Management of Distal Biceps and Triceps Ruptures

SCIENTIFIC/CLINICAL ARTICLES JHT READ FOR CREDIT #025

Management of Distal Biceps and Triceps Ruptures Susan M. Blackmore, MS, OTR/L, CHT Ryan M. Jander, MD Randall W. Culp, MD The Philadelphia Hand Center King of Prussia, Pennsylvania

Once considered rare injuries, distal biceps and triceps muscle avulsions may be growing in incidence, as a greater percentage of the population stays active longer. The management of theses injuries spans the continuum of conservative care to operative repair. More often than not, operative intervention is chosen to maximize recovery. In these authors’ opinions, a rehabilitation program following surgical treatment is critical to ensure a successful outcome. This article is designed to familiarize the reader with the clinical entities of distal biceps and triceps tendon injuries as well as to offer insight into postoperative management.

EPIDEMIOLOGY Indirect injuries to either the distal biceps or triceps are extremely rare occurrences.1 Only 3% of biceps injuries are distal tendon avulsions.2,3 Most of the biceps injuries involve its proximal portion, usually the long head tendon. However, these injuries may now become more frequent as

Correspondence and reprint requests to Susan M. Blackmore, MS, OTR/L, CHT, The Philadelphia Hand Center, 700 South Henderson Road, Suite 200, King of Prussia, Pennsylvania 19406; e-mail: . doi:10.1197/j.jht.2006.02.001

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ABSTRACT: The management of distal biceps and triceps ruptures is reviewed. Epidemiology, clinical presentation, evaluation, surgical management, nonoperative management, and rehabilitation rationale and techniques are presented. Although various surgical repair techniques are used, none has been shown to produce superior clinical outcomes. The literature is lacking information to provide evidence-based decisions regarding rehabilitation strategies. Prospective studies comparing types and timing of repairs and timing and techniques for a postoperative program are needed. As that information is not yet available, the rehabilitation plan outlined in this article is based on timetables for healing tissue, strength of repair, prevention of complications, consideration of patient’s medical history and injury history, and review of the literature. Familiarity with the different treatment options assists the surgeon and therapist tailor a therapy program that is optimal for each individual patient. J HAND THER. 2006;19:154–69.

active lifestyles are maintained during aging. Distal biceps injuries are typically seen on the dominant side in 40- to 60-year-old males.2,4–8 The patient population often includes weight lifters, professional athletes, and laborers. There is also an association between distal biceps rupture and anabolic steroid use.9 Mechanical abrasion from a hypertrophic radial tuberosity, diminished vascular perfusion, and intratendinous degeneration are some of the proposed causative factors leading to distal biceps ruptures.10 In contrast to biceps injuries, triceps injuries occur almost universally at its distal insertion. No case reports in the English literature describe proximal tendon avulsions. Distal triceps ruptures are the most rare tendon rupture in the upper extremity (UE), representing less than 1% of all UE tendon injuries.11 Several case reports detail the occurrence of myotendinous and muscle belly injury.11–13 For the acute injury, the patient profile is predominantly male in the mid-40s, though the age range over which these injuries can be seen is broader.11,14 Triceps ruptures can be associated with a traumatic injury or following a surgical procedure where the triceps was reattached. There have been case reports of triceps ruptures following total elbow arthroplasty. Cited predisposing factors for this injury include systemic endocrine disorders, renal failure, anabolic steroid use, local steroid injection, and possibly chronic olecranon bursitis.1,15–17

EXAMINATION AND EVALUATION Examination and evaluation begin first with a thorough history and physical related to this injury, lifestyle factors, and comorbidities that may influence recovery. Typically, the mechanism of acute injury involves an eccentric load placed across a contracting muscle belly. Most often, this occurs when performing heavy lifting/lowering for biceps injuries and a fall on an outstretched hand for triceps injuries. Triceps injury can also occur spontaneously due to attritional conditions, due to a blow to the posterior elbow, or after surgical repair for another injury.18 Those patients who have attritional triceps ruptures or ruptures after a total elbow arthroplasty may have compromised tendon integrity. It is beyond the scope of this paper to discuss the distal triceps repair following total elbow arthroplasty. (Refer to the paper by Szekeres and King in this issue.) Like other muscles that span two joints, both the biceps and triceps can be particularly at risk when placed in an unfavorable loading condition such as lowering a very heavy object. The patient will often describe a sudden ‘‘pop’’ or giving way followed by pain and weakness in the extremity. Included as the differential diagnosis are fracture, joint dislocation, and intramuscular tear. It is critically important to rule out these clinical entities prior to treatment onset. Certain physical examination findings are characteristic for each injury and should be sought out when evaluating the patient. For distal biceps tendon pathology, there usually are no prodromal symptoms. A change in the biceps contour, pain with elbow flexion and supination, ecchymosis, and difficulty palpating the biceps tendon distally are detected on examination.19 Partial ruptures and subacute injury can make the diagnosis more difficult.19 Elbow flexion and forearm supination strength will be decreased and likely painful with biceps injury. The ‘‘biceps squeeze’’ test19 has been recently described; it involves the examiner squeezing the biceps muscle belly and looking for forearm supination, akin to the Thompson test for Achilles tendon ruptures. The test is determined to be positive when the squeezing does not result supination. Sensitivity of the squeeze maneuver is reported at 96% and all subjects in the control group (n ¼ 65) had a supination response to the biceps squeeze test.19 The most universal physical finding with a complete triceps rupture is the inability to extend the arm against gravity.11 A palpable defect in the posterior arm may be found, though this is not always present.11 Other nonspecific findings include swelling and ecchymosis. Viegas20 described a provocative maneuver as the ‘‘modified’’ triceps Campbell Thomson test, similar to the Thomson test for Achilles rupture. The patient is positioned with the elbow flexed to 90°, the upper arm supported, and the forearm and hand

