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)
Goals:
- 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
Activity:
- 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)
Goals:
- 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
Precautions:
- Nlifting with affected upper extremity
- Nfriction massage tthe proximal biceps tendon / tenodesis site
Activity:
- 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)
Goals:
- Normalize strength, endurance, neuromuscular control
- Return tchest level full functional activities
Precautions:
- 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
Activity:
- 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)
Goals:
- Continue stretching and PROM as needed/indicated
- Maintain full non-painful AROM
- Return to full strenuous work activities
- Return to full recreational activities
Precautions:
- Avoid excessive anterior capsule stress
- With weight lifting, avoid military press and wide grip bench press.
Activity:
- 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