* This chapter is an updated version of an article that appeared in the Journal of Hand Therapy. (Blackmore SM, Jander RM, Culp RW. Management of distal biceps and triceps ruptures. J Hand Ther. 2006;19(2):154-168.
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Postoperative management of distal biceps tendon injuries varies according to the surgical repair technique. It is essential to obtain information about which of the many possible repair techniques was used in order to plan the most effective therapy program.
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Restoration of biceps muscle tendon unit length and elbow extension can be difficult if the elbow is immobilized longer than 3 weeks.
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Distal triceps tendon injuries are extremely rare and require careful monitoring in a therapy program.
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Partial distal biceps and triceps tendon injuries can be managed nonoperatively.
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Clinical research is considerably lacking for the therapy management of these injuries.
Therapy management for distal biceps and triceps ruptures is not well described in the literature. Evaluation, nonoperative management, and postoperative rehabilitation rationale and techniques are presented in this chapter. A variety of surgical repair techniques have been described (see Chapter 84 ). Laboratory and case series evidence suggests that these repairs can be actively mobilized earlier than has been reported in the past. , Clinical research is needed to confirm the efficacy of immediate active contraction of the repaired muscle tendon unit. Rehabilitation is often described in surgical review articles as bracing, range of motion (ROM), and strengthening. The specifics of the type of motion (active vs. passive) are often not identified, and techniques for strengthening (isometric/isotonic) are often excluded. Prospective studies comparing types and timing of repairs and timing and techniques for a postoperative program are needed. Lacking these data, the rehabilitation timetables and techniques outlined in this chapter are based on guidelines for tissue healing, strength of repair, prevention of complications, consideration of the medical and injury history, and review of the literature. Familiarity with the different treatment options assists the surgeon and therapist to tailor a therapy program that is optimal for each patient. Although various surgical repair techniques are used, none has been shown to produce a superior clinical outcome and to limit all complications.
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 these injuries spans the continuum of conservative care to operative repair. More often than not, operative intervention is chosen to maximize recovery. Based on expert clinical experience and opinion, a supervised rehabilitation program following surgical treatment is critical to ensure a successful return to preinjury functional levels. This chapter discusses the clinical presentation and evaluation of distal biceps and triceps tendon injuries as well as nonoperative and postoperative management.
Clinical Presentation and Examination
Examination begins first with a thorough history and physical. Typically, the mechanism of acute injury involves a load placed across an eccentrically contracting muscle belly. Most often, this occurs when performing heavy lifting or lowering for biceps injuries and a fall on an outstretched hand for triceps injuries. Those patients who have attritional triceps ruptures or ruptures after a total elbow arthroplasty may have compromised tendon integrity.
Like other muscles that span two joints, both the biceps and triceps can be particularly at risk when placed in an unfavorable loading condition. The patient often describes a sudden “pop” or “giving way” followed by pain and weakness in the extremity. Included in the differential diagnosis are fracture, joint dislocation, and intramuscular tear. These conditions must be ruled out before treatment is initiated.
Certain physical exam findings are characteristic for each injury and should be looked for when examining the patient. For distal biceps tendon pathology, there usually are no prodromal symptoms. The physical exam can reveal a change in the biceps contour, pain with elbow flexion and supination, ecchymosis, and difficulty palpating the biceps tendon distally. Partial ruptures and subacute injury can make the diagnosis more difficult. Elbow flexion and forearm supination strength are decreased and likely painful with biceps injury. The clinical exam technique known as the “biceps squeeze” test involves the examiner squeezing the biceps muscle belly and looking for forearm supination. It is akin to the Thompson test for Achilles tendon ruptures. A lack of supination indicates a positive test. Sensitivity is reported at 96%, and all 65 subjects in the control group had a supination response to the biceps squeeze test. With the hook test the patient is positioned in 90 degrees of elbow flexion and actively supinates. The examiner hooks his or her finger from the lateral side under the biceps tendon (described as a cord) as it passes through the antecubital fossa. If the distal biceps is intact, the finger can be placed under the “cord.” The hook test was compared with operative findings and MRI results. Sensitivity and specificity for full ruptures was 100% for the hook test in 36 patients compared with MRI (92% and 85%, respectively).