hanging relaxed. The examiner squeezes the triceps muscle belly with a fingertip grasp, which will partially extend the normal elbow. If there is a triceps rupture, no elbow extension is observed. Sensitivity and specificity of this test have not been determined. Discerning between partial and complete injuries can be a diagnostic challenge, but is important as partial tears can be treated nonoperatively. For both biceps and triceps injuries, if the diagnosis is in question, reexamination can be performed several days following the injury when swelling and pain have subsided. An MRI can be obtained to look for tendon integrity. MRIs are not found to be necessary when the clinical exam identifies a full tear but may be more helpful to determine degree of partial tears.21–23

TREATMENT OVERVIEW For distal biceps injuries, treatment is based upon location of rupture, patient age, level of activity, and, to a lesser degree, cosmetic desires. Although both operative and nonoperative treatments have been reported, recommendations for surgical repair are supported in the literature.4,6 Nonoperative treatments of distal biceps tendon avulsions may lead to weakness in flexion and supination strength and endurance in the injured arm. Nonoperative treatment typically includes splinting the elbow at 90° for several weeks and if needed, using physical agents for pain relief. Strengthening exercises follow the immobilization period if pain relief can be obtained. Two published case series have reported significant losses in strength and endurance in nonsurgically treated patients.5,24 These results, and the generally excellent functional return with operative repair,7 appear to support the surgical reattachment as a viable option for many patients. The natural history of untreated complete triceps avulsion injuries is not well documented in the literature. However, as the only significant elbow extensor (the anconeus provides only minimal extension), a predictable elbow flexion contracture would ultimately develop due to muscle imbalance in addition to profound extension weakness and difficulty with overhead activities. Most authors recommend surgical reattachment of the complete triceps avulsion.11,25 There are case reports of nonoperative management of partial triceps ruptures involving four to six weeks of splinting in 30° flexion followed by range of motion exercises.26

SURGICAL MANAGEMENT There is more than one choice for surgical management, and controversy exists concerning the

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‘‘site for tendon reattachment, the method of surgical exposure and the technique of attachment.’’4 Operative repair of the distal biceps involves reattachment of the tendon to its insertion onto the radial tuberosity. One alternative was to attach the biceps to the brachialis tendon; this is technically easier and poses less risk to surrounding neurovascular structures.14 However, in contemporary practice, this nonanatomic reattachment is rarely performed due to the resultant significant limitations in supination motion and strength. When these injuries are treated within the first four weeks, direct attachment of the tendon to the bone is usually possible. Early direct repair can be performed even if the lacertus fibrosis is ruptured. As the time interval between injury and operative treatment grows longer, biceps contracture will limit tendon excursion if the lacertus fibrosis is ruptured and, as a result, tendon augmentation may be required.23 Tendon augmentation with fascia lata, flexor carpi radialis, and semitendinosus has been described.27–30 If the lacertus fibrosis is not ruptured, delayed direct repair can often be performed. With regard to anatomic reattachment, either one or two incision methods are used. Boyd and Anderson24 proposed the two-incision technique as a way to reduce radial nerve injury associated with the one-incision anterior approach; the biceps is mobilized through the anterior incision and reattached into the tuberosity through the posterior incision. The major drawback of the two-incision technique, aside from the added morbidity of the extended operative exposure, is the possibility of radioulnar synostosis.31,32 There have been suggested modifications to the two-incision technique involving a muscle splitting approach to reduce complications.31,33,34 The one-incision technique uses a single anterior incision. Tendon attachment to the tuberosity is more difficult with this method, and the major potential complication described is radial nerve palsy. Comparative studies between one and two incision techniques have shown little difference in outcome.8 From a rehabilitation perspective, there is no significant difference between the one and two incision techniques. What may impact the speed of postoperative mobilization is the quality of bone and the manner in which the tendon is attached to the tuberosity. If the patient has osteoporotic bone or if tendon augmentation has been used, therapy may be slower. Various attachment techniques are described in the literature with none shown clinically to be superior. The original technique uses a bone trough created in the radial tuberosity with the tendon secured by sutures tied over a bone bridge (Figure 1). More recently, suture anchor attachment to the tuberosity using a one-incision technique has been described7,8 (Figure 2). The stated advantage of using suture anchors is that it minimizes the amount of dissection ordinarily required for a single incision approach and 156

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FIGURE 1. Distal biceps sutured to radial tuberosity over a bone bridge using a bone trough. (A) The lateral incision posterior to the lateral epidondyle of the humerus. (B) The area of the reattachment through an osseous tunnel, with pull-out sutures in the bicipital tuberosity. (C) The reattached bicipital tendon with the sutures in place. Reprinted from reference 5. With permission from The Journal of Bone and Joint Surgery.

therefore minimizes the risk to surrounding neurovascular structures. We favor a bone anchor using a sliding/locking suture technique (Figure 3). More recently, the Endobuttonä (Acuflex, Smith and Nephew, Inc., Anover, MA) has been used for tendon reattachment into bone (Figure 4). One cadaveric biomechanical study demonstrated that the

FIGURE 2. Suture anchor fixation for distal biceps repair. Reprinted from British Journal of Hand Surgery. Balabaud L, Ruiz C, Nonnemacher J, Seynaeve P, Kehr P, Rapp E. Repair of distal biceps ruptures using a suture anchor and an anterior approach. J Hand Surg [Br] 2004;Apr 29(2):178–82. With permission from the British Society for Surgery of the Hand.

