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In part I, chiropractor, Dr. Alexander Jimenez brought insight into the relevant anatomy and functional biomechanics of the distal biceps unit, the mechanisms of injury and clinical tests commonly used to diagnose distal bicep tendon ruptures. In part two, Dr. Jimenez outlines and explores the post-surgical rehabilitation of distal bicep tendon repairs… The recent trend in postoperative rehabilitation of acute distal biceps tendon repairs has been towards pushing for early range of movement, as the risk of tendon retraction and postoperative complications is less(1,2). However, in chronic repairs, the exact protocol will depend on the quality of the tendon at the time of surgery, and if tendon grafting is needed. Often these chronic rupture repairs need a period of immobilization in a brace in flexion and neutral rotation from 2 weeks to 6 weeks(3-9). The brace may initially start at 90 degrees flexion and be gradually opened over the 6-week post-operative period so that by week six, the patient can extend to 30 degrees elbow flexion. After the 6-week post-operative period the elbow is gradually stretched into full elbow extension and full pronation. Formal strength retraining is usually started at 2-3 months post-operative but return to sport and heavy lifting is delayed to 6 months following surgery. The discussion below focuses on the rehabilitation schedule following an acutely repaired distal bicep tendon, and doesn’t discuss the complications of delayed repairs. It is assumed that in a professional and elite sport setting, the risk of ‘missing’ a rupture of the distal biceps tendon would not be as apparent as it may be in general practice. Elite athletes have access to a host of sports medicine practitioners who can push for diagnostics and imaging quite quickly. Therefore, the risk of missing a tendon rupture and subsequent delayed surgery would not be as prevalent as in the non-athletic population. These athletes are more likely to undergo acute repairs of the distal biceps tendon, thus negating the complications associated with delayed repairs. Stages In The Post-Operative ScheduleAs with any sports-related post-operative surgical procedure, the time to return to sport and competition is influenced not only by the healing capacities of the surgically repaired tissues (which usually follow predictable timelines) but also by the functional progressions of the athlete. As has been the theme with many of the discussions in the SIB Rehabilitation series, a list of ‘exit criteria’ has again been presented to help guide the sports therapist in progressing from one stage to the next. A common post-operative schedule in an acutely ruptured tendon is described below. Phase 1: Protection & Healing(first 3 weeks post-operative)
As with the majority of post-surgical rehabilitation programs, the first few weeks after the operation are crucial to allow a healthy healing environment to be created. This allows timely and optimal healing of the repaired tissues. Therefore, care and consideration must be taken to avoid large tensile forces on the bicep tendon through either passive over-stretching or strong muscle contraction. In the non-elite athlete, this may involve protected home stay for the first 3 weeks. However, in the elite strength athlete, measures must be taken to avoid a huge loss of range of motion at the elbow and the development of gross muscle atrophy in the biceps/triceps and forearm muscles. Therefore, the common approaches used are as follows: - Some surgeons may brace the elbow immobile in a posterior elbow splint for the first week. Others may choose to apply a removable elbow splint, which is fixed to 90 degrees elbow flexion (the splint can be removed for washing and for exercises).
- A collar and cuff is used to support the arm during walking and standing.
- The elbow may be passively flexed and extended from 30 degrees to 130 degrees. This needs to be done in a controlled, slow fashion by the physiotherapist or athletic trainer – 20-25 repetitions, five times per day.
- Icing of the elbow crease is undertaken post exercise.
- Active shoulder abduction, flexion and external rotation may be performed with the elbow brace on – 2-3 sets of 10-15 reps is sufficient.
- Seated scapular retraction exercises are performed with the brace on and elbows supported on a pillow.
- Active wrist and finger flexion/ extension exercises are performed.
- Muscle stimulation using the atrophy mode for the bicep and triceps, and hypertrophy mode on the deltoids may be used at this stage.
- Cardio work would be limited to recumbent cycle or 1 arm rowing on a rowing ergometer.
Exit criteria for Phase 1 (first 3 weeks). 1. Pain-free passive elbow flexion from 30-130 degrees flexion. 2. Minimal swelling and no wound complications. 3. Normal skin sensation over forearm indicating no nerve damage intra- operatively. 4. Full passive forearm supination and pronation at 30 degrees elbow flexion. Phase 2: Passive Range Of Movement (Weeks 3-6)- From week 3, the brace is opened 10 degrees each week. In week six, the patient has full range of movement with the brace in situ. (This will differ with the delayed tendon repairs where they are protected over the first 6 weeks.)
- Active extension in the brace is allowed, but flexion is still passive and in the brace.
- Scar tissue massage to prevent adhesions at operative site is recommended. This can be done regularly throughout the day.