The most universal physical finding with a complete triceps rupture is the inability to extend the arm against gravity. Also, a palpable defect in the posterior arm may be found, though this is not always present. Other nonspecific findings include swelling and ecchymosis. The diagnosis of an acute triceps rupture can be missed due to swelling and pain. Viegas described the “modified” triceps Campbell Thompson test, similar to the Thompson test for Achilles rupture. The patient is positioned with the elbow flexed to 90 degrees, the upper arm supported, and the forearm and hand hanging relaxed. The examiner squeezes the triceps muscle belly with a fingertip grasp, which partially extends the normal elbow. If there is a full 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 this distinction is important since 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. MRIs are not considered necessary when the clinical examination identifies a full tear, but they may be more helpful for determining the degree of a partial tear.
Treatment Overview
Biceps Tendon Injuries
For distal biceps injuries, treatment is based on the location of rupture, patient age, level of activity, and, to a lesser degree, cosmetic concerns. Although both operative and nonoperative treatments have been reported, recommendations for surgical repair are supported in the literature. Nonoperative treatments of distal biceps tendon avulsions may lead to weakness in flexion and supination strength and diminution of endurance in the injured arm. Nonoperative treatment typically includes positioning the elbow at 90 degrees of flexion for several weeks and using analgesics for pain relief. Strengthening exercises follow the immobilization period if pain relief can be obtained. Several case series have reported significant losses in strength and endurance in patients treated nonsurgically. , Because of these results, and the generally excellent functional return with operative repair, surgical reattachment is recommended for most patients.
Comparative studies between one- and two-incision techniques for distal biceps repairs have shown little difference in outcome. , From a rehabilitation perspective, the postoperative treatment plan is the same for the one- and two-incision techniques. What may change 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, the timetable for advancement of therapy may be slower than the standard postoperative timetable.
Various attachment techniques are described in the literature, with none shown clinically to be superior. Alternatively, tenodesis may be performed to attach the distal biceps to the underlying brachialis muscle. Data comparing suture anchors and bone tunnels is conflicting, and variables such as size of suture anchor and quality of bone may be more important. , How much strength is “enough” is unknown at present. Theoretically, it is logical to believe that stronger fixation would allow for faster rehabilitation.
Triceps Tendon Injuries
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 ultimately develops 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. , There are case reports of nonoperative management of partial triceps ruptures involving 4 to 6 weeks of orthotic positioning in 30 degrees of flexion followed by ROM exercises.
Surgical management for complete distal triceps ruptures can be divided based on time since injury. Most acute injuries (diagnosis within 3 weeks from injury ) can be managed with immediate surgical reattachment of the tendon to the olecranon and may include anconeus rotation. Late reconstruction, however, often requires a tendon graft that may alter the triceps muscle resting length and often detrimentally affects outcome.
Several factors may dictate more protection in the early phase of rehabilitation ( Box 85-1 ). Alternatively, the suggested time frames for motion and strengthening in Table 85-1 have been moved forward if full motion is easily achieved at 4 weeks following biceps repairs and 6 weeks following triceps repairs. The therapist should be knowledgeable about the specifics of the surgical procedure to ensure that appropriate choices are made during the postoperative period.