FIGURE 3. Bone anchor using a sliding/locking suture technique for distal biceps repair.

Endobuttonä has the greatest pull out strength of any attachment method.35 Data comparing suture anchors and bone tunnels are conflicting, and variables such as size of suture anchor and quality of bone may be more important.35,36 It is unknown how much strength is ‘‘enough’’ at the present time. Theoretically, it is logical to believe that stronger fixation would allow for faster rehabilitation.

FIGURE 4. Endobutton technique used for distal biceps repair. Reprinted with permission.35 The Journal of Shoulder and Elbow Surgery Board of Trustees.

Surgical management for complete distal triceps ruptures can be divided into categories based on time since injury. Most acute injuries can be managed with immediate surgical reattachment of the tendon to the olecranon. As with biceps injuries, various attachment methods can be used, which include sutures through olecranon bone tunnels and suture anchors11,37,38 (Figure 5). Chronic tears in which proximal retraction of the muscle tendon unit makes direct reattachment impossible can be managed through several methods. An autologous tendon augmentation is woven through the native triceps and attached to the olecranon. In effect, this graft lengthens the native tendon so that it can reach across the elbow joint.39 Alternatively, allograft, anconeus rotation, and ligament augmentation device have been described.11,18 However, any graft affects the triceps muscle resting length and often detrimentally affects outcome. There are several factors that may require more protection in the early phase of rehabilitation outlined in Table 1. Alternatively, the suggested time frames for motion and strengthening in Table 3 have been moved forward if full motion is easily achieved at four weeks following biceps repairs and six weeks following triceps repairs. The therapist should be informed about the specifics of the surgical procedure and expected outcome to ensure that appropriate choices are made during the postoperative time period.

FIGURE 5. Distal triceps repair. Reprinted from reference 11. By permission of Mayo Foundation for Medical Education and Research. All rights reserved. April–June 2006 157

TABLE 1. Modifiers to the Rehabilitation Time Table The time frame for introduction of active motion, restoring full length to the repaired muscle tendon unit and strengthening may be delayed if any of the following factors are present and warrants discussion between therapist and surgeon: 1. Delayed primary tendon repair (over three weeks since injury) 2. Tendon repair with tendon graft or augmentation 3. Excessive tension on the tendon repair 4. Surgeon’s assessment of the quality of repair 5. Rerepair of tendon 6. Repair associated with a total elbow replacement 7. Associated medical conditions that might delay tendon healing such as: anabolic steroid use, insulin dependent diabetes, chronic renal failure secondary to hyperparathyroidism, or rheumatoid arthritis12,54–56

SURGICAL COMPLICATIONS Potential complications exist with any of the surgical repair methods described in the previous section. With regard to biceps injuries, complications can be stratified according to surgical approach. The anterior one-incision approach has the major risk of injury to the radial nerve;14,40 this can manifest as parasthesia of the superficial sensory branch or as a more problematic posterior interosseous nerve palsy. The major complication with the two-incision technique is radioulnar synostosis.31,32 If the repair is performed through muscle instead of immediately adjacent to bone, the risk of this complication may be reduced. Other complications, which can occur with any surgical approach, include lateral antebrachial cutaneous nerve parasthesias, loss of elbow and forearm motion, heterotopic ossification (HO), median nerve parasthesias, anterior arm pain, and superficial infections.14,22,33,40 Rerupture does not appear to be a significant problem with any method of biceps repair, even when, anecdotally, patients are not adherent to their postoperative rehabilitation restrictions. In contrast to biceps repairs, rerupture can be more problematic following triceps surgery.11 Other complications include ulnar neuropathy and loss of elbow motion.11,14 Prominent hardware has been reported, but this is more an issue with olecranon fracture treatment rather than with triceps avulsion.11 In some instances the hardware is removed after the triceps repair has healed.

POSTOPERATIVE REHABILITATION CONCEPTS The trend in hand therapy toward earlier active or passive mobilization of intrasubstance tendon repairs instead of immobilization has improved patient outcomes following repair of tendons in the digits and wrist.41 Due to these improved outcomes, one might consider the use of early motion for all tendon surgery in the UE. In fact, Holleb and Bach42 did suggest early active motion for triceps repairs. However, before generalizing early active motion to repairs of tendons about the elbow, which are tendon into bone 158

