Biceps Tendon Rupture

Repair
Sara Gralitzer
Ruthanna Rosner

Anthony,2014

Distal Biceps Brachii

Rupture Overview
Distal biceps brachii ruptures are rare and typically
occur in middle aged men. (Sarda, 2013; Chillemi, 2007; Virk, 2014)

This is typically the result of a forceful eccentric

contraction. (Grewal, 2012; Mandeep, 2014)

96% of biceps ruptures involve the long head of the

biceps tendon.

(Sarda, 2013)

Traumatic long head biceps brachii ruptures typically

occur from fall on an outstretched arm, powerful

deceleration of the arm during pitching or a powerful
supination force (Sethi, 1999; Mariani, 1986)

Typically long head biceps brachii ruptures occur as a

result of a degenerated tendon

(Sethi, 1999)

Anatomy
Long head

biceps tendon

Short head

biceps tendon

Distal biceps
tendon

Bicipital groove
Radial

Tuberosity

(Sethi 1999)
www.rad.washington.edu

Distal Biceps Tendon Rupture

Surgeries
Modified single incision
Two cortical buttons were placed intramedullary at the radial
tuberosity to reattach the distal biceps tendon (Siebenlist, 2011)
Suture anchors to attach distal biceps to radial tuberosity,
three sutures are used. (Ro, 2012)

Biotenodesis screw
Single anterior incision
The distal biceps tendon is anchored to the radial tuberosity

with the use of a biotenodesis screw (Khan, 2003)

This has shown better results than suture anchors due to the
tendon displacing from the anchors. (Krushinski, 2007)
If the Biceps tendon was not viable for anchoring then the
semitendinosis tendon was harvested to use as a graft. (Fenton,
2009)

Biceps Tendon Rupture Surgical

Repair
Suture Anchors

Ro, 2012

Biotenodesis Screw

Khan,2004

Long head biceps Tendon

repair
Tenodesis
Open subpectoral incision
The tendon was placed in the bicipital groove with a

Biotenodesis screw into the humerus.

Surgical complications are less in a tenodesis repair
(Anthony 2014)

Anthony, 2014

Overview Rehabilitation
Long Head
vRehabilitation:
v typically follows protocols
similar to a rotator cuff
tear repair

vPhase 1: weeks 0-4

v AROM and AAROM
v Improve PROM

vPhase 2: weeks 4-8

v AROM

(Ryu, 2010; Krupp, 2009; Sherry, 2014)

vPhase 3: weeks 8-12

v Initial Strengthening
v Rotator Cuff
v Biceps
v Proprioception
v Agility
v Power

vPhase 4: weeks 12 and

beyond
v Advanced Strengthening
v Sport Specific Exercises

Phase 1: weeks 0-4

Goals
Protection of repair
Decrease pain and swelling
Activation of Glenohumeral and scapulothoracic muscles
Avoid Biceps tension, resisted forearm supination, elbow flexion,

shoulder flexion, and extension or horizontal abduction past body

External Rotation limited to 400
Achieve Full PROM within 6 weeks

Precautions
Avoid Biceps tension, resisted forearm supination, elbow flexion,

shoulder flexion, and extension or horizontal abduction past body

No AROM of elbow
Do not lift heavy objects
Limit external rotation

(Ryu, 2010; Krupp, 2009; Sherry,

2014)

Phase 1: weeks 0-4

Stretching/ROM
AROM and AAROM of elbow and wrist
Pronation and Supination, Flexion, Extension
PROM of shoulder
Flexion, Abduction, Internal and External Rotation
Pendulum Exercises
Strengthening
Submaximal Isometrics (begin week 3)
Internal and External Rotation, Abduction, Adduction
Hand Gripping Exercises
Cardiovascular Endurance
Recumbent Bike

Phase 2: weeks 4-8

Goals
Protection of Surgical Repair
Achieve full AROM
Increase Muscle Endurance of

scapulothoracic and
glenohumeral muscles
Initiate rhythmic stabilization
exercises
Perform 30 repetitions of active
shoulder elevation w/o upper
trap substitution (at least 80%
of opposite shoulder w/no pain
or swelling)
30 repetitions of side lying
external rotation (at least 80%
of opposite shoulder w/no pain
or swelling)

Stretching/ROM
AAROM and AROM
Internal and External

Rotation
Horizontal adduction and
abduction
Flexion and Gentle Extension
Pulley ROM
Flexion, Abduction
Lawn Chair AROM-from
supine to sitting

Lawn Chair AROM

Precautions

Do not lift objects with operative

shoulder
No friction massage at tenodesis site
(Ryu, 2010; Krupp, 2009; Sherry,
2014)

Krupp, 2009

Phase 2: weeks 4-8 cont.

