Biceps tenodesis — rehabilitation protocol

Who is this for?

Adults after isolated tenodesis of the long head of the biceps, with a typical postoperative course. The tendon fixation site and method, tissue quality, associated procedures and surgeon’s instructions must be known. This programme is not automatically a protocol for rotator cuff, subscapularis or labral repair.

Shoulder and elbow — two separate decisions

We do not prolong restrictions on the entire shoulder simply because the tenodesis needs protection. Early shoulder movement remains unloaded and within the tolerated range. If active movement is painful, passive or assisted movement is used initially. Active movement of the shoulder itself is not routinely delayed until week 6.¹

Restrictions on active elbow flexion and supination — turning the forearm palm upwards — arising from the specific tenodesis still apply. In this programme, resisted elbow flexion and resisted supination are avoided for the first 6 weeks. Permission for greater shoulder movement does not authorise lifting or testing biceps strength.^{1, 2}

Sling use and elbow movement

The sling is used initially, usually for 2–4 weeks according to the orthopaedic surgeon’s instructions, to support the forearm and keep the elbow flexed. It is removed for hygiene and prescribed exercises. It is not intended to prevent all shoulder movement for six weeks.

The poster’s phrase “full motion without resistance” does not override an individual restriction on active elbow flexion or supination. While such a restriction applies, permitted mobility is maintained passively or with appropriate assistance. Do not force elbow extension or keep the elbow completely still unless this has been prescribed.

Passive, assisted and active movement

Passive movement is guided by a therapist, a trained helper or a suitable aid; the patient does not generate it through deliberate contraction of the operated limb’s muscles. During active-assisted movement, the patient contributes while receiving help. Active movement is performed independently. The poster’s abbreviations mean: PROM — passive range of motion; AAROM — active-assisted range of motion; AROM — active range of motion.

Early shoulder movement

Initially choose a comfortable lying or seated position with the arm supported. If active movement is painful, the unaffected hand or physiotherapist helps guide the operated arm. Progress to independent elevation without a weight. Do not force movement by twisting or leaning the trunk or abruptly shrugging the shoulder.

Elbow and forearm

Perform permitted movement with the upper arm supported and without added load. If active flexion or supination is temporarily prohibited, use passive or assisted movement as instructed. The absence of a weight does not mean that every movement is passive or free of biceps contraction.

Later strengthening

Elbow flexion with a light band and supination exercises belong to the phase after resistance is permitted, not the first postoperative weeks. Begin with low resistance and avoid jerking. Develop rotator cuff and scapular strength alongside this, adding more demanding functional tasks later.

A daily programme and separate resistance training

The physiotherapist selects the exercises, range, repetitions and frequency and checks technique. Later resistance training has its own dosage and recovery intervals. Patients do not need to perform every possible exercise or make up for a missed session with heavier loading.

Phase I — the first 2 weeks

Goals: protect the fixation site, control pain, maintain hand and wrist motion and restore shoulder mobility early.

Begin progressive shoulder movement in the first postoperative days. If independent movement is painful, start with passive or active-assisted movement in a comfortable supported position. Introduce active movement early as tolerated, without added weight, jerking or forcing end range. Progress from gravity-reduced positions towards sitting and standing.¹

Hand and wrist movement begins from the start. Elbow and supination exercises must respect the postoperative restrictions on biceps activity. Avoid strong active elbow flexion, resisted supination and lifting.

Progression: pain is controlled, there are no concerning wound findings, and permitted movements can be reproduced correctly without abrupt biceps contraction.

Phase II — approximately weeks 2–6

Increase shoulder range and the contribution of active movement according to tolerance and movement quality. Do not artificially restrict shoulder range solely because a tenodesis has been performed. Wean from the sling as instructed, without abruptly moving to loaded use of the arm.

Continue to protect fixation: no resisted elbow flexion or supination, lifting or sudden loading. Active elbow movement resumes according to the separate instructions for the tenodesis, not simply because the shoulder already moves more freely.

Progression: good tolerance of the existing programme, improving mobility and arm control, and clearance for the next loading stage. Absence of pain does not replace assessment of healing.

Phase III — approximately weeks 6–12

Restore full functional active range of motion. Once this phase is permitted, introduce light resistance for elbow flexion and supination progressively from approximately week 6. Strengthen the rotator cuff and scapular stabilisers as well. Starting light resistance does not authorise heavy lifting.^{1, 2}

Controlled technique and tolerance of a low load come first. Increase one variable at a time: resistance, repetitions or task difficulty. If movement deteriorates or pain increases substantially after exercise, return to the previous dose.

Phase IV — approximately months 3–6

Around weeks 12–16, develop biceps, shoulder and scapular strength and endurance. Then progressively reproduce the loading required for work and sport.

Return to higher loads is usually considered around months 4–6, depending on the operation, recovered strength, mobility and activity demands. This is not a guaranteed date or automatic clearance for full training.³

Criteria: functional range of motion, good arm control, strength appropriate to the task and tolerance of repeated loading without significant pain or deterioration the following day.