Biceps Tenodesis Protocol

Progression to the next phase based on Clinical Criteria and/or Time Frames as Appropriate.

Phase I – Passive Range of Motion Phase (starts approximately post op weeks 1- 2)


  • Minimize shoulder pain and inflammatory response
  • Achieve gradual restoration of passive range of motion (PROM)
  • Enhance/ensure adequate scapular function

Precautions/Patient Education:

  • Nactive range of motion (AROM) of the elbow
  • Nexcessive external rotation range of motion (ROM) / stretching. Stop when you feel the first end feel.
  • Use of a sling tminimize activity of biceps
  • Ace wrap upper forearm as needed for swelling control
  • Nlifting of objects with operative shoulder
  • Keep incisions clean and dry
  • Nfriction massage tthe proximal biceps tendon / tenodesis site
  • Patient education regarding limited use of upper extremity despite the potential lack of or minimal pain or other symptoms


  • Shoulder pendulum hang exercise
  • PROM elbow flexion/extension and forearm supination/pronation
  • AROM wrist/hand
  • Begin shoulder PROM all planes ttolerance /dnot force any painful motion
  • Scapular retraction and clock exercises for scapula mobility progressed tscapular isometric exercises
  • Ball squeezes
  • Sleep with sling as needed supporting operative shoulder, place a towel under the elbow tprevent shoulder hyperextension
  • Frequent cryotherapy for pain and inflammation
  • Patient education regarding postural awareness, joint protection, positioning, hygiene, etc.
  • May return tcomputer based work

Milestones tprogress tphase II:

  • Appropriate healing of the surgical incision
  • Full PROM of shoulder and elbow
  • Completion of phase I activities without pain or difficulty

Phase II – Active Range of Motion Phase (starts approximately post op week 4)


  • Minimize shoulder pain and inflammatory response
  • Achieve gradual restoration of AROM
  • Begin light waist level functional activities
  • Wean out of sling by the end of the 2-3 postoperative week
  • Return tlight computer work


  • Nlifting with affected upper extremity
  • Nfriction massage tthe proximal biceps tendon / tenodesis site


  • Begin gentle scar massage and use of scar pad for anterior axillary incision
  • Progress shoulder PROM tactive assisted range of motion (AAROM) and AROM all planes ttolerance
  • Lawn chair progression for shoulder
  • Active elbow flexion/extension and forearm supination/pronation (Nresistance)
  • Glenohumeral, scapulothoracic, and trunk joint mobilizations as indicated (Grade I - IV) when ROM is significantly less than expected. Mobilizations should be done in directions of limited motion and only until adequate ROM is gained.
  • Begin incorporating posterior capsular stretching as indicated
  • Cross body adduction stretch
  • Side lying internal rotation stretch (sleeper stretch)
  • Continued Cryotherapy for pain and inflammation
  • Continued patient education: posture, joint protection, positioning, hygiene, etc.

Milestones tprogress tphase III:

  • Restore full AROM of shoulder and elbow
  • Appropriate scapular posture at rest and dynamic scapular control with ROM and functional activities
  • Completion of phase II activities without pain or difficulty

Phase III - Strengthening Phase (starts approximately post op week 6-8)


  • Normalize strength, endurance, neuromuscular control
  • Return tchest level full functional activities


  • Dnot perform strengthening or functional activities in a given plane until the patient has near full ROM and strength in that plane of movement
  • Patient education regarding a gradual increase tshoulder activities


  • Continue A/PROM of shoulder and elbow as needed/indicated
  • Initiate biceps curls with light resistance, progress as tolerated
  • Initiate resisted supination/pronation
  • Begin rhythmic stabilization drills
  • External rotation (ER) / Internal Rotation (IR) in the scapular plane
  • Flexion/extension and abduction/adduction at various angles of elevation
  • Initiate balanced strengthening program
    • Initially in low dynamic positions
    • Gain muscular endurance with high repetition of 30-50, low resistance 1-3lbs)
    • Exercises should be progressive in terms of muscle demand / intensity, shoulder elevation, and stress on the anterior joint capsule
    • Nearly full elevation in the scapula plane should be achieved before beginning elevation in other planes
    • All activities should be pain free and without compensatory/substitution patterns
    • Exercises should consist of both open and closed chain activities
    • Nheavy lifting should be performed at this time
      • Initiate full can scapular plane raises with good mechanics
      • Initiate ER strengthening using exercise tubing at 30° of abduction (use towel roll)
      • Initiate sidelying ER with towel roll
      • Initiate manual resistance ER supine in scapular plane (light resistance)
      • Initiate prone rowing at 30/45/90 degrees of abduction tneutral arm position
      • Begin subscapularis strengthening tfocus on both upper and lower segments
  • Push up plus (wall, counter, knees on the floor, floor)
  • Cross body diagonals with resistive tubing
  • IR resistive band (0, 45, 90 degrees of abduction
  • Forward punch
  • Continued cryotherapy for pain and inflammation as needed

Milestones to progress tphase IV:

  • Appropriate rotator cuff and scapular muscular performance for chest level activities
  • Completion of phase III activities without pain or difficulty

Phase IV – Advanced Strengthening Phase (starts approximately post op week 10)


  • Continue stretching and PROM as needed/indicated
  • Maintain full non-painful AROM
  • Return to full strenuous work activities
  • Return to full recreational activities


  • Avoid excessive anterior capsule stress
  • With weight lifting, avoid military press and wide grip bench press.


  • Continue all exercises listed above
    • o Progress isotonic strengthening if patient demonstrates no compensatory strategies, is not painful, and has no residual soreness
  • Strengthening overhead if ROM and strength below 90 degree elevation is good
  • Continue shoulder stretching and strengthening at least four times per week
  • Progressive return to upper extremity weight lifting program emphasizing the larger, primary upper extremity muscles (deltoid, latissimus dorsi, pectoralis major)
    • o Start with relatively light weight and high repetitions (15-25)
  • May initiate pre injury level activities/ vigorous sports if appropriate / cleared by MD

Milestones to return to overhead work and sport activities:

  • Clearance from MD
  • No complaints of pain
  • Adequate ROM, strength and endurance of rotator cuff and scapular musculature for task completion
  • Compliance with continued home exercise program

Neofitos Stefanides, MD