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:
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Delayed primary tendon repair (>3 weeks since injury)
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Tendon repair with tendon graft or augmentation
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Excessive tension on the tendon repair
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Surgeon’s assessment of the quality of repair
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Rerepair of tendon
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Repair associated with a total elbow replacement
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Associated medical conditions that might delay tendon healing, such as anabolic steroid use, insulin-dependent diabetes, chronic renal failure secondary to hyperparathyroidism, metabolic bone disease, or rheumatoid arthritis
| Distal Biceps Repair | ||||||
|---|---|---|---|---|---|---|
| Author | Type of Repair | Timing of Repair After Injury | Immobilization/Protected Mobilization | Active Motion | Strengthening of Repaired Muscle | Outcome Overview (see articles for specifics) |
| Thompson 1 case | 2-incision anatomic with tendon graft | 8 weeks | 6 weeks immob, no position identified f/b splint limiting full e. until week 12. | Unclear, possible at week 6 | Week 16 | Full ROM, strength, function |
| Strauch 3 cases | 1-incision anatomic with suture anchors | 1–3 weeks | 2 weeks immob at 90 degrees elbow f. f/b hinged brace with e. stop at 80 degrees Allows passive f, and p, s with elbow at 90 degrees. At 6 weeks brace adjusted to progress elbow e by 20 degrees/week 2 weeks immob. At 90 degrees elbow f. | Week 8 |
| Full ROM, strength, function |
| McKee 53 cases | 1-incision anatomic with suture anchors | 2–3 weeks mean (0.3–12 weeks) | Week 2 with therapist. Full range expected by week 4 |
| Full ROM, 94%–96% strength, DASH mean score 8.2 ± 11.6 | |
| Davison 8 cases | 2-incision anatomic | Within 22 days | 4–6 weeks immob. At 90 degrees elbow flex and neutral rotation. | Week 4–6 AROM and AAROM | 3 months | 5–30 degrees limited s/p, full strength, decreased endurance. 1 R/U synostosis. 6 of 8 satisfied |
| D’Arco 13 cases | 2-incision anatomic | Not listed | 1 week immobilization f/b hinged brace with ROM blocks (range not identified). EPM program at 2 weeks | Week 4 |
| Full ROM, strength, return to premorbid activity level and 70%–90% very satisfied to satisfied. |
| Rantanen 19 cases |
| 0 days to 5 months | 3–5 weeks immob at 90–100 degrees flexion | Unclear, passive motion at 3–5 weeks | After AROM is normal | Excellent-to-good result in 18 of 19 cases |
| Cheung et al. 13 cases | 2-incision anatomic | 19 days | ECM day 1 post op. Allows 60 e week 1, 40 e week 2, 20 e week 4, full e week 6. Allow full p/s | Not listed | Week 8 | Mean DASH 42.8. Mean loss of 5.8 e, 10 s, 3.5 p. Strength at 89 to 91% of uninjured |
| D’Alessandro et al. 10 cases | 2-incision anatomic | 1–42 days | 3 weeks immobil. At 90 elbow f, full s. | Week 3 | Week 6 |
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| Kelly et al. 8 cases of partial rupture | Single posterior incision | 2 months–3 years | Sling for comfort for 6 week. Active and passive flexion and forearm rotation immediately and gravity assisted extension. “Use no more force than needed to lift a glass of water” | Day 1 |
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| Vidal et al. No cases, overview article | Not listed | Not listed | 7–10 days immobilization at 90 degrees flexion f/b hinged flexion assist brace with extension block at 30 degrees for 6–8 weeks | Week 6–8 |
| N/A |
| Distal Triceps Repairs | ||||||
|---|---|---|---|---|---|---|
| Author | Type of Repair | Timing of Repair After Injury | Immobilization/Protected Mobilization | Active Motion | Strengthening of Repaired Muscle | Outcome Overview (see articles for specifics) |
| Sierra et al. 1 case bilateral complete rupture | Repair through drill holes | Not listed |
| Week 6 | Not listed | 118%–134% of normal triceps strength |
| Kibuule et al. | Repair through bone tunnels | 4 weeks | 2 weeks immobilization at 45 degrees f/b 2 more weeks at 90 degrees | Week 4 |
| Not listed |
| Vidal et al. No cases, overview article | Not listed | Not listed |
| Week 6 | 4–6 months | N/A |
Complications
Potential complications exist with any of the surgical repair methods. The complications that accompany surgery for biceps injuries can be related to the surgical approach. The anterior one-incision approach has the major risk of injury to the radial nerve, , which may manifest as paresthesia when the superficial radial sensory nerve branch is involved or as the more problematic posterior interosseous nerve palsy. The major complication with the two-incision technique is radioulnar synostosis. , 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 paresthesias, loss of elbow and forearm motion, heterotopic ossification, median nerve paresthesias, anterior arm pain, persistent weakness, and superficial infections. Rerupture does not appear to be a significant problem with any method of biceps repair, even when patients do not adhere to their postoperative rehabilitation restrictions. Vidal and colleagues reported on two ruptures found in the literature. Katolik and coworkers described one case report of a delayed (4 weeks after injury) repair rerupturing at day 3 while the patient was in a long arm orthosis and lifting a small suitcase and rotating the arm into a supinated position. Possible causes for rerupture include inadequate attachment of tendon to bone, a repair under tension, or a patient who forcibly flexes or supinates against resistance in the early postoperative period.
