Distal Biceps Repair: Recovery & Rehab
REHABILITATION
Progression of Rehabilitation Phases
The postâoperative rehabilitation protocol for distal biceps repair utilized at the senior author's (MTP) institution has been provided (Appendix 1). A standard therapy program progresses through sequential phases of rehabilitation, including an acute recovery phase, an intermediate phase featuring motion progression and onset of light isotonics, an advanced strengthening phase, and lastly, a phase focused on return to preferred activity. Each phase must be tailored to the individual patient's needs and restrictions. Temporal phase progressions are provided for guidance; however, the treating therapist should evaluate the patient's readiness to advance at each phase change. Progression of the protocol should be performed under the careful supervision of a rehabilitation team, with strong communication between treating providers. A complaint of persistent or recurrent pain and/or swelling indicate inappropriate phase progression. The overall principles guiding rehabilitation of the distal biceps tendon repair include protection of the tendon from excess load, followed by the safe and stepâwise return to activities of daily living and sport.
Bracing and Early Range of Motion
Bracing is implemented postâoperatively to protect the soft tissue repair (Appendix 1). Range of motion parameters are established intraâoperatively. In the case of a retracted distal biceps tendon, the surgeon may initially limit extension range of motion and progress to full extension based on the amount of tension present in the repaired tendon over four to six weeks. In these cases of restricted extension range of motion, a hinged elbow brace may be implemented to help the patient maintain these parameters.
Phase I: Early Recovery (Weeks 0 to 6)
Early goals include pain and effusion reduction, protection of the surgical repair, and optimization of the tissue healing environment. Cryotherapy should be used and may be incorporated via multiple mediums, including ice massage, ice packs, cold whirlpool, or the CryoâCuff, for durations of 5 to 20 minutes with careful attention to avoid skin irritation.18 Hand and wrist range of motion and gripping exercises should begin immediately, and may include rubber ball squeezing or simple daily tasks such as using a smart phone. Shoulder girdle range of motion is also encouraged to avoid shoulder pain and stiffness and allow hygiene, including glenohumeral and scapulothoracic passive and active motion. Patients may perform computer work/typing; but must refrain from any lifting with their operative extremity. No active elbow flexion or supination is permitted, including tasks such as drinking coffee or feeding. Gravityâassisted flexion and extension may begin at two weeks postâoperatively; with restriction in the full arc of motion if an extension limitation has been determined necessary. Contraindication to progression to phase II of the rehabilitation protocol includes persistent or recurrent pain and/or swelling.
Cardiovascular fitness training, such as using a treadmill or elliptical, also be introduced as early as week one postâoperatively and is recommended to enable continued overall health; however, the treating therapist must place emphasis on safety and balance in order to avoid a fall onto the operative extremity.
Phase II: Weeks 6 to 12
Isometric triceps exercises may begin at six weeks postâoperative with isotonics beginning at week 8. Strengthening of wrist flexion and extension and the shoulder girdle may also commence at week 8. In addition to traditional isotonics, correction of underlying scapulothoracic dyskinesia to promote proper biomechanics of the shoulder girdle during upper extremity elevation should be incorporated. Postural control exercise is an essential foundation prior to the strengthening progression included in Phase III.
Phase III: Weeks 12 to 16
At the start of Phase III, biceps isometrics begin, followed by light biceps isotonics at week 16. Continuation of rotator cuff and periscapular stabilization exercises enable maintenance of overall upper extremity and postural health and promote proper mechanics as the patient advances to more complex exercises and activities. Inclusion of both open and closed kinetic chain exercises is essential, as activity of shoulder girdle musculature demonstrates significant electromyographic (EMG) differences when activated in exercises performed in an open versus closed kinetic chain.19,20
Phase IV: Week 16+
Biceps strengthening is advanced to include side curls. Upon attainment of full upper extremity strength, readiness to return to sport may be assessed on a sportâspecific basis. No specific test for return to sport following distal biceps repair exists; instead therapists must assess the quality and strength of movements specific to the preferred sport. At this stage, therapists are encouraged to employ creativity in designing a gym program focused on functional movement patterns that include the upper body, lower body and trunk prepare the individual for return to their preferred activity. Criteria for return to activity include full and painless range of motion, strength within 10% of the contralateral upper extremity and painâfree participation in activityâspecific movement patterns.