- Patients should continue with active wrist/shoulder exercises.
- Scapular retraction/depression exercises can be started in prone – if the position is tolerated.
- Patients should start light Theraband shoulder internal and external rotation exercises, with the brace on and locked at 90 degrees (from week five).
- Weighted wrist extension and flexion exercises, and ulnar/radial deviations can be performed with a weighted stick.
- Continued use of muscle stimulator to the bicep, tricep and deltoids is recommended.
Exit criteria for Phase 2 (weeks 3-6) 1. Full passive range of motion in flexion. Full active extension. 2. No swelling or inflammation at operative site. 3. Full active pronation in all positions. Full passive supination in all positions. Phase 3: Early Strength Phase (Weeks 6-12)1. Early active biceps muscle contraction. This can be done as the following progression; a. Protected range of movement (preacher curl position – see figure 1). Weeks 7,8. i. 3 x 15 reps neutral pronation to full supination (see diagrams below). ii. 3 x 15 reps full supination with isometric supination bias using Theraband. Theraband places a pronation force onto the forearm to create an extra supination effect on the bicep (see diagrams below). iii. Note: full pronation is avoided initially as this increase compressive load on the distal radial insertion of the tendon. b. Neutral Range of Movement (upright sitting). Weeks 9,10 i. 3 x 15 reps full supination with isometric supination bias (Theraband – figure 2) ii. 3 x 15 reps neutral pronation to full supination. iii. Note: full pronation is avoided initially as this increase compressive load on the distal radial insertion of the tendon. c. Stretch Position (80 degree incline). Weeks 11,12. i. 3 x 15 reps full supination with isometric supination bias (Theraband). ii. 3 x 15 reps neutral pronation to full supination. iii. Note: full pronation is avoided initially as this increase compressive load on the distal radial insertion of the tendon. 2. Commence all pushing movements (bench press, shoulder press). These movements are unrestricted; however use logical progressions based on time away from weight lifting. 3. No deadlifts, cleans or other pulling movements requiring elbow flexion such as chin ups, seated rows. Patients can perform straight arm pulldowns and straight arm reverse flyes. 4. Commence straight line running drills/ technique and build up speed work. 5. Commence running based fitness drills. 6. Continue passive range of movement and scar tissue massage as needed. 7. Superior radioulnar joint mobilisations if required. Exit criteria 1. Equal isometric elbow-flexion strength. Tested at 90 degrees flexion. Full supination and neutral pronation positions. 2. Straight line speed. Back to pre-injury speed levels. Phase 4: Advanced Sports-Specific Strength & Skill Acquisition(weeks 12-18)
1. Increase load on 80-degree incline bicep curls, from full pronation to full supination. 2. Forward lying incline curls with full supination (see figure 6 illustrations below). 3. Weighted pronation to supination movements. Performed in both elbow flexion and elbow extension, using a weighted bat or hammer. The forearm is taken from full pronation to neutral position (this requires active supination) and then taken down to full supination (this requires an eccentric contraction of the pronators). The weight is then taken back to neutral (pronation contraction) and dropped down to the start position (controlled eccentrically by the bicep). 4. Start sport-specific weight lifting in progressive overload fashion – deadlifts, clean and jerk, all pulling movements (chin ups, seated rows). 5. Return to non-contact skill acquisition. Exit Criteria 1. Confidence with elbow flexion in strength tasks.
2. Elbow flexion strength 90% compared with unaffected side.
3. Confidence with bicep tendon with skill based efforts. Phase 5: Return To Competition Phase (Weeks 18-24)1. Advanced strength and conditioning content. 2. Elbow flexion strength 95% compared with unaffected side. 3. Full contact skill if in contact sport. ConclusionDistal bicep tendon ruptures in athletes are rare but potentially debilitating if not managed correctly. Surprisingly, a lot of literature exists on the ‘best practice’ management for these injuries. The supporting evidence on the types of different surgeries is quite varied, and the best approach therefore will be determined by the treating surgeon. Irrespective of the type of surgery and fixation used, the rehabilitation process can be quite protracted to ensure the athlete returns to competition with an anatomically sound distal bicep tendon attachment. It also allows elbow flexion strength and supination strength return to the best levels possible. References
