Background: The global time and effort attributed to improving outcomes in the management of flexor tendon injury are large, but the degree of advance- ment made over the past 50 years is relatively small. This review examines the current perceived wisdom in this field and aims to explore the limitations to the authors’ understanding of the tendon healing process, examining how this may be a factor that has contributed to the authors’ modest progress in the field. Methods: The authors critically evaluate the sum of laboratory and clinical literature on the topic of zone II flexor tendon management that has guided their practice and provide evidence to support their methods. Results: The review highlights some of the key developments over the years and assesses their influence on changing current practice. It also highlights recent innovations, which have the potential to influence flexor tendon outcomes by altering the surgical approach, techniques, and rehabilitation regimens. Future innovations in the field will also be discussed to examine their potential in expanding the development in the management of flexor tendon injury. Conclusions: A better understanding of flexor tendon biology will allow prog- ress in developing new therapies for flexor tendon injuries; however, there are few real breakthroughs that will dramatically change current practice at present.