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Post Surgical Biceps Tenodesis Rehab

Physio Penrith Recommended Rehabilitation

Post Surgical Biceps Tenodesis Rehab at Sydney Muscle & Joint Physio Penrith

Why have I had biceps tenodesis surgery?

The long head of the biceps is located at the shoulder girdle and is at risk of injury and degenerative changes due to its proximity to the rotator cuff and the acromion. Since the long head of the biceps can act as a secondary stabiliser of the shoulder, it is also subject to injury during high speed overhead movements; repetitive overhead movements; or forceful shoulder activities when the elbow is straight. It can be implicated in injuries such as sub-acromial pain syndrome (SAPS), shoulder impingement, rotator cuff tears and SLAP tears. The long head of biceps tendon can also become inflamed and irritated. Bicep tendon degeneration and/or tearing can cause significant shoulder discomfort and dysfunction.


A biceps tenodesis is a surgical procedure that may be performed for treatment of severe shoulder symptoms involving the biceps tendon, including inflammation or partial tears. It may be performed in isolation or as part of a larger shoulder surgery, including surgery involving the rotator cuff. During the biceps tenodesis, the normal attachment of the biceps tendon on the shoulder socket is cut and reattachment of the tendon is made on the humerus (upper arm bone). This takes the pressure off the biceps attachment and places the attachment below the actual shoulder joint. The goal is to eliminate the shoulder pain coming from the bicep tendon. Different techniques are used to perform a biceps tenodesis.

Biceps tenodesis rehab Physio

What are the different surgical techniques used in biceps tenodesis surgery?

The surgical techniques can be broken down in to two categories: soft tissue techniques and hardware fixation techniques.Both techniques are effective, and are based on surgeon preference and patient indications.


The primary soft tissue technique is the “open key hole procedure”. An open keyhole technique relocates the tendon within the groove in the humerus bone after cutting it from its original location in the shoulder. The procedure involves the proximal end of the biceps tendon being rolled into a ball and then sutured together as a mass, this procedure is repeated with the needle placement reversed to create a locking pattern of the sutures. A knot is used to secure the sutures to the transverse ligament in the shoulder instead of to the bone.


The hardware fixation techniques include screw fixation or endobutton fixation. In the screw fixation the tendon is detached and then place in a hole made at the top of the bicipital groove. Then an interference screw is placed over the tendon, in to the bone, to hold it in place.

Most often your surgeon will have clear physiotherapy-led rehab guidelines that they like patients to follow and these are certainly respected and followed by our Penrith physiotherapists.

Key factors in post-surgical biceps tenodesis rehab

At Sydney Muscle & Joint Physio Penrith our physiotherapists pride ourselves on a high quality, consistent approach and this is very important when you participate in a post-surgical rehab program. High quality physiotherapy at Sydney Muscle & Joint Clinic means:

  • we correspond with your surgeon to ensure we follow the protocols specific to you and the surgical technique

  • we use useful measurements to ensure consistent progress - these include range of motion, muscle strength measurements and grip strength

  • we use research supported outcome measures - SPADI, quickDASH, UEFI and PSEQ questionnaires

  • we follow specific phases of rehabilitation that are in line with phases of healing

Phases of soft tissue healing:

  • Acute (2-4 days) – Protection Phase: a soft tissue injury is termed as acute from the initial time of injury and while the pain, bleeding and swelling is at its worst. Your body’s aim at this point is to protect your injury from further damage.

  • Sub-Acute (up to 6 weeks) – Repair Phase: a soft tissue injury is termed as sub-acute when the initial acute phase makes a transition to repairing the injured tissues. This phase commonly lasts up to six weeks post-injury when your body is bust laying down new soft tissue and reducing the need to protect your injury as the new scar tissue etc begins to mature and strengthen.

  • Late Stage (6 weeks to 3 months)– Remodelling Phase: your body does not magically just stop tissue healing at six week post-injury. Healing is a continuum. At six weeks post-soft tissue injury your healing tissue is reasonably mature but as you stretch, strength and stress your new scar tissue it often finds that it is not strong enough to cope with your increasing physical demand. When your body detects that a repaired structure is still weaker that necessary, it will automatically stimulate additional new tissue to help strengthen and support the healing tissue until it meets the demands of your normal exercise or physical function.