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repairs, we must consider the following: 1) the anatomy of the specific tendon; 2) basic science research on tendon healing; 3) complications reported in the literature; 4) outcomes with standard postoperative immobilization; and 5) patient ability to comply with more complicated programs. Biologically, the goal is to promote tendon ingrowth into bone for these repairs. Load to failure information for various fixation methods has been determined through cadaveric studies. It is not known if early active or passive motion delays or facilitates ingrowth at the repair site. Impairments in passive range of motion after repair of a distal biceps or triceps tendon are primarily due to elbow joint stiffness, muscle tendon unit shortening, or surgical complications (heterotopic ossification, radioulnar synostosis) rather than due to tendon adhesions. No reports were found in a Medline search from 1966 to 2005 regarding tenolysis of a repaired distal biceps or triceps muscle. Currently, support for early passive motion for biceps and triceps repairs stems from experience with other elbow injuries where immobilization beyond three weeks after injury may result in range of motion deficits.43 Morrey44 identifies that a minor nonarticular injury can cause joint contracture. Anterior capsule hypertrophy is noted via scanning electron microscopy with both direct and minimal trauma or indirect injury. ‘‘Severe elbow contracture has been observed after surgery for lateral epicondylitis and after elbow trauma that appears to result only in hemarthrosis without any articular or extensive soft tissue damage. Under these circumstances the elbow may contract rapidly, often within 2 to 3 weeks’’.44 Rehabilitation in the early postoperative phase includes protecting the repaired tendon, preventing elbow joint stiffness, and instruction in one-handed adaptive activities of daily living techniques. Subsequently, in the fibroplasia stage of tendon healing the focus is on regaining muscle tendon unit length through maintained muscle stretch, as active muscle function is frequently easily achieved. Any remaining joint stiffness is resolved at this time. In the scar maturation stage the patient performs strengthening of the entire limb and scapulo-thoracic musculature, core stabilization exercises, dynamic stabilization, and sport/work specific activities.45 The time frame for introduction of active use and

TABLE 2. Literature Review: Timetables for Postoperative Rehabilitation Following Distal Biceps Repairs Distal Biceps Repair Author

Type of Repair

Timing of Repair Postinjury

Thompson,9 one case

Two incision anatomic with tendon graft

Eight weeks

Strauch et al.,4 three cases

One incision anatomic with suture anchors

One to three weeks

McKee et al.,40 53 cases

One incision anatomic with suture anchors

0.3–12 weeks, mean ¼ 2.3 weeks

Davison et al.,51 eight cases

Two incision anatomic

Within 22 days

D’Arco et al.,52 13 cases

Two incision anatomic

Not listed

Rantanen and Orava,21 19 cases

12- two incision; 7- one incision all anatomic Two incision anatomic

0 days to five months

Two incision anatomic

1–42 days

Cheung et al.,7 13 cases

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D’Alessandro et al.,2 10 cases

19 days

Immobilization/ Protected Mobilization Six weeks immobil., no position identified f/b splint limiting full e. until week 12. Two weeks immobil. at 90 f. f/b hinged brace with e. Stop at 80° Allows passive f, and p, s with elbow at 90. At six weeks brace adjusted to progress elbow e by 20°/week Two weeks immobil. at 90° elbow f.

Four to six weeks immobil. at 90° elbow flex and neutral rotation. One-week immobilization f/b hinged brace with ROM blocks (range not identified). ECM program at two weeks Three to five weeks immobil. at 90–100° flexion ECM day 1 postop. Allows 60 e week 1, 40 e week 2, 20 e week 4, full e week 6. Allow full p/s Three weeks immobil. at 90 f, full s.

Active Motion

Strengthening of Repaired Muscle

Outcome Overview (See Articles for Specifics)

Unclear, possible at week 6

Week 16

Full ROM, strength, function

Week 8

Week 12; unrestricted use by week 16

Full ROM, strength, function

Week 2 with therapist. Full range expected by week 4 Weeks 4–6: AROM and AAROM

Week 6. Unrestricted use by week 8

Full ROM, 94–96% strength, DASH mean score 8.2

Three months

5–30° limited s/p, full strength, decreased endurance. One R/U synostosis. Six of eight satisfied Full ROM, Strength, return to premorbid activity level and 70–90% very satisfied to satisfied.

Week 4

Week 4: submax isomet. Week 6: submax isotonic. Week 8 as tolerated

Unclear, passive motion at three to five weeks Not listed

After AROM is normal

Excellent to good results in 18 of 19 cases

Week 8

Mean DASH 42.8. Mean loss of 5.8 e, 10 s, 3.5 p. Strength at 89–91% of uninjured

Week 3

Week 6

Subjective 9.75 on 10 scale, up to 25% decreased s and f strength and endurance. Full athletic activity

immobil. ¼ immobilization; f/b ¼ followed by; f ¼ elbow flexion; e ¼ elbow extension; p ¼ forearm pronation; s ¼ forearm supination; ECM ¼ early controlled motion; ROM ¼ range of motion; AROM ¼ active range of motion; AAROM ¼ active assisted range of motion; DASH ¼ Disabilities of the Arm, Shoulder and Hand Questionnaire.

TABLE 3. Authors Suggested Timetable for ECM Postoperative Rehabilitation Distal Biceps Repair

Immobilization 10–14 days at 90° elbow flexion, neutral forearm rotation and wrist in neutral/free

Protected Motion (ECM program): Progressive Extension Block, Full Passive Flexion and Passive Forearm Rotation at 90° Flexion 10–14 days to four to six weeks. Extension block as follows: week 2: 90° ext.; week 3: 45–60° ext.; week 4: 30–45° ext.; week 5: full to 30° ext.; week 6: full ext. allowed

Active Motion of Repaired Muscle

Strengthening

Begin active flexion 10–12 weeks for elbow and supination at four to flexion and supination. six weeks Begin with submax Begin passive extension isometric advance to if needed at weeks 6–8 submax isotonic contractions. Shoulder and hand strengthening earlier as needed without stressing repair.

Unrestricted Activity Five months

Distal Triceps Repair

Immobilization 10–14 days at 30° elbow extension, neutral rotation and wrist in neutral/free. Night full extension splint if full passive ext. is difficult to achieve.