1. J Shoulder Elbow Surg. 2005; 14:516–8.
2. Am J Sports Med. 2009; 37:989–94.
3. J Shoulder Elbow Surg. 2006; 15:614–9.
4. J Shoulder Elbow Surg. 2000; 9:227–33.
5. Am J Sports Med. 2000; 28:538–40.
6. J Bone Joint Surg. 2002;84-A:999–1005.
7. J Hand Surg. 2009;34-A:545–52.
8. Clin Orthop Relat Res. 2008;466: 2475–81.
9. J Shoulder Elbow Surg. 2002;11:633–6.
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In the first of this 2-part series, chiropractor Dr. Alexander Jimenez brings insight into the anatomy and biomechanics of the biceps brachii muscle, the mechanisms of injury, and the typical signs and symptoms that may alert a clinician to a biceps tendon rupture. Athletes in contact and strength-based sports place an enormous amount of stress onto the distal bicep tendon. However injuries to the distal biceps tendon are not common in athletes, accounting for 10% of all bicep tendon ruptures, with the long head of the proximal insertion rupturing most frequently(1). If an injury to the distal bicep tendon does occur, it usually in the dominant arm of middle aged men (40-60yrs), suggesting a degree of degeneration must be present to rupture(1). There have been a growing number of case reports in the media about these injuries – in particular athletes such as powerlifters and bodybuilders with a history of anabolic steroid use. More recent studies have shown that the incidence of this injury is increasing and the age group that sufferers is getting younger(1,2). It is believed that full tendon ruptures will require surgery to restore the biceps role as an elbow flexor and supinator of the forearm to prevent loss of strength in these movements(3). Anatomy & BiomechanicsThe long head of the bicep originates from the supraglenoid tubercle of the scapula, and the short head arises from the coracoid process. It is common for the muscle to course distally as two separate heads or bellies, with the fibres from the short head on the ulnar side of the arm and the long head on the radial side. However, the two bellies may interdigitate closer to the elbow(4,5). As the tendons course to the radial insertion, they twist counter clockwise in right arms, with the anteromedial fibres from the short head inserting inferiorly on the radial tuberosity, with the posterolateral long head inserting more superior on the tuberosity (see Figures 1 and 2)(5,6). It is suggested that this twisting arrangement differentiates the short head as primarily being an elbow flexor and the long head as a supinator(5). The aponeurosis of the biceps (also called the lacertus fibosus – see Figure 3) originates at the level of the musculotendinous junction and attaches to the superficial fascia of the ulnar in three distinct layers, which envelope the forearm flexor muscles(5). It has been suggested that as the forearm flexors contract, they tense the aponeurosis and create a medial pull on the bicep tendon, possibly contributing to its rupture. An intact bicipital aponeurosis at the time of tendon rupture makes surgical repair much easier. The common distal bicep tendon inserts onto the biceps tuberosity, which is around 25mm from the radial head(7). The ridge of bone that forms the tuberosity is usually a single ridge and is 22-24mm long and 12-15mm wide. It attaches into the most ulnar side of the tuberosity(8,9). The primary function of the biceps muscle is to supinate the forearm. Its action as an elbow flexor is secondary as the brachioradialis and brachilias can also perform elbow flexion. Mechanism Of InjuryThe most common mechanism of injury is a sudden elbow extension force applied whilst the elbow is flexed. This eccentric force produces a tensile stress that can suddenly rupture the distal tendon. Added to this may be the added compression of the tendon found in pronation(10) and with the forearm flexors contracted, which may tense the aponeurosis and displace the tendon medially(5), thus producing a torsional force to the tendon. It is a rare injury (1.2 ruptures per 100,000 patients per year) and the typical sufferer age is a male in his late 40s. The dominant arm is involved 86% of the time, and smokers have 7.5 times greater risk of injury(1). PathogenesisThe two current theories for the pathogenesis of distal biceps tendon ruptures are hypovascularity in the tendon and mechanical stress. It has been found in cadaver studies that a consistent zone of hypovascularity and degeneration is found in an approximate 2.14cm diameter of the tendon(10), similar to the hypovascular zone seen in ruptured Achilles tendons that rupture(11). A lack of blood supply may also lead to poor healing capacity and tendency towards degeneration. The mechanical-stress theory relates to the compressive effect of the radius and ulnar on the distal biceps tendon in positions of supination and pronation. With the arm fully pronated, the space for the distal tendon between the lateral border of the ulnar and the radial tuberosity corresponds to the space available for the tendon. In full supination the space is 52% greater. It is suggested therefore that repeated and forced pronation may continually compress the tendon(10). Signs & SymptomsPatients with a distal biceps tendon injury typically experience a tearing sensation or ‘twanging’ and an acute onset of pain after an unexpected or massive extension force has been applied to the flexed elbow. Typically, there is pain and deformity with weakness of supination. Gross swelling may develop over the cubital fossa in the hours following. If the biceps aponeurosis remains intact, the rupture may be clinically missed(7,12). Two tests have been proposed to assess for a ruptured bicep tendon: 1. Biceps squeeze test – With patient sitting and arm bent to 60-80 degrees, squeeze the bicep with both hands. If the forearm does not supinate this is indicative of a full bicep tendon rupture(13). This test has been found to be 96% sensitive to tendon rupture. 2. Hook test – With patient sitting and elbow bent to 90 degrees and fully supinated, the examiner uses their fingers to hook the tendon from the lateral side. If the tendon is intact, the tendon is easily ‘hooked’. In a ruptured tendon there is no palpable tendon structure(14). This test is reported to have 100% sensitivity and specificity, and is better than MRI for assessing tendon rupture. ImagingImaging is usually quite limited for an effective diagnosis of a complete rupture. Often, performing the hook test and squeeze test should be enough to confirm a full rupture. However, radiograph X-rays can be useful to visualise enlargement or irregularity at the radial tuberosity(15) or an avulsion of the radial tuberosity(16). MRI can be useful to visualise the integrity of the tendon and any intrasubstance degeneration. The best position to MRI the tendon is in the FABS position. The arm is held with 90 degrees elbow flexion, 180 degrees of shoulder abduction and supination of the forearm(17). Management Of Biceps Tendon RupturesIt is generally accepted that operative repair leads to better functional outcomes versus non-operative repairs. To summarise some of the leading studies on non-operative versus operative management: - Operative repair leads to better supination strength and elbow flexion strength and endurance(18,19).