Phases of post-surgical biceps tenodesis rehab

Phase 1 (surgery to 2 weeks) - rehabilitation appointments begin 5-8 days after surgery

  • Rehabilitation goals: education on rehabilitation expectations and expected time frame for return to function, precautions; normalise scapular positioning and mobility; reduce pain and swelling in the post-surgical shoulder; maintain active range of motion (AROM) of the elbow, wrist and neck; minimise loads placed over healing repair.

  • Precautions: standard sling utilisation is 6 weeks continuously or at the surgeons request, then weane from use.; no active range of motion (AROM); no lifting or supporting body weight with hands; relative rest to reduce inflammation.

  • Progression criteria: at least 14 days post-operative; passive forward elevation 60-90°; passive external rotation to 20° at 20° of abduction.

Phase 2 (usually 2-4 weeks post-op) - begin after meeting Phase I progression criteria

  • Rehabilitation goals: progression of elevation in scapular plane and external rotation in 20-30° of abduction; correct postural dysfunctions.

  • Precautions: sling utilisation will be determined by communication between surgeon and our physiotherapist; no active abduction range of motion for 8 weeks to protect repair and no external resistance to abduction and supraspinatus for 12 weeks.

  • Progression criteria: at least 8 weeks post-operative; passive forward elevation 90-120°; passive external rotation to 20-30° at 20° of abduction.

Phase 3 (usually 8-12 weeks post-op) - begin after meeting Phase 2 progression criteria

  • Rehabilitation goals: passive forward elevation to 130-155°; passive external rotation at 20° of abduction to at 30-45° and passive external rotation at 90° of abduction to at 45-60° to full; controlled progression of active assistive range of motion (AAROM) and AROM; initiate light muscle performance activities; correct postural dysfunctions; active elevation 80-120° without compensation.

  • Precautions: wean out of the sling slowly starting post-op weeks 6-8 based on surgeons preference; no active abduction range of motion for 8 weeks to protect repair and no external resistance to abduction and supraspinatus for 12 weeks.

  • Progression criteria: passive forward elevation to at least 140° to full; passive external rotation at 20° of abduction to at least 30° to full and assistive external rotation at 90° of abduction to at least 75° to full; active elevation to at least 120° without compensation; appropriate static and dynamic scapular positioning.

Phase 4 (usually 3-5 months post-op) - begin after meeting Phase 3 progression criteria

  • Rehabilitation goals: full passive and active range of motion (PROM & AROM); gradually restore shoulder strength, power, and endurance; return to ADLs, work, and recreational activities that do not require heavy lifting, powerful movements, or repetitive overhead activities; advance proprioceptive and dynamic neuromuscular control retraining.

  • Precautions: post-rehabilitation soreness should alleviate within 12 hours of the activities; no lifting of objects more than 8-12kg with short lever arm; lifting only light resistance with long lever arm; no sudden lifting, jerking, or pushing movements.

  • Progression criteria: not all patients will progress to Phase V. Individuals that are involved in sports and physical labor will be progressed, those that are not should continue with progressive, low velocity loading; full shoulder AROM in all planes and multi-plane movements; manual muscle testing (MMT) of 5/5 in neutral' pain free during strengthening exercises; negative impingement signs.

Phase 5 (usually 18-22 weeks post-op) - begin after meeting Phase 4 progression criteria

  • Rehabilitation goals: normalise muscular strength, power and endurance; return to high demand activities; complete return to sport training; develop strength and control for movements required for sport/work; develop work capacity cardiovascular endurance for sport/work.

  • Precautions: post-rehabilitation soreness should alleviate within 12 hours of the activity; avoid activities that result in substitution patterns; avoid exercises that generate a large increase in load compared to previous exercises

  • Progression criteria: the patient may return to sport after receiving clearance from the orthopaedic surgeon and the sports rehabilitation provider.

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