1. Biceps Tendon Rupture Repair Sara Gralitzer Ruthana Rosner Anthony,2014

2. Distal Biceps Brachii Rupture Overview Distal biceps brachii ruptures are rare and typically occur in middle aged men. (Sarda, 2013; Chillemi, 2007) This is typically the result of a forceful eccentric contraction. (Grewal, 2012) 96% of biceps ruptures involve the long head of the biceps tendon. (Sarda, 2013) Traumatic long head biceps brachii ruptures typically occur from fall on an outstretched arm, powerful deceleration of the arm during pitching or a powerful supination force (Sethi, 1999; Mariani, 1986) Typically long head biceps brachii ruptures occur as a result of a degenerated tendon (Sethi, 1999)

3. Anatomy Long head biceps tendon Distal biceps tendon Bicpital groove Radial Tuberosity (Sethi 1999) www.rad.washington.edu

4. Distal Biceps Tendon Rupture Surgeries Modified single incision Two cortical buttons were placed intramedullary at the radial tuberosity to reattach the distal biceps tendon (Siebenlist, 2011) Suture anchors to attach distal biceps to radial tuberosity, three sutures are used. (Ro, 2012) Biotenodesis screw Single anterior incision The distal biceps tendon is anchored to the radial tuberosity with the use of a biotenodesis screw (Khan, 2003) This has shown better results than suture anchors due to the tendon displacing from the anchors. (Krushinski, 2007)

5. Biceps Tendon Rupture Surgical Repair Suture AnchorsBiotenodesis Screw Ro, 2012 Khan,2004

6. Long head biceps Tendon repair Tenodesis Open subpectoral incision The tendon was placed in the biciptal groove with a Biotenodesis screw into the humerus. Surgical complications are less in a tenodesis repair (Anthony 2014) Anthony, 2014

7. Rehabilitation Long Head  The most commonly torn tendon of the biceps.  Rehabilitation: typically follows same protocol as rotator cuff tear repair  Return to sport: 6-8 weeks  Phase 1: weeks 0-4  Immobilization-3 weeks  Improve PROM  Phase 2: weeks 4-6  Improve AROM  Phase 3: weeks 6-10  Initial Strengthening  Proprioception  Agility  Power  Phase 4: weeks 8-12  Advanced Strengthening  Sport Specific Exercises

8. Distal Biceps Tendon Rehabilitation Goals by Phase Phase 1: (0-3 weeks) Decrease inflammation and Pain Protect Repaired tissue Avoid Active Supination, Excessive Shoulder Extension, and Biceps Contraction Begin PROM Phase 2: (3-6 weeks) Protect Repaired Tissue No resisted supination Begin AAROM and progress to AROM Full supination by week 5 Isometric Triceps

9. Goals Continued Phase 3: (6-10 weeks) Discontinue use of Elbow Brace: 0-145 0 by 8 th week Begin RROM Phase 4: (10-16 weeks) Begin Biceps Isometrics Begin UBE Begin Proprioception Phase 5: (16-26 weeks) Begin Biceps Contractions Begin Agility and Power training Phase 6: (26 to RTP) Sport Specific Exercises

10. ROM/Stretching Phase 1 Immobilization: 90 0 flexion Hinged Elbow Brace: 45 0 to full flexion PROM: Elbow at 90- Flexion and Supination AROM: Elbow at 90-Extension and pronation Joint Mobilizations: Grades 1 and 2 Phase 2 Hinged Elbow Brace: 10 0 to full flexion AAROM  AROM: Flexion, Extension, Pronation, and Supination Passive  Assisted Active Supination Joint Mobilizations: Grades 3 and 4 Phase 3 Continue phase 2 exercises RROM: Flexion, Supination PNF Diagonals: Upper Body D1 and D2 Phase 4 RROM: Elbow extension Continued stretching for flexion, extension, supination, and pronation Phase 5 Continue Stretching elbow flexors, extenders, pronators, and supinators Phase 6 Continue Stretch.

11. Strengthening Phase 1 Hand and Wrist Gripping exercises Phase 2 Scapulothoracic Strength Wrist flexion and extension Isometric Triceps Phase 3 Concentric Triceps Concentric wrist extensor/flexor Concentric Shoulder Phase 4 Biceps Isometric UBE Phase 5 Light concentric Biceps Phase 6 Sport specific Return to throwing Eccentric Biceps

12. Cardiovascular Exercise Phase 1 Recumbent Bike Phase 2 Aquatherapy Gait Training Stationary Bike Phase 3 Aquatherapy Aquajogging Stationary Bike Phase 4 Aquatherapy Return to Running Stationary Bike Phase 5 Return to Running Elliptical Phase 6 Sport Specific

13. Proprioception Progressions Phase 1 Phase 2 Phase 3 Begin when active Flexion is achieved without pain Double arm raise  eyes closed Phase 4 Hands and Knees on ground Progress to 1 hand on ground. Phase 5 Two hand balance on Bosu Ball Progress to 1 hand on Bosu Ball Phase 6 Proprioception perturbation Sport Specific exercises

14. Speed, Power, Agility Begin late phase 5 Speed Shadow Boxing Punching bag Speed Bag Number wall Power Plyometrics Rebounder Agility Ball toss Underhand  Over hand Wall ball Catching and throwing

15. References 1. Anthony SG, McCormick F, Gross DJ, Golijanin P, Provencher MT. Biceps tenodesis for long head of the biceps after auto-rupture or failed surgical tenotomy: results in an active population. J. Shoulder Elbow Surg. 2. Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal biceps tendon rupture: Current concepts. Injury 2013;44(4):417-420. doi:10.1016/j.injury.2012.10.029. 3. Grewal R, Athwal G, MacDermid JC, et al. Single Versus Double-Incision Technique for the Repair of Acute Distal Biceps Tendon Ruptures A Randomized Clinical Trial. J. Bone Jt. Surg. 2012;94-A(13):1166-1174. 4. Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J. Shoulder Elbow Surg. 1999;8(6):644-654. 5. Mariani ME, Cofield RH, Askew LJ, Li G, Chao EYS. Rupture of the Tendon of the Long Head of the Biceps Brachii Surgical Versus Nonsurgerical Treatment. Clin. Orthop. 1988;228:233-239. 6. Siebenlist S, Elser F, Sandmann GH, et al. The double intramedullary cortical button fixation for distal biceps tendon repair. Knee Surg. Sports Traumatol. Arthrosc. 2011;19(11):1925-1929. 7. Ro DH, Baek GH, Gong HS. Modified Single-Incision Distal Biceps Tendon Repair Using Three Suture Anchors: Surgical Technique. Hand Surg. 2012;17(3):409-412. 8. Khan W, Agarwal M, Funk L. Repair of distal biceps tendon rupture with the Biotenodesis screw. Arch. Orthop. Trauma Surg. 2004;124(3):206-208. 9. Krushinski EM, Brown JA, Murthi AM. Distal biceps tendon rupture: Biomechanical analysis of repair strength of the Bio-Tenodesis screw versus suture anchors. J. Shoulder Elbow Surg. 2007;16(2):218-223.