Protected Motion (ECM Program): Progressive Flexion Block, Full Passive Extension and Active/ Passive Forearm Rotation with Elbow in Extension 10–14 days to six weeks. Flexion block as follows: week 2: 30°; week 3: 45°; week 4: 60°; week 5: 90°; week 6: full flexion allowed

Active Motion of Repaired Muscle

Strengthening

Begin active extension 10–12 weeks for elbow at six weeks extension. Begin with Begin passive flexion submax isometric if needed at week 8 advance to submax isotonic contractions. Shoulder and hand strengthening earlier as needed without stressing repair.

Unrestricted Activity Five months

Protected motion phase: weeks 1–4(6); progressive motion phase (fibroplasia): weeks 4(6)–10(12); strengthening phase (scar maturation): week 10(12) to five months. ext. ¼ extension; submax ¼ submaximal.

strengthening of the repaired muscle–tendon unit will vary depending on factors listed in Table 1. A review of the literature was performed to identify published time frames for postoperative care and associated outcomes for distal biceps repairs (Table 2). Therapist awareness of signs and symptoms of surgical complications such as radioulnar synostosis can ensure timely referral back to the surgeon and prevent unnecessary extensive therapy when instead; problems need to be addressed by the surgeon. Synostosis is observed by a progressive limitation of motion, inflammation, and pain with forearm rotation. Range of motion and strengthening are introduced as postoperative precautions are lifted. Time frames for the three phases of rehabilitation are suggested in Table 3. The guidelines are based on tissue healing principles, knowledge of repair strength, prevention of complications, and on review of the literature. The time frames are of course only general guidelines that are modified based on each patient’s unique situation and the factors listed in Table 1. The review of the literature has identified time frames for full-time immobilization following distal biceps repair ranging from one to eight weeks. The considerable variation 160

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may be due to the choice of surgical procedure and personal experience or opinion. It is interesting to note that regardless of the type of surgery performed, the time frames for immobilization, or initiation of active motion and strengthening, the outcomes are generally favorable. Most outcomes report full or near full motion, nearly full strength, minimal limitations in endurance, high level of patient subjective satisfaction, and return to most premorbid functional activity. Professional and collegiate athletes have returned to competitive football following biceps and triceps repairs six months after surgery.9,25 Most of the past literature has not used standardized outcome measures, thus making it more difficult to compare study results. Patient satisfaction and function are often subjective reports, rather than validated outcomes instruments.

THERAPIST EXAMINATION AND OUTCOME MEASURES Examination procedures are introduced during the rehabilitation phases as postoperative precautions

are lifted. These include range of motion, edema (via inspection of infracondylar recesses and girth measurements), manual muscle testing, muscle length testing, sensibility (if a concomitant nerve injury has occurred), and functional testing. Joint specific outcome measures may include the Patient Rated Elbow Evaluation46 and the American Society of Elbow Surgeon’s self-report.47 (Refer to MacDermid and Michlovitz article in this issue.)

PROTECTED PHASE Splinting Following Biceps Repairs There are several splint options to immobilize or to allow protected mobilization following surgery. Biceps repairs are immobilized initially in a long arm splint positioning the elbow in 90° of flexion, the forearm in neutral rotation, and the wrist supported. To provide even more protection to the repair site, the forearm can be positioned in supination. Another alternative is a commercially available hinged brace locked in 90° of elbow flexion; the forearm positioned in neutral with/without an attached wrist support. In our experience, it is more difficult to maintain proper immobilization of forearm rotation with most of the commercially available hinged splints unless a wrist component is used. If early controlled motion (ECM) is desired, one option is to unlock the hinged splint. A range of motion block is set to limit end range elbow extension

FIGURE 6. Commercial hinge splint (Bledsoeä, 2601 Pinehurst Dr., Grand Prairie, TX 75051) used with ROM blocks and adapted to provide dynamic flexion assist following distal biceps repair.

during exercise sessions. The patient passively assists elbow flexion and actively extends through defined ranges. These range of motion blocks are advanced weekly to allow progressive extension. A Velcro sling or hinge lock immobilizes the elbow at 90° when not exercising. Another alternative is the use of elastic bands such as TherabandÒ (NorthCoast Medical, CA) to provide a dynamic elbow flexion assist (Figure 6). A custom fabricated thermoplastic-hinged splint can be an alternative to the commercial splint (Figure 7A, B). The illustrated splint was made with thermoplastic hinges and a thermoplastic block to end range elbow extension. An insert can be used to position the elbow in 90° when not performing protected motion (Figure 8). Dynamic assist to flexion may/may not be used (Figure 9). Alternatively, metal hinges applied to a thermoplastic splint can provide adjustable blocks to limit end range extension and can be locked in any static position. All of these splints also allow for easy performance of exercises in the splint. Most authors’ support limiting the amount of elbow extension following bicep repair to some degree to protect the site of repair from undue stress and strain for several weeks (see Table 2). Our suggested treatment paradigm is listed in Table 3.

FIGURE 7. (A) Custom thermoplastic-hinged splint with extension block used following distal biceps repair. Wrist inclusion in the splint is optional, but does provide more control of forearm rotation. (B) Pattern for custom hinged splint with extension block and the wrist included. April–June 2006 161

FIGURE 8. Insert used with custom hinged splint to position the elbow at 90° when not performing protected motion program.

Splinting Following Triceps Repairs Following triceps repairs, the elbow is typically immobilized in a long arm splint initially positioning the elbow in 30–45° of elbow flexion, the forearm in neutral and the wrist often supported. The literature varies widely in recommendations for postoperative management. Van Reit et al.11 reported on a series of 23 repairs where immobilization ranged from two to six weeks in a position ranging from full extension to 90° flexion, others had dynamic extension splints, some had continuous passive motion (CPM), and still others used a sling and began immediate active motion. Due to the considerable variability in management, the decision for postoperative position is unique to each patient and is made by the surgeon based on tension and quality of the tendon repair, other concomitant injuries, and the patient’s medical history. This information must be shared with the therapist to facilitate optimum outcomes.

