Should a biceps tendon rupture be immobilized or have restrictions of activity?

Management of Biceps Tendon Rupture: Immobilization and Activity Restrictions

For distal biceps tendon ruptures treated surgically, complete immobilization is not necessary and early active range of motion within 1-2 days post-repair is safe and effective, with activity restrictions limited to avoiding lifting more than 1 pound for the first 6 weeks. 1, 2, 3

Acute Post-Injury/Post-Repair Phase (0-2 Weeks)

Surgical Management

• Surgical repair is recommended for acute distal biceps ruptures to optimize functional outcomes, particularly for active individuals who require strength in flexion and supination. 1, 2
• After surgical repair using modern fixation techniques (cortical button or modified two-incision approach), the arm should be placed in a sling for only 1-2 days, not weeks. 3

Early Mobilization Protocol

• Immediate active range of motion should begin within 1-2 days after repair, as this approach has been proven safe without increasing rerupture risk. 3
• Early mobilization (self-weaning from sling and active range of motion as tolerated during first 6 weeks) produces significantly better QuickDASH scores and greater passive forearm supination compared to 6 weeks of immobilization. 4
• A randomized controlled trial of 101 patients demonstrated no difference in tendon rerupture rates between early mobilization (2% rerupture) versus 6 weeks of immobilization (2% rerupture), confirming the safety of early motion. 4

Protected Activity Phase (0-6 Weeks)

Activity Restrictions

• Limit lifting to 1 pound or less for the first 6 weeks while allowing activities of daily living as tolerated by the patient. 3
• The American Academy of Orthopaedic Surgeons recommends using a protective device that limits excessive strain on the repair during this period, though complete immobilization should be avoided. 5
• Patient compliance with weight restrictions is essential to prevent rerupture, as documented reruptures occur with non-compliance to protective protocols. 5

Range of Motion Goals

• Patients following immediate active range of motion protocols achieve mean flexion of 141 degrees and mean extension of 0 degrees by final follow-up. 3
• Early mobilization produces significantly more passive forearm supination and trends toward greater active extension and supination compared to prolonged immobilization. 4

Progressive Strengthening Phase (6 Weeks to 5 Months)

Strengthening Initiation

• Formal strengthening exercises may begin as early as 8 weeks post-repair, with protected return of motion emphasized during the first 8 weeks. 1, 2
• Unrestricted range of motion and gentle strengthening should begin after the 6-8 week protection period. 2

Return to Full Activity

• Return to unrestricted activities, including heavy lifting, is typically allowed by 5 months after surgery. 1, 2
• The American Academy of Orthopaedic Surgeons recommends planning return to sports between 3-6 months post-surgery for surgically treated tendon repairs. 5

Expected Functional Outcomes

Strength Recovery

• Patients following early mobilization protocols demonstrate isometric flexion strength 5% greater on the operated side and dynamic flexion strength 12% greater than the non-operated side. 3
• Supination strength may be 9-11% less on the operated side compared to the non-operated side, though this does not result in clinically significant disability. 3
• Mean DASH scores of 3.6 (range 0-11.4) indicate minimal pain and disability at 2-year follow-up. 3

Critical Pitfalls to Avoid

Excessive Immobilization

• Prolonged immobilization beyond 1-2 days is unnecessary and may delay functional recovery without providing any protective benefit. 4, 3
• Six weeks of immobilization does not reduce rerupture rates compared to early mobilization but results in worse patient-reported outcomes. 4

Premature Heavy Loading

• While early active motion is safe, lifting restrictions must be maintained for 6 weeks to avoid premature stress to the healing repair. 3
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning, but this does not mean unrestricted activity. 6

Non-Compliance Monitoring

• Patient education regarding the importance of adhering to weight restrictions while maintaining active motion is crucial, as non-compliance is associated with documented reruptures. 5