Transcript
josh MacDonald: Hi, I'm Josh McDonald.
Miranda Materi: And I'm Miranda Materi, and we are Hand Therapy Academy.
josh MacDonald: We got some ideas from our staff for a couple of podcast topics. So today we're gonna talk about distal bicep rupture. What do you do for therapy? They've had the repair and therapy is kind of simple and basic. And so what are some ideas you would do for like distal bicep repair recovery?
Miranda Materi: Yeah. And I was going to say something too, before we really got started, I think the reason why, like, we don't have a lot of these in my clinic. I don't know if you do in yours, but we don't see a lot of them. And I think it's because they don't have a lot of therapy demands.
josh MacDonald: Yeah, yeah, definitely. You end up with patients who are probably young and active and they heal well. And I think like a lot of diagnosis surgeons are like, yeah, you're probably gonna do fine on your own. You know, immobilize it maybe in a hinged elbow with an extension block.
josh MacDonald: Week one or two follow up, they decrease some of that block range of motion. And then if they're young and healthy and healing well, they're off on their own because it's not usually a diagnosis that has comorbidities or slower healing times.
Miranda Materi: Right. Right. Especially because it's usually the young person. So when they're, we're talking surgeries, I know that there's, you know, various procedures. There's one that I've commonly seen and that's the button. What are, what are you seeing with your distal biceps repair?
josh MacDonald: Yeah, like you, we don't see a ton. I would say we get like one, maybe two a year kind of thing. So we don't see a ton of them. but But yeah, it's usually the button. It's just so super secure. Basically, they just drill a hole through the radial tuberosity through to the backside, clear through, attach an anchor to the end of the existing distal bicep.
josh MacDonald: feed it through and then it like toggles open so it catches on the posterior aspect of that radius and then they put like a set screw in that hole to really cinch that tendon and graft at the end the the synthetic graft into that hole and really get some strong purchase so it's a very successful strong sturdy surgery the limitation is that you've taken a tendon that used to attach to the anterior aspect And you take it and try to pass it a greater distance through to the backside, never mind the length loss with the rupture. So it ends up being a tighter muscle tendon unit. You just have to make sure you're not overstretching it because it can be uncomfortable. You're not going to pop that thing out of its button, out of that hole that was screwed.
josh MacDonald: You're more likely going to cause micro tears or musculotendous junction tears if you load it too early.
Miranda Materi: Yeah, that makes sense. Okay. So you get your patient, they're sent to you. You're ideally seeing them at what week, 10 days post-op or what would be your ideal timeframe to get these patients in?
josh MacDonald: Yeah, in that seven to 10 days, I think is is ideal. if you there's There's no need to see them super early because they're probably immobilized with an extension block and probably doing fine and hinged elbow they got from the doctor.
josh MacDonald: We've gotten a couple where they sent them to us to get the hinged elbow. And so we provide that and get them some super basic early stuff. um But it's almost in concept, it's like a giant flexor tendon, right? Like if I think about the precautions and what I'm allowed to do for early active with a bicep repair,
josh MacDonald: it's a giant flexor tendon. So I don't wanna do resisted flexion. I'll do partial short arc flexion and I can do extension to a block, but this is a great big giant muscle with a very secure repair going through a short arc range of motion is not gonna put this a significant enough load to do any rupture and blocked extension just because it's this tighter unit Just make sure you're not aggressively pushing that extension passively, and you're probably going to be fine because it's just such a big, strong muscle. But it gives me the idea of what can I do? Short arc flexion is fine against no resistance and then blocked extension like a giant flexor tendon.
Miranda Materi: And then are you doing are you having these patients supine when they start or?
josh MacDonald: Yeah, early on, I'll have them do active gravity. you call it gravity eliminated but basically they're supine and i'll have them do it in a supinated forearm because it's