FIGURE 9. Custom thermoplastic-hinged splint with extension block and dynamic flexion assist used after distal biceps repair. 162

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If ECM is desired following triceps repairs, a hinged splint blocking elbow flexion can be used and allows for dynamic/gravity assisted elbow extension (Figure 10). The range of motion block is advanced weekly to allow for progressive elbow flexion. The hinged splint allows for easy performance of passive elbow extension and active elbow flexion through a defined range. It is locked in one position when not exercising. If using dynamic extension traction, care must be taken to prevent the elastic component from resting on the posterior surface of the elbow to prevent skin breakdown. If the elastic component is on the medial and lateral sides of the splint, care must be taken to prevent the dynamic traction from acting to assist elbow flexion that may occur if the traction rises anterior to the joint axis and as greater amounts of flexion are allowed in the postoperative period. Greer and Miklos-Essenberg48 illustrated the use of a dynamic splint following triceps repair. Patient education must include prohibiting active elbow extension, especially when using the arms to push out of a low chair. The active extension in this early phase could lead to avulsion or rupture of the repaired tendon. If the patient has difficulty with obtaining full passive elbow extension in this phase, typically the elbow is splinted at end range extension at night to facilitate range of motion gains. In our clinical experience, the addition of dynamic traction to hinged splints for biceps and triceps repairs is often unnecessary. In fact, for the reliable

FIGURE 10. Hinged splint with ROM block for flexion used following distal triceps repair. Gravity assists extension. The patient can also perform passive elbow extension in the splint. The splint is locked when not performing exercises.

patient, a static custom thermoplastic long arm splint is issued and removed to perform the ECM home program. A dynamic traction splint is used for the patient who has difficulty relaxing the repaired muscle or is unreliable when performing exercises out of a protective splint.

PROTECTED PHASE Therapy Program Whether a static, hinged, or dynamic splint is used, ECM can begin in this phase. If the static splint is used, the patient must be reliable when performing the exercise program out of the splint. Lack of adherence to range of motion limitations or active contraction of repaired muscle tendon unit may result in tendon rerupture. If a hinged splint is used, blocks are placed to limit end range and dynamic motion assists can be used to prevent this problem. A Medline review of the literature from 1966 to 2005 did not reveal scientific data to identify the optimum time frame to begin ECM program for either biceps or triceps repairs. Reports indicate starting ECM as early as day 1 postoperatively.7 In our setting ECM begins day 10 to day 14 postoperatively. This allows for the reduction of postoperative edema and pain before commencing range of motion. The authors recommend initiating some amount of passive elbow motion no later than three weeks postoperatively to prevent joint capsular and ligament tightness. Following biceps repairs the ECM program (Figure 11A–C) includes the following: full passive elbow flexion; active and passive elbow extension to 90° (or less as determined by the surgeon if there is tension on the repaired tendon or if the tendon was shortened in surgery); and passive forearm rotation with the elbow flexed at 90°. To ease performance of the home program, the flexion/extension exercises are often performed in the supine position. Gravity assists elbow flexion to prevent the biceps from actively contracting, and extension against gravity prevents unnecessary deconditioning of the triceps. Increased extension is allowed with each successive week (Table 3). A template splint can block range for those patients who do not use a hinged splint and have difficulty limiting extension to various degrees during exercises (Figure 12). For all patients, the elbow is maintained in 90° flexion, neutral forearm rotation and wrist supported when not performing exercises. Active elbow and forearm range of motion is initiated between weeks 4 and 6 following surgery. The ECM program for triceps repairs (Figure 13A–D) includes the following: full passive elbow extension, active and/or passive elbow flexion to 30°, the use of

FIGURE 11. Early controlled motion (ECM) home program following distal biceps repair. (A) Full passive elbow flexion in supine. (B) Active/passive elbow extension to establish ROM blocks. (C) Passive forearm supination and pronation with elbow supported in 90° of flexion. a template splint, and passive forearm rotation. Again, gravity can assist motion performance during the home program. Increased flexion is allowed with each successive week as outlined in Table 3. At week 6, full active elbow and forearm range of motion is permitted. Frequently the patient with a triceps repair has edema in the hand. Following triceps April–June 2006 163

FIGURE 12. Home program using a template splint to limit degree of elbow extension. The template splint is remolded as progressive extension is allowed. repairs, the hand is in a dependent position for much of the day due to immobilization of the elbow in the extended position. Elevation above heart level, hand pumping, and the use of compressive glove or wrap

are recommended beginning immediately after surgery. For both biceps and triceps repairs, wrist and digit motions are unrestricted. Generally, the patient can be followed only to update the home program and modify the splint range of motion blocks. In the event passive motion goals (full elbow flexion for biceps and full elbow extension for triceps) are not met during the first three to four weeks, additional therapy interventions including thermal agents, therapist assisted motion within range limits, edema control, pain management, and scar mobilization can begin. If needed, isometric strengthening for the hand and shoulder rotation, abduction, and adduction can be performed in this early phase. Care must be taken while performing shoulder active motion exercises in the first and early second phase of treatment. Combined elbow extension and end range shoulder extension will stress the biceps repair and combined elbow flexion and end range shoulder elevation will stress the triceps repair. If ECM is not desired when more protection to the repair is needed, full-time immobilization is used for no more than three to four weeks. Passive elbow flexion from 60° to full flexion is performed for the

FIGURE 13. Early controlled motion (ECM) home program for distal triceps repairs. (A) Full passive elbow extension. (B) Active/passive elbow flexion to establish ROM block. (C) Use of a template splint to block degree of active flexion. Template is remolded as progressive flexion is allowed. (D) Passive forearm pronation and supination with the elbow held in extension. 164

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next two weeks for biceps repairs. Passive elbow extension from 45° to full extension is performed for triceps repairs also for the next two weeks. Range blocks can be increased weekly by 20°. At weeks 6–8 full active elbow motion is allowed.

