From Splinting to Strengthening: The 3 Phases of Therapy After Distal Bicep Tendon Repair

Therapy for bicep tendon ruptures and repairs can be challenging, requiring careful planning and a strict protocol to ensure safety during the first few critical weeks of healing.

Bicep ruptures can happen after any stressful load to the biceps. They are most common in middle-aged men and typically occur after water skiing or lifting weights.¹

The repair includes suturing the bicep tendon and muscle to the proximal radius until the tendon can heal and adhere to the bone.

When performing therapy for the repair, I recommend this structured 12-week program that is comprised of three phases of healing:

• Static progressive orthosis for protection
• Range of motion
• Strengthening

Phase One: Orthosis for Protection

The goal of phase one is to reduce tension at the distal biceps tendon by splinting the elbow in a neutral position and limiting extension of the elbow.

There remains variability in rehabilitation protocols for bracing. While some physicians will use a postoperative splint for the first week, others may use a long arm or hinge orthosis.

Weeks 0 to 1

• Post operative cast, long arm, or hinge orthosis (per protocol)
• Begin wrist and digit flexion and extension
• Cryotherapy

Week 2

• Progress to hinge orthosis (per protocol)
• Suture removal
• Gravity assisted flexion and extension of the elbow
• Begin passive range of motion (PROM) for elbow flexion and supination

Weeks 3 through 6

• Begin scar management
• Increase hinge orthosis by ten degrees of extension
• Continue exercises from week two

After the repair, most patients will be in a post-operative cast with the hand in neutral and the elbow at 90 degrees for ten to 14 days. This position is safe during the acute phase.

After week two, or after the follow-up visit with the physician, the patient will typically be placed in a hinge orthosis and begin therapy. The physician will determine the amount of extension allowed for the hinge orthosis, and the therapist can usually add ten degrees of extension every week.

If a hinge orthosis isn’t available, you can make a custom long arm orthosis starting at the mid humerus and extending to the wrist.

The wrist should be in a neutral position and able to flex and extend outside the confines of the splint. The splint should be modified each week to increase elbow extension by ten degrees until the elbow reaches full extension.

Home Exercises

Home exercise programs should begin immediately and include digit and wrist flexion and extension. Range of motion exercises for the shoulder and scapula should be included to reduce shoulder weakness.

After week two, the patient can perform gravity-assisted flexion and extension of the elbow. Should the patient’s pain increase, discontinue these exercises.

Active range of motion (AROM) of the elbow should not begin until phase two, unless approved by the physician.

Phase Two: Range of Motion

The goal of phase two is to achieve full AROM of the elbow and wrist.

Weeks 6 through 8

• Discontinue orthosis
• Begin elbow AROM
• Begin AROM for wrist supination/pronation
• Begin passive wrist pronation
• Begin functional exercises (such as light swimming, jogging, dancing, etc)
• Begin isometric tricep exercises (such as pressing down on a tabletop/armrest with the arm at 90º)
• Continue scar management

At week six, discontinue orthosis use unless the patient still hasn’t achieved full extension of the elbow. AROM exercises of the wrist and elbow should be fully initiated.

Phase Three: Strengthening

Weeks 8 through 12

• Begin light strengthening
  • Bicep curls
  • Resistive pronation/supination with elbow at 90º
  • Weighted wrist curls
  • Resistive tricep extension
  • Hand grip strengthening
  • Shoulder strengthening may be included

At week eight, progressive strengthening should begin. Open chain exercises and plyometrics should be included, as well as activities appropriate to return to work.

By week 12, heavy strengthening should be implemented to insure appropriate scapular stabilization.

Benefits of Plyometric and Functional Exercises

If you’ve been around athletes, you’ve probably heard how plyometric exercises can rapidly improve strength and performance.

After a bicep tendon repair, it is most beneficial to focus on light plyometric activities while also focusing on functional exercise.

Having your patient start a low-competitive sport may also help them become more intrinsically motivated and consistent with their home exercise program. These open chain exercises will also increase strength to the other muscles of the upper extremity that may have weakened after the tendon repair of the repair.

A few functional activities for the upper extremity in phase three of therapy include basketball, golf, tennis, ball toss, and swimming.

Bicep tendon ruptures and repairs require careful attention, specifically in the first six weeks of therapy. Explain to your patient that the first phase of therapy is the most critical period to avoid a tendon rupture.

Review the plan of care with your patients. Provide clear instructions and appropriate patient education. This will reduce breakdowns in communication, increase adherence to treatment recommendations and home exercises, and help patients regain full function quicker. For ease, you can download a handout of these three phases of therapy above to quickly refer back to in your clinical practice.