Postoperative Rehabilitation Protocol Distal Biceps Tendon Repair

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Distal biceps tendon repair.  It is by no means intended to replace or substitute the clinical decision making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

*This protocol applies to DISTAL biceps tendon repair.  If proximal biceps tenodesis is performed the therapist should utilize that specific protocol.  There are many variables which can influence how conservative or aggressive the patient may be rehabilitated.  These include but are not limited to the following: Quality of tissue and integrity of repair, acute vs chronic tears, primary vs revision repair, and use of allograft donor tissue.    

*Return to work/activity will be based on the individual patient's profession and workplace demands, ability of employer to accommodate restrictions, and postoperative progress.

*Progression from one “phase” to the next is based upon experience of the therapist, necessity to reduce complications, accelerate recovery, and the time constraints of soft tissue healing associated with undergoing a surgical procedure.  

*A word about “pain” and management of anticipated discomfort following arthroscopic rotator cuff surgery...

  • Adequate management of pain is essential to progressing the patient’s mobility, strength, range of motion, and independence.  However, pain is a subjective measure and should be expected for weeks to months after surgery.  A divergence between the subjective complaints and objective findings observed by an experienced therapist should arouse concern and potential need for further consultation/evaluation.  



Phase I- Early Post-Operative Phase (Post-op Day 0-7)

The goal of physical therapy intervention during the early post-operative phase is to protect the repair, reduce swelling and edema, and monitor wound healing. 

Goals: 

  1. Implement use of nonpharmacologic modalities to control pain and swelling such as circulating cryotherapy pumps, manual massage, elevation of the extremity, etc

Assessment by Therapist:

  1. No physical therapy is necessary for the first week post-op.  Patient should be kept in sling/splint at all times except when bathing (after post-op day 3)
  2. Assess for signs of wound infections, DVT/PE, Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. None with elbow
  2. May perform wrist flexion/extension and grip strengthening 

Precautions:

  1. Use sling/brace
  2. No weightbearing on operative extremity 
  3. Avoid active flexion of elbow and supination of forearm 

Phase II (Post-op Week 1-6)

Goals:

  1. Begin formal physical therapy sessions.  
  2. Decrease swelling/inflammation (Ice, TENS unit, Dry Needling, Cupping, etc)
  3. Week 2: 90 degrees to full flexion. PROM only flexion/extension/pronation/supination
  4. Week 3: 45 degrees to full flexion. AAROM/AROM flexion/extension, PROM/AAROM pronation/supination with elbow at 90 
  5. Week 4: 30 degrees to full flexion. AROM flexion/extension, begin AROM pronation/supination at 90 if pain control acceptable
  6. Week 5: 20 degrees to full flexion.  OK AROM flexion/extension/pronation/supination 
  7. Week 6: 0 degrees to full flexion

Assessment by Therapist:

  1. Assess frequency of narcotic and non-narcotic analgesic use 
  2. Assess pre-treatment and post-treatment ROM 
  3. Encourage avoidance of nicotine/smoking and control of glucose if diabetic 


Therapeutic Exercises:

  1. Continue hand/wrist exercises
  2. OK to progress ROM of shoulder as tolerated

Precautions:

  1. Sling/brace should be used unless patient is bathing, performing exercises at home, or under direct supervision by physical therapist.   
  2. No weightbearing on operative extremity
  3. No resisted exercises week 1-6 

 

Phase III (Post-op Week 6-12)

Goals:

  1. Initiation of ADLs and proprioception exercises below shoulder level
  2. No pain at rest
  3. Discontinue sling/brace

Therapeutic Exercises:

  1. Begin gradual weighted and band resistance from 90 degrees to full flexion 
  2. Begin combined motions (extension with supination) if adequate pain control
  3. Advance scapulothroacic exercises (pulley, wall walks/slides, forearm planks, shrugs/rows) 
  4. Wall pushups
  5. OK for running/cycling

Precautions:

  1. No lifting > 10lbs 
  2. No pushing, pulling, loading
  3. No rapid movements (excessive/forceful muscle contractions) 

Phase IV (Post-op Week 12-16)

Goals:

  1. Full AROM without pain.  Advanced combined/composite strengthening movements and ensure proper mechanics of hand/wrist/elbow/shoulder
  2. Continue Phase I, II and III exercises
  3. Progressive strengthening and complete functional activities/heavier ADLs below shoulder height
    1. Progress endurance before strength (ie. higher reps before adding resistance)

Therapeutic Exercises:

  1. Initiate sub-maximal isometrics and advance to isotonics as tolerated 
  2. Begin incline pushups
  3. Increase resistance biceps/triceps 

Precautions:

  1. Do not advance strengthening exercises if lacking full ROM or experiencing pain
  2. Do not progress shoulder strengthening exercises unless proper scapulothoracic mechanics
  3. No return to work unless sedentary job or cleared by surgeon 

Phase V (Post-op Week 16+)

Goals:

  1. Increase strength
  2. Work conditioning/hardening
  3. Return to work without restrictions

Therapeutic Exercises:

  1. Continue Phase I-IV exercises
  2. Rhythmic Stabilization exercises 
  3. High Plank Progression

Precautions: 

Do not advance strengthening exercises if patient experiencing painful response.  Goal is maximize endurance of movements before increasing loads