What is the recommended rehabilitation protocol after elbow mass excision with 20% shaving of the triceps tendon?

Rehabilitation Protocol After Elbow Mass Excision with 20% Triceps Tendon Shaving

Begin immediate protected range of motion exercises within the first postoperative week, prioritizing early mobilization while protecting the triceps repair through progressive loading protocols adapted from tendon repair literature.

Immediate Postoperative Phase (Weeks 0-2)

Pain and Inflammation Management

• Apply cryotherapy during the first postoperative week to reduce pain and swelling, as it is inexpensive, easy to use, and has high patient satisfaction with rare adverse events 1, 2
• Cryotherapy benefits are most pronounced in the first 3 postoperative days for pain medication reduction and swelling control 1, 2
• Patient education on safe ice application is necessary to avoid cold injury 2

Early Range of Motion

• Initiate immediate elbow mobilization starting at postoperative day 1-10, as early active mobilization has been shown safe and effective after triceps-involving procedures 3
• Begin with gentle passive and active-assisted range of motion exercises
• Restrict elbow flexion to 90-45° during weeks 0-4 to protect the partially shaved triceps tendon, adapting protocols from tendon repair literature 1, 4
• Avoid resisted elbow extension during this phase to prevent excessive stress on the healing triceps 5

Muscle Activation

• Start isometric quadriceps-equivalent exercises (isometric elbow flexion/extension at neutral) from postoperative week 1 when they provoke no pain 1
• These exercises are safe and effective for reactivating muscles without placing excessive stress on healing tissues 1

Early Rehabilitation Phase (Weeks 2-4)

Progressive Range of Motion

• Continue protected range of motion with flexion restricted to 90-45° through week 4 1, 4
• Monitor for pain, effusion, or temperature increase as signs to slow progression 1
• Ensure no reactive swelling or pain with each advancement 1

Strengthening Initiation

• Begin closed kinetic chain exercises from week 2 postoperative, as these should be prioritized over open kinetic chain exercises in early phases 1
• Replace isometric exercises with gentle concentric and eccentric exercises when the elbow does not react with effusion or increased pain 1
• Avoid adding extra resistance or weight during this phase to prevent tendon elongation and protect the healing triceps 1

Modality Considerations

• Consider neuromuscular electrostimulation in combination with isometric training during the first 6-8 weeks to improve muscle strength and re-educate voluntary contraction 1
• This can be particularly useful for reactivating the triceps muscle after partial tendon shaving 1

Intermediate Rehabilitation Phase (Weeks 4-8)

Progressive Flexion Protocol

• Week 5: Progress flexion ROM to 90-30° 1, 4
• Week 6: Progress to 90-20° 1, 4
• Week 7: Progress to 90-10° 1, 4
• Week 8: Progress to full ROM 1, 4

Advanced Strengthening

• Introduce open kinetic chain exercises from week 4 postoperative in the restricted ROM of 90-45°, but add no extra weight for the first 12 weeks to prevent excessive stress on the partially compromised triceps 1, 4
• Continue closed kinetic chain exercises with progressive resistance 1
• Add neuromuscular training to strength training to optimize functional outcomes and movement quality 1

Advanced Rehabilitation Phase (Weeks 8-12+)

Full Strengthening Program

• After week 12, gradually introduce additional resistance to open kinetic chain exercises as tolerated 1
• Continue neuromuscular training combined with progressive strength training 1
• Focus on functional movement patterns relevant to the patient's activities 1

Criteria-Based Progression

• Use goal-based rehabilitation rather than strict time-based protocols, as rehabilitation duration should depend on the patient demonstrating ability to safely return to activities 1, 2
• Monitor for pain, swelling, and loss of motion as indicators to modify progression 1

Return to Activity Criteria (Typically 3-6 Months)

Objective Discharge Criteria

• No pain or swelling with activities 1, 4
• Full elbow range of motion achieved 1, 4
• Limb symmetry index >90% for strength testing (comparing operative to non-operative side) 1, 4
• For high-demand activities, consider requiring LSI of 100% 1, 4
• Completion of activity-specific training program 4

Functional Testing Battery

• Perform strength testing of elbow flexion and extension 1, 4
• Test triceps strength with the elbow fully flexed (beyond 90°), as the deep triceps insertion is critical for strength in this position 5
• Assess quality of movement, not just quantity 1, 4

Critical Pitfalls to Avoid

• Do NOT use postoperative elbow bracing routinely, as bracing is associated with increased failure rates and lower quality of life in tendon repairs 4
• Do NOT advance ROM or resistance if reactive swelling, pain, or temperature increase occurs 1
• Do NOT add weight to open kinetic chain exercises before 12 weeks to protect the compromised triceps tendon 1
• Recognize that the medial head of the triceps has a distinct deep insertion, and partial tendon shaving may affect strength differently at various elbow flexion angles 5
• Do NOT rely solely on time-based criteria for return to activities; use objective functional testing 1, 2

Rehabilitation Timeline Summary

The expected rehabilitation duration is typically 3-6 months for return to full activities, though this should be criteria-based rather than time-based alone 1, 2. Accelerated timelines can be used safely when appropriate criteria are met without adverse events 1, 2. The 20% triceps tendon shaving requires more conservative early protection than intact tendons, but aggressive early mobilization within protected ranges prevents stiffness while allowing healing 1, 3.