- An untreated biceps tendon rupture can result in 40% loss of supination power, with 30% loss in elbow flexion strength(3).
- There are better subjective outcomes and objective isokinetic testing following operative repairs(20).
- Retrospective studies of non-operative versus operative repair show that at 5 years post injury, supination strength was only 74% to that of operated tendons. Flexion strength was 88% compared to repaired tendons(21). The difference was even more pronounced if the dominant arm was injured.
Non-operative treatment is now generally reserved for sedentary patients who do not require elbow flexion and supination strength/endurance, or for patients who are not medically fit for operative treatment. Non-operative treatment consists of temporary immobilisation, pain control, and physiotherapy. If surgical treatment of a complete distal biceps tendon rupture is delayed, a combination of muscle retraction, adhesion formation, distal tendon shortening, and degeneration can make anatomic reinsertion of the original tendon difficult(2,19,22). Outcome comparisons of acute and chronic repairs suggest a surgical delay greater than 10 days post-injury increases the risk of complications and the extent of anterior dissection required(23,24). Surgical TreatmentThe literature describes anatomic versus non-anatomic repairs, single incision repairs and two incision repairs using bone anchors, suture tunnels, suture anchors, cortical buttons and interference screws to attach the distal tendon to the radial tuberosity(24-30). Number Of IncisionsIt was initially believed that the use of two incisions reduces the post-operative complications such as nerve damage, heterotrophic ossification, loss of forearm pronation and wound infection(34). In view of the difficulty and complications of a direct anterior approach such as a radial nerve palsy, Boyd and Anderson described a dual-incision technique where the tendon is retrieved anteriorly and passed through the forearm bones to be reattached through a posterior approach to the radial tuberosity, exposed by pronation of the forearm(34). A host of studies have compared the relative success of 1-incision repairs and 2-incision repairs for regaining both elbow flexion strength and supination strength in post-operative complications such as nerve palsies and heterotrophic ossification. Overall, on the balance of evidence, it seems that with regards to functional outcomes and post-operative complications, the 1 and 2-incision repairs are equally successful(18,24-27,35-43). Fixation & GraftingNumerous studies have looked at the relative benefits of the different fixation methods such suture anchors, trans- osseous tunnels, cortical button repairs, interface screw fixation (27,29,30,44-49). The consensus is that cortical button fixation methods are superior to suture anchors, sutures in bone tunnels and interface screws(27,38,48,49). As for tendon grafting, this technique is usually reserved in cases whereby the biceps tendon repair has been delayed, and the tendon has retracted a distance making direct repair very difficult. Due to the retraction, there is a need to restore tendon length to actually achieve a fixation onto the radial tuberosity. Typical grafts used are semitendinosis (22,50,51), flexor carpi radialis(52), Achilles tendon(12,52,53), tensor fascia lata (55,56), and palmaris longus, plantaris and long toe extensors autografts(57). ConclusionDistal biceps tendon ruptures are reasonably uncommon injuries in athletes. However, if they do occur then early surgical treatment is almost always necessary to restore the biceps attachment so the athlete does not lose strength and endurance in elbow flexion and forearm supination. Multiple surgical techniques exist all with their own strengths and weaknesses. In part two this Rehab Masterclass article, we will look in detail at the most effective rehabilitation protocols following surgical repair of the distal biceps tendon. References
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In part two, Dr. Jimenez outlines and explores the post-surgical rehabilitation of distal bicep tendon repairs. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900