Strength

Scapular squeezes
Thera-band exercises-Internal and External rotation
Ball Squeezes
Proprioception

Rhythmic Stabilization
Cardiovascular Conditioning

Aquatherapy
Stationary Bike
Walking-No treadmill

Phase 3: weeks 8-12

Goals
Full AROM w/ normal

scapulothoracic and
glenohumeral movement
5/5 rotator cuff strength at
900 abduction in the scapular
plane
5/5 peri-scapular strength
Increase Biceps Strength and
Endurance
Perform 1 minute of sport
cord external rotation at 300
of abduction
Perform 1 minute of rhythmic
stabilization standing with w/
arm at 900 anterior flexion
Performance of above
exercises w/o pain or swelling
following rehab.

(Ryu, 2010; Krupp, 2009; Sherry, 2014)

Precautions
Do not start functional

exercises until patient has full

ROM and strength in different
planes of motion
Educate patient about a
gradual increase of shoulder
activities
No swimming or throwing
sports

ROM/Stretching
Anterior capsule doorway and

wall stretch
Seated Anterior Deltoid
PNF stretching
Joint Mobilizations-Grades 3-4
Posterior glides

Phase 3: weeks 8-12 cont.

Strength
Deltoids, Biceps, Rotator
Cuff
Scapulothoracic
strengthening

PNF Diagonals Upper body-D1 and D2

Supine to standing
Isometric strength
Prone-Flexion
Wall-Abduction

(Ryu, 2010; Krupp, 2009; Sherry, 2014)

Isotonic Strength
Concentric Biceps:

Elbow Flexion,
Forearm Supination
Theraband
through
ROMadd weight
5+Internal and
External Rotators
w/ arm in 300
abduction
Eccentric

Biceps contraction

Phase 3: weeks 8-12 cont.

Cardiovascular
Aqua-therapy
Aqua-jogging
Aerobic Exercises
Treadmill

Proprioception
Push up positionTripod positionBalance board push up
position
Prone Swiss Ball Walk outs
Rhythmic Stabilization-Varying positions
Body Blade

Speed, Power, Agility

Speed Bag punching
Bi-directional ball pass

Phase 4: weeks 12 and

beyond

Goals
Maintain ROM
Increase Muscle Strength
Increase Muscle Power
Initiate Return to Throwing
Program
Full ROM in all directions
Demonstrate Stability w/ power
and agility movements
5/5 Rotator Cuff Strength w/
multiple repetition testing at 900
abduction in the scapular plane
Return to Play
Precautions
Avoid excessive anterior capsule
stress
Avoid wide grip bench press and
military press

ROM/Stretching
Biceps, Triceps, Deltoids, Rotator
cuff, Scapulothoracic Muscles
Anterior capsule doorway and
wall stretch
Seated Anterior Deltoid
PNF stretching
Joint Mobilizations-Grades 3-4
Posterior glides

Strength
Biceps, Triceps, Deltoids, Rotator
cuff, Scapulothoracic Muscles
Thera-band exercises
Internal and external
rotation in 900 of abduction
Dumbbell and medicine ball
exercises w/ control
Core strengthening

(Ryu, 2010; Krupp, 2009; Sherry,

2014)

Phase 4: weeks 12 and

beyond cont.
Strength (continued)
Progressive weight training
Initiate throwing program
Cardiovascular Endurance
Stationary Bike
Initiate Return to running
program

Proprioception
Medicine ball Exercises
Dynamic Stabilization
Diagonal Plane Exercises
Stabilize ball on wall: large

Speed and Agility

Speed Bag
Plyometric PNF
(show picture)
Table Tennis

Power
Push ups
Wallinclineme
dicine
balltrampoline
boxclap

ballsmaller progress

Ryu, 2010; Krupp, 2009; Sherry, 2014)

Plyometric PNF

Krupp, 2009

Distal Biceps Rehabilitation

Overview
v Rehabilitation:
v Phase 1: weeks 0-3
v Immobilization
v Pain and Inflammation
Management

v Phase 2: weeks 3-6

v AROM and AAROM
v Improve PROM
v Pain and Inflammation
Management

v Phase 4: weeks 10-16

v Moderate Strengthening
v Rotator Cuff
v Biceps
v Proprioception

v Phase 5: weeks 16-26

v Advanced Strengthening
v Agility
v Power
v Speed

v Phase 3: weeks 6-10

v Phase 6: weeks 26 and beyond

v Initial Strengthening
v Rotator Cuff
v Biceps

v Sport Specific Exercises

v Return to running, throwing,
golf, or swimming programs

(Mazarra, 2014; Awan, 2014; Horschig, 2012; Fenton, 2012; Siebenlist,

2011; Jerome, 2006)