In contrast to biceps repairs, rerupture can be more problematic following triceps surgery. , Other complications include ulnar neuropathy and loss of elbow motion. Prominent hardware has been reported, but this is more an issue with olecranon fracture treatment than triceps avulsion. In some instances the hardware is removed after the triceps repair has healed.
Postoperative Rehabilitation
The trend in hand therapy toward earlier active or passive mobilization of finger flexor and extensor tendon repairs instead of immobilization has improved patient outcomes. Based on these improved outcomes, the use of early motion for other tendon surgery in the upper extremity has been considered. In fact, Holleb and Bach did suggest early active motion for triceps repairs. Recently, there have been more reports of protected active contraction of the repaired biceps during the immediate postoperative period. Kelly and associates allowed full active and passive flexion and forearm rotation with gravity-assisted extension and sling support following repair of partial distal biceps injuries beginning on postoperative day 1. Specific guidelines for use of minimal force for active contraction were provided to the patients. Basic science support for active contraction is provided by Fernandez and colleagues. These authors found the mean force to bring the elbow to 90 degrees against gravity in a controlled lab setting was 32 ± 12 N during simulated active flexion. This amount of force was felt to be less than the pull-out limits of bone fixation repairs. However, supination, a major function of the biceps was not studied. All resistive tasks would exceed the pull-out limits and therefore would be prohibited. Other biomechanical studies support the idea that modern fixation methods for distal biceps repairs are capable of withstanding the force of active biceps muscle contraction against gravity. Kettler and coworkers found that the surgical fixation including the TwinFix, Quick, and BioCuff screw had lower failure loads in a controlled lab study and cautioned against early active biceps motion, especially for patients with poor bone quality. Bisson and associates examined two-incision approaches in a controlled lab study during cyclic loading and cautioned against early active biceps contraction with repairs using FiberWire.
The application of early active motion to repairs of tendons about the elbow, which are primarily tendon-into-bone repairs, requires consideration of the following: (1) the anatomy of the specific tendon and repair strength, (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 the healing of tendon to 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 healing in this location.
Impairments in passive range of motion (PROM) after repair of a distal biceps or triceps tendon are primarily due to elbow joint stiffness, muscle tendon unit shortening, or surgical complications (e.g., heterotopic ossification [HO], radioulnar synostosis) rather than tendon adhesions. No reports were found in a Medline search from 1966 to 2008 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 in which immobilization beyond 3 weeks after injury may result in ROM deficits. Morrey states that even 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.”
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 (ADL) techniques. During the next phase the focus is on regaining muscle tendon unit length through maintained muscle stretch. Active muscle function is frequently easily achieved. Any remaining joint stiffness is resolved at this time. In the scar maturation stage the patient performs exercises to strengthen the entire limb and scapulothoracic musculature, as well as core stabilization exercises, dynamic stabilization. and sport- and work-specific activities. The time frame for introduction of active use and strengthening of the repaired muscle–tendon unit varies depending on factors listed in Box 85-1 . A review of the literature was performed to identify published time frames for postoperative care and associated outcomes for distal biceps and triceps repairs ( Table 85-1 ). The therapist should use caution if instituting an early active motion program for the repaired muscle–tendon unit. The type of repair, quality of bone, and the patient’s ability to limit all resistive tasks play a part in the decision for this type of postoperative program.
The therapist’s awareness of potential surgical complications such as radioulnar synostosis can ensure timely identification of the problem and referral back to the surgeon and can help to avoid prolonged therapy when there is no potential to improve. Synostosis is observed by a progressive limitation of motion, inflammation, and pain with forearm rotation.
Active range of motion (AROM) and strengthening are introduced as postoperative precautions are lifted. Time frames for the three phases of rehabilitation are suggested in Table 85-2 . The guidelines are based on tissue healing principles, surgical repair strength, potential complications, and review of the literature. The time frames are, of course, only general guidelines that should be modified based on each patient’s unique situation and the factors listed in Box 85-1 . The review of the literature has identified time frames for full-time immobilization following distal biceps repair ranging from 1 to 8 weeks. The considerable variation 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 and the 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, a high level of patient subjective satisfaction, and return to most premorbid functional activities. Professional and collegiate athletes have returned to competitive football following biceps and triceps repairs 6 months after surgery. , 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.
