Injury to the recurrent branch of the median nerve results in loss of thumb opposition and functional pinch. Patients often develop poor thumb mechanics with a dominant adductor pollicis, causing a tight web space and ineffective prehension. Native recovery of thumb opposition is uncommon following proximal median nerve injury due to the lengthy regenerative distance to the thenar muscles. The abductor digiti minimi-to-thenar nerve transfer is a reliable, synergistic surgery that helps restore true opposition, compared to tendon transfers. Postoperative rehabilitation includes three phases based on the donor activation focused rehabilitation approach (DAFRA). Therapy progresses based on results of monthly manual muscle testing of the recipient muscles: opponens pollicis and abductor pollicis brevis. Frequent donor activation with active small-finger abduction is encouraged throughout the first two phases. Exercise and functional activities that combine small-finger abduction (donor) with active-assisted and active recipient function (thumb opposition and palmar abduction) are included in the motor reeducation program.