the situations where timing matters, which is most of the surgical and stiff-joint work and very little of the mild overuse work.

Hand therapist, physio, or surgeon?

  • A general physiotherapist is excellent for the shoulder, neck and general upper limb, and is often the right first stop for elbow tendon problems. Less likely to make you a custom splint or to know the flexor tendon protocols cold.
  • A hand therapist owns the splinting, the post-surgical protocols, the stiff hand and the detailed measurement.
  • A hand surgeon decides whether an operation is needed and does it. Most good hand surgeons refer to a hand therapist immediately afterwards, and many refer before, because a proportion of their referrals do not need surgery at all.
  • Your family doctor (GP) is the route to imaging and referral in most systems, and worth going to armed with specifics: date of injury, what you cannot do, and what you have already tried.

Availability varies enormously by country and by system. Where there is no hand therapist within reach, an experienced physiotherapist working from the correct protocol is far better than nothing. Take the protocol with you.

How to get the most out of hand therapy

  • Bring your operation note or clinic letter. The protocol depends on exactly what was repaired and how.
  • Know the date. Of injury or of surgery. The whole plan is indexed to it.
  • Name three specific tasks you cannot do. That is what the plan gets built around.
  • Ask what your measurements are, and what the target is by next visit. If nobody has measured anything, nobody can tell you whether you are improving.
  • Ask what happens if you are not on track. A good answer exists: a different splint, a change of protocol, or a conversation with the surgeon.
  • Do the home program. Five minutes, six times a day beats an hour once, and the frequency is the part your therapist cannot do for you.
  • Wear the splint as prescribed. The commonest reason a splint fails is that it was worn some of the time.

The people who do best are not the ones who attend most. They are the ones who do the boring five minutes, six times a day, between visits.

Get it checked today if

  • After hand surgery: increasing redness, warmth and throbbing, discharge, or a fever.
  • After a tendon repair: a pop, or the finger suddenly won’t bend the way it did yesterday. Call your surgeon today; a re-rupture is repaired best early.
  • In a cast or splint: fingers going pale, blue, cold or numb, or pain that keeps climbing. Loosen what you’re allowed to loosen, and get seen.

Get it checked if

And ask for a hand therapy referral while you’re there.

  • You have had hand or wrist surgery and have not been given a rehab plan.
  • A joint is losing range rather than gaining it.
  • You are six weeks out and still cannot do the tasks that matter to you.
  • Pain is increasing rather than settling.
  • Your splint is uncomfortable, or you are not sure you are wearing it right.
  • Nobody has measured anything, so nobody can say whether you are improving.

Hands recover on a schedule. A hand therapist’s real value is knowing that schedule, measuring where you are against it, and telling you when you have fallen off, while there is still time to get back on.

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. If you’ve been told to “see a hand therapist” and nobody’s said why, the timeline is usually the why.

Part of: Hand, wrist and elbow splints: which one, why and how long

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