PROGRESSIVE MOTION PHASE Active contraction of the muscle of the repaired tendon begins anywhere from four to six weeks postoperatively for the biceps ECM program and at six weeks for the triceps ECM program. Both active supination and elbow flexion are emphasized for biceps repairs. Elbow extension against gravity is emphasized for triceps repairs to encourage active motor recruitment rather than having extension assisted by gravity. Techniques to restore end range of active motion include place and hold exercises at available end range, proprioceptive neuromuscular facilitation (PNF) patterns of exercise, and neuromuscular electrical stimulation. Treatment may be required for capsular tightness or joint contractures. This can include thermal agents, joint mobilization, sustained positioning, and splints designed to increase range of motion. Initially, composite elongation of the muscle over two joints is delayed until nearly full active motion is achieved, or at approximately eight weeks following surgery. Treatment for muscle–tendon unit shortening can include contract–relax exercises for biceps and triceps sustained positioning of the muscle at available end range, strengthening of the antagonist, thermal agents followed by or in conjunction with stretch, and yoga positions.

strengthening includes both elbow flexion and forearm supination, and triceps strengthening includes positioning the forearm in supination, neutral, and pronation to address all three heads of the triceps. Scapulo-thoracic muscular strength is addressed at this time if diminished due to immobilization of the limb. The strengthening program for the repaired biceps and triceps is advanced to isotonic concentric exercises, using free weights, elastic bands and PNF diagonal patterns, and eventually to eccentric muscle contractions. A full complement of stabilization and mobilization exercises is performed as needed (Figure 14A, B) to return the patient back to his or her preinjury activities. In the event of significant deconditioning due to advanced age or other medical conditions, a patient might also receive instructions for a core-strengthening program. Strengthening intensity is reduced if pain at the surgical site develops. Sports-specific and work-specific activities begin at

STRENGTHENING PHASE Strengthening exercises are often delayed until weeks 10–12. Return of strength may take several months and the delay in initiating the program does not appear to impact the end result (Table 2). Active range of motion should be equal to passive range at this time. Treatment for passive limitations can continue as long as improvements continue to be made. In our experience, beginning strengthening after weeks 10–12 ensures adequate tendon healing to tolerate the stress the strengthening program puts on the repair site. Strengthening begins with up to 50% effort isometric contraction of the repaired muscle tendon unit. Determination of effort is made by measuring maximal voluntary contraction (MVC) of the uninvolved side with a hand held dynamometer and having the patient exercise up to 50% of MVC. Contraction begins in midrange and advances to the end of available range of motion. Effort increases to maximum if pain does not develop. Biceps

FIGURE 14. (A) Demonstration of weight-bearing and scapular control exercise to facilitate full limb reconditioning. (B) Demonstration of the Body BladeÒ (Hymanson, Inc., Los Angeles, CA). April–June 2006 165

16 weeks postoperatively. Weight bearing through the UE can also begin at this time. Collaboration with the team therapist or trainer is essential when rehabilitating the athlete. Rehabilitation for a heavy manual laborer will require a full understanding of the job demands and in some instances require job modification until five months postsurgery.

NONOPERATIVE MANAGEMENT The focus of this paper is on surgery and postoperative management. However, the literature for nonoperative management was reviewed. Nguyen et al.49 outlined specific interventions for nonoperative management for distal biceps rupture in a case study. These authors suggest that the lack of success for nonoperative management may be due to limited or no treatment other than immobilization. The treatment outlined consisted of 12 weeks of care including ultrasound, tissue tractioning massage, ice, at week 4 progressing to isometric exercises for elbow wrist and forearm, and additional strengthening at week 6.49 Specifics of the therapy interventions are thoroughly described in the article. Only a clinical diagnosis was made such that degree of (partial vs. complete) tendon rupture could not be confirmed. The patient obtained full return of elbow flexion and supination strength but the authors did not state how strength was measured.49 Other studies5,6 do not specifically identify rehabilitation methods other than immobilization period and time frame for initiation of strengthening. The conclusions from the literature are that the losses for supination are greater than losses of elbow flexion power and endurance when biceps ruptures are treated nonoperatively. Functional deficits due to the losses appear to be related to the degree of tendon rupture and are specific to individual patient and their preinjury activity level. Nonoperative management for triceps ruptures is reserved for the patient with a partial rupture.39,50 Morrey39 further cautions that delay in repair of the incompetent triceps can lead to a less-reliable reconstructive procedure. Farrar and Lippert16 suggest a nonoperative management program for partial triceps ruptures. The elbow is splinted at 30° flexion for four weeks. Bos et al.26 described a partial rupture case where the elbow was splinted at 30° for six weeks. Range of motion exercises followed immobilization. Full strength and range of motion was achieved at six months postinjury. Further specifics for nonoperative management could not be identified in the literature. Most authors support some degree of immobilization of the elbow until pain is relieved. Our suggested nonoperative program for partial biceps ruptures includes splinting the elbow in 90° elbow flexion 166

