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Solving Hand/Finger Pain Problems with the Pencil Test and Relative Motion Splinting

Lalonde, Donald H. MD, MSc, FRCSC*; Flewelling, Lisa A. MScOT

Plastic and Reconstructive Surgery – Global Open: October 2017 - Volume 5 - Issue 10 - p e1537
doi: 10.1097/GOX.0000000000001537
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Supplemental Digital Content is available in the text.

From the *Dalhousie University, Saint John, NB, Canada; and Occupational Therapy Department, Saint John Regional Hospital, Saint John, NB, Canada.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

Donald H. Lalonde, MD, MSc, FRCSC, Dalhousie University, Suite C204, 600 Main Street Saint John, NB, E2K 1J5 Canada, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

The pencil test and relative motion splinting are a simple way to help heal many problems that cause hand and finger pain. The videos in this article guide surgeons, hand therapists, and patients through this form of diagnosis and treatment.

When patients present with acute or chronic hand and/or finger pain after an injury, try placing a pencil first over and then under the proximal phalanx of the finger that is generating the pain. Ask the patient to flex and extend the fingers several times (see video, Supplemental Digital Content 1, which gives an explanation of the pencil test and relative motion splinting. This video is available in the “Related Videos” section of or at Putting the affected metacarpal phalangeal (MP) joint more relatively flexed or extended than the other MP joints will often take away the pain with active movement with the pencil in place. When this happens, our hand therapist builds a relative motion splint that simulates the effect of the pencil.

These are very functional splints that patients wear 24 hours a day, 7 days a week. Most people can work with these splints on. Video 2 shows 3 different patients with interosseous muscle tears who had their hand pain solved with the pencil test and relative motion flexion splinting (see video, Supplemental Digital Content 2, which shows 3 patient examples of interosseous tear pain patients. This video is available in the “Related Videos” section of or at





Video 3 shows 4 other kinds of acute and chronic pain and stiffness problems solved with relative motion splinting after the pencil test took the pain away with active movement (see video, Supplemental Digital Content 3, which shows the pencil test and relative motion splinting solving problems in 4 patients. This video is available in the “Related Videos” section of or at



Video 4 shows how to build relative motion splints (see video, Supplemental Digital Content 4, which shows how a hand therapist makes a relative motion splint. This video is available in the “Related Videos” section of or at A relative motion flexion splint keeps the MP joint of the pain generating finger more flexed than the MP joints of the other fingers. A relative motion extension splint keeps the MP joint of the affected finger more extended than the MP joints of the other fingers.

The principle is pain-guided healing and pain-guided therapy. The pencil and the relative motion splint rebalance the forces of active movement in such a way that injured structures can heal, as evidenced by the fact that they take the pain away. We did not spend 2 billion years evolving pain because it is bad for us. It is nature’s only way to tell us if we are helping or hurting the healing of injured tissue.1

Relative motion extension splints are helpful in early protected movement of extensor tendon laceration, sagittal band tears, proximal interphalangeal flexor lag, and pain of unknown origin. Relative motion flexion splints are useful in boutonniere, interosseous tear, PIP extension lag, and pain of unknown origin.2–4

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The patient provided written consent for the use of her image.

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1. Brand P, Yancey P. Grand Rapids, Mich.; The Gift of Pain: Why We Hurt and What We Can Do About It Paperback. 1997.
2. Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4-7 extensor tendon repair. J Hand Ther. 2005;18:182–190.
3. Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair. J Hand Surg Am. 2014;39:1187–1194.
4. Lalonde DH. Extensor tendon repair of the finger. In: Wide Awake Hand Surgery. 2016:New York; Thieme; 209–212.

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Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.