Reviewed by Tyler Tice, PT, DPT, OCS, ATC
Introduction:
Distal biceps tendon rupture is an injury resulting in the complete tearing of the distal biceps tendon. The mechanism of biceps tendon rupture often involves a forceful eccentric contraction of the bicep. Though rare, treatment for distal biceps tendon rupture is usually surgical, as non-operative treatment generally results in a loss of functional strength with elbow flexion and radioulnar supination.
Bicep tendon repair surgeries have two common approaches: single incision and double incision. There are multiple factors influencing a patient’s surgical approach such as mechanism of injury and surgeon preference.
Athletes who sustain a distal biceps tendon rupture are generally younger and more active than the average patient population that receives this surgery and they usually require more intensive rehabilitation to reach their prior level of function and return to sport.
The purpose of this article was to assess multiple rehabilitation approaches to compare their effectiveness in functional outcomes and return to sport.
Methods:
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was performed using the MEDLINE, Cochrane, Web of Science and Scopus databases for articles referring to treatment and rehabilitation of distal biceps tendon rupture in athletes.
The initial search yielded 1254 results. Those results were then scanned for duplicates, accessibility and exclusion criteria, leaving 10 articles that were ultimately included in this review.
Results:
This systematic review demonstrated that the return to sport rate of athletes following distal biceps tendon rupture was 97.5%, interestingly this figure as well as the recovery time seem to be independent of postoperative immobilization times and strengthening protocols used. Although return to work is expected in 3-4 months, return to sport time for athletes ranged from 7-15 months. The authors attributed this to the increased demands that athletes place on their biceps.
Although there is no consensus on optimal rehabilitation or strengthening protocols, most studies focused on early mobilization followed by a graded strengthening protocol. Most of the rehabilitation protocols featured in these studies included a 2-week post-operative period of immobilization with strengthening exercises beginning at the fourth post-operative week. No differences in return to sport time were noted between differing rehabilitation protocols.
Discussion/Clinical Utility:
This systematic review is useful because it allows us to look at a collection of the current best evidence regarding the rehabilitation of distal biceps tendon rupture. Though there was no noted difference in recovery times between different rehabilitation protocols, it is important to note that there are similarities in the overall course of treatment for this type of pathology.
Based on the evidence presented, it is important to start with a short period of immobilization to allow the injured tissue to begin healing. After this, the next stage in the rehabilitation process is to regain range of motion in the affected arm. Next at around 4-weeks post-surgery, strengthening of the injured muscle can begin. Although this doesn’t give any specific recommendations in terms of a strengthening or stretching protocol, it does provide a basic timeline and methodology to guide treatment for athletes who are hoping to return to sport. Due to the variable nature of human anatomy and recovery times in the population, specific protocols can have limited utility in the clinic. It is instead preferable to allow basic concepts paired with continual assessment of a patient’s progress and pain state to guide the course of rehabilitation.
One of the limitations of this study is that it focused specifically on athletes, a relatively small portion of the population. Though the data cannot be blindly generalized to the entire population, this is still useful data because the overall course of treatment is likely to remain mostly unchanged. The main difference in the athletic population is the higher level of function that is required to get back to. Keeping this in mind, a non-athletic member of the population without comorbidities is likely to actually have a faster recovery due to the lower demands that will be placed on their bicep muscles.
References
Pitsilos, C., Gigis, I., Chitas, K., Papadopoulos, P., & Ditsios, K. (2022). Systematic review of distal biceps tendon rupture in athletes: Treatment and Rehabilitation. Journal of Shoulder and Elbow Surgery, 31(8), 1763–1772. https://doi.org/10.1016/j.jse.2022.02.027