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and full supination. Seiler et al.10 performed an anatomic study, which supported the supinated position. Positioning the arm in pronation could contribute to hypovascularity within the healing tendon. Triceps partial ruptures are splinted in 30° of elbow flexion. Nonsteroidal antiinflammatory drugs, physical agents, and massage can be used to decrease pain and edema. If a positive response is achieved, we have found that pain should be reduced within three to four weeks. Passive motion and an arc of pain-free active motion can be performed to maintain joint motion during the splinting time period. A strengthening program commences as pain is reduced. The program advances from isometrics to isotonic concentric and finally to eccentric contractions of the injured muscle tendon unit. The strengthening program is performed for all muscles of the UE as needed.

Outcome: Review of Selected Literature Case studies and case series identify a high level of patient satisfaction following distal biceps surgical repair.21,39,51 Many of these studies have only subjective estimates of satisfaction with some reports of function. Recent authors used standardized outcome measures.40 D’Arco et al.52 suggested a series of clinical, functional, and radiographic measures to assess outcome. It is interesting to note that Davison et al.51 reported complete subjective satisfaction for six of eight patients even given deficits in range of motion, strength, and endurance. Strauch et al.4 reviewed the literature for distal biceps repairs. They report that most authors recommend operative anatomic repair and that comparative studies ‘‘uniformly found deficits of supination power and endurance for patients treated non-operatively.’’ Baker and Bierwagen5 compared operative to nonoperative outcomes for 10 surgical cases and three nonsurgical cases. All surgical cases had full strength and endurance for elbow flexion and extension. Nonoperative cases had a 50% decrease in supination endurance, 30% decrease in supination strength, and a 20% decrease in flexion strength and endurance through mechanical dynamic testing. Morrey et al.6 also found a 30–40% loss of flexion and supination strength with nonoperative treatment. The strength deficit was not functionally limiting to the patients, but the limitations in endurance for activity were problematic. Rantanen and Orava’s21 review reported fair outcomes for two nonoperative cases. Leddy et al.53 treated 20 cases nonoperatively. Full motion was achieved and supination strength and endurance loss were greater than flexion loss. No patient regretted the nonoperative choice.53 Some authors suggest that improved outcome is achieved when the tendon is repaired within the first two to four weeks after rupture.4 Many authors divide outcomes into those patients with early and

late repairs, again suggesting improved outcomes for earlier repairs. As time passes, the muscle tendon unit may shorten if the lacertus fibrosis is detached and the tract to the biceps is obliterated. This makes retrieval of the tendon more difficult and may require the use of tendon or fascia lata interpositional grafts.4,9 Rantanen found that up to a three-year delay between injury and surgery did not affect the ability to obtain good results using an anatomic reinsertion of the tendon. He also states that poor surgical outcomes are due to complications from surgery requiring reoperation.21 There is considerably less literature for the outcomes of triceps repairs. Van Riet et al.11 retrospectively reviewed their series of 23 surgical treatments following distal triceps rupture. Primary repairs were performed on 14 patients and a variety of reconstructive procedures were performed on nine elbows. Three of the 14 patients experienced a rerupture of their primary triceps tendon repair. Average elbow range of motion at an average 93 months follow-up was 10–136°. Functional range deficits in two patients were felt to be due to posttraumatic arthritis and not due to the triceps repair. Endurance testing of the repairs achieved 99% compared to the uninvolved extremity, and strength testing was 82%.11 Good results have been reported with nonoperative management for partial triceps rupture.13,26 Mair et al.25 reported on six professional football players with partial tears up to 75% who returned to competitive football when treated nonoperatively. Three of the six were followed up with MRI after rehabilitation and testing revealed the tendons capacity to heal. However, the degree of partial tear did not correlate with potential to heal. A 75% tear healed and a 30% tear did not heal.

CONCLUSIONS At this time, there is little consensus for the type of surgical management and rehabilitation guidelines following distal biceps ruptures. There is more consensus for the management of distal triceps ruptures, but less published literature. Operative management is often indicated due to the good to excellent outcomes for most patients and low complication rates. Nonoperative management can be used for the patient with low physical demands for full/partial ruptures for biceps or partial ruptures of triceps if pain can be eliminated and function is satisfactory for the individual patient. Delayed repairs are more technically difficult for the surgeon to perform but also have reasonable outcomes. We have suggested a timeline and specific rehabilitation techniques that have not been well defined in previous literature. Rehabilitation requires modifications based on individual patient factors.

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JHT Read for Credit Quiz: Article #025

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue. There is only one best answer for each question. #1. The evidence for basing any rehab strategies following distal biceps avulsion and repair is: a. conclusive b. inconclusive c. unequivocal d. overwhelming #2. The majority of biceps injuries involve: a. the distal portion b. the muscle belly c. the proximal portion of the short head d. the proximal portion of the long head #3. The majority of triceps injuries involve: a. the muscle belly b. the proximal insertion

c. the distal insertion d. concomitant biceps avulsion #4. The following may impact the speed of post-op mobilization following biceps repair: a. the patient’s occupation b. the quality of bone and manner in which the tendon is attached to the tuberosity c. the portals used if performed arthroscopically d. the patient’s white count #5. Following distal biceps reattachment, loss of ROM of the elbow is most likely caused by: a. joint stiffness b. tendon adhesions c. pain d. weakness When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of three or more to get full credit.

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