Rehabilitation Distal Biceps

Phase 1: Weeks 0-3
Goals
Decrease inflammation and

Pain
Protect Repaired tissue
Avoid Active Supination,
Excessive Shoulder Extension,
and Biceps Contraction
Begin PROM
Immobilization of the joint
with Posterior Splint- 900
elbow flexion-one week
Progress to Elbow Brace
locked at 900 at week 2
(Except PROM)
Hinged Elbow Brace: 450 to
full flexion

ROM
Immobilization of the joint

with Posterior Splint- 900

elbow flexion-one week
Progress to Elbow Brace
locked at 900 at week 2
(Except PROM)
PROM: Elbow at 90- Flexion
and Supination
AROM: Elbow at 90-Extension
and pronation
Joint Mobilizations: Grades 1
and 2

Strengthening
Wrist and hand Gripping
exercises

Precautions
Avoid Active Supination,

Excessive Shoulder Extension,

and Biceps Contraction

(Awan, 2014; Horshig, 2012; Mazzara, 2014)

Hinged Elbow Brace

Horschig, 2012

Phase 2: Weeks 3-6

Goals
Protect Repaired Tissue
Begin AAROM and progress to
AROM
Full passive supination by
week 5
Isometric Triceps

Precautions
No resisted supination
Do no perform RROM
ROM
Hinged Elbow Brace: 100 to
full flexion
AAROMAROM: Flexion,
Extension, Pronation, and
Supination
Passive Assisted Active
Supination
Joint Mobilizations: Grades
3 and 4

(Awan, 2014; Mazzara, 2014; Horschig, 2012)

Strengthening
Shoulder Exercises
Rotator cuff muscles
Internal and External
Rotation, Abduction
and adduction
Scapulothoracic Strength
Exercise Scapular retraction
with tubing
Standing Scaption
Wrist flexion and extension
Isometric Triceps
Elbows flexed 900dorsum of hand pushes
down on table

Cardiovascular Endurance
Recumbent Bike

Scapular retraction w/
tubing

Horschig, 2012

Phase 3: Weeks 6-10

Goals
Discontinue use of Elbow

Brace: 0-1450 by 8th week

Begin RROM

Precautions
No resistive exercises until week
8

ROM
Continue phase 2 exercises
RROM: Flexion, Supination
PNF Diagonals: Upper Body
D1 and D2

(Horschig 2012; Jerome, 2006; Siebenlist,

2011; Virk, 2014)

Strength
Isotonic Triceps Exercise-Triceps Extension
Isotonic wrist extensor/flexor
Exercise-Wrist Curls
Isotonic Shoulder
Exercise- light weight
shoulder press

Cardiovascular Endurance
Stationary Bike

Proprioception
Begin when active Flexion is

achieved without pain

Double arm raiseeyes closed

Phase 4: Weeks 10-16

Goals
Begin Biceps Isometrics
Begin UBE
Begin Proprioception
Precautions
Do not lift heavy objects
ROM
RROM: Elbow extension
Continued stretching for

flexion, extension,
supination, and pronation

Strengthening
Biceps Isometrics
Table lift
UBE
Light Upper Extremity
Weight Training
(Horschig,2012)

Cardiovascular Endurance
Stationary Bike
Initiate Return to Running,
throwing, golf,
Aqua-therapy
Water Aerobic
Lower Extremity
Exercises
Gentle Upper
Extremity Resistance

Proprioception
Hands and Knees on

ground
Progress to 1 hand on
ground.
.

Phase 5: Weeks 16-26

Goals
Begin Biceps Contractions
Begin Agility and Power
training

ROM
Continue Stretching elbow

flexors, extenders, pronators ,

and supinators

Strengthening
Light Isotonic Biceps
Cardiovascular Endurance
Aquatherapy
Return to Running
Elliptical
Proprioception
Two hand balance on Bosu

Ball
Progress to 1 hand on Bosu
Ball

(Horschig 2012)

Agility
Ball toss
Underhand Over hand
Wall ball
Catching and throwing
Power
Plyometrics
Rebounder
Speed
Shadow Boxing
Punching bag
Speed Bag
Number wall

Phase 6: Weeks 26 and

Beyond
Goals
Return to activities
Continue sport specific
exercises

ROM
Continue Stretch.
Strengthening
Sport specific
Return to throwing
Eccentric Biceps
Cardiovascular Endurance
Return to Running
Elliptical
Swimming
(Horschig, 2012)

Proprioception
Proprioception
perturbation

Agility
Ball Reaction Drill
Juggling
Turn and Catch
Power
Medicine Ball Tosses
Speed
Quick Hand touches

References

1.
Anthony SG, McCormick F, Gross DJ, Golijanin P, Provencher MT. Biceps tenodesis for long head of the
biceps after auto-rupture or failed surgical tenotomy: results in an active population. J. Shoulder Elbow Surg. 2014

2.
Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal biceps tendon rupture: Current
concepts. Injury 2013;44(4):417-420.

3.
Grewal R, Athwal G, MacDermid JC, et al. Single Versus Double-Incision Technique for the Repair of
Acute Distal Biceps Tendon Ruptures A Randomized Clinical Trial. J. Bone Jt. Surg. 2012;94-A(13):1166-1174.

4.
Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J. Shoulder Elbow Surg.
1999;8(6):644-654. 5.
Mariani ME, Cofield RH, Askew LJ, Li G, Chao EYS. Rupture of the Tendon of
the Long Head of the Biceps Brachii Surgical Versus Nonsurgerical Treatment. Clin. Orthop. 1988;228:233-239.

6.
Siebenlist S, Elser F, Sandmann GH, et al. The double intramedullary cortical button fixation for distal
biceps tendon repair. Knee Surg. Sports Traumatol. Arthrosc. 2011;19(11):1925-1929.

7.
Ro DH, Baek GH, Gong HS. Modified Single-Incision Distal Biceps Tendon Repair Using Three Suture
Anchors: Surgical Technique. Hand Surg. 2012;17(3):409-412.

8.
Khan W, Agarwal M, Funk L. Repair of distal biceps tendon rupture with the Biotenodesis screw. Arch.
Orthop. Trauma Surg. 2004;124(3):206-208.

9.
Krushinski EM, Brown JA, Murthi AM. Distal biceps tendon rupture: Biomechanical analysis of repair
strength of the Bio-Tenodesis screw versus suture anchors. J. Shoulder Elbow Surg. 2007;16(2):218-223.

References cont.

10.
Khan W, Agarwal M, Funk L. Repair of distal biceps tendon rupture with the Biotenodesis screw. Arch.
Orthop. Trauma Surg. 2004;124(3):206-208.

11.
Krushinski EM, Brown JA, Murthi AM. Distal biceps tendon rupture: Biomechanical analysis of repair
strength of the Bio-Tenodesis screw versus suture anchors. J. Shoulder Elbow Surg. 2007;16(2):218-223.

12.
Fenton P, Qureshi F, Ali A, Potter D. Distal Biceps Tendon Rupture A New Repair Technique in 14 Patients
Using the Biotenodesis Screw. Am. J. Sports Med. 2009;37(10):2009-2015.

13.
Ryu JHJ, Pedowitz RA. Rehabilitation of Biceps Tendon Disorders in Athletes. Clin. Sports Med.
2010;29(2):229-246.

14.
Horschig A, Sayers S, LaFontaine T, Scheussler S. Rehabilitation of a surgically repaired rupture of the
distal biceps tendon in an active middle aged male: a case report. Int. J. Sports Phys. Ther. 2012;7(6):663-667.

16.
Awan T, Marsh S, Miller P, Lemos S. Distal Biceps Tendon Rupture in a Female Patient. Int. J. Athl. Ther.
Train. 2014;19(1):23-26.

17.
Krupp RJ, Kevern MA, Gaines MD, Kotara S, Singleton SB, Long Head of the Biceps Tendon Pain:
Differential Diagnosis and Treatment. JOSPT. 2009; 39(2): 55-70.

18.
Sherry M. Rehabilitation Guideline for Biceps Tenodesis.http://www.uwhealth.org/physical-therapyathletic-training/sports-medicine-rehabilitation-guidelines/20398

19.
Mazzara J. Post-operative Distal Biceps Tendon Repair Rehabilitation Protocol. Connecticut Center for
Orthopedic Surgery http://www.orthoontheweb.com/physical_therapy.asp

20.
Ethan Jerome. Department of Rehabilitation Services. Distal Bicep Tendon Repair- Rehabilitation
Protocol. 2007. Available at
http://www.brighamandwomens.org/Patients_Visitors/pcs/rehabilitationservices/Physical%20Therapy
%20Standards%20of%20Care%20and%20Protocols/Elbow%20-%20Distal%20biceps%20repair
%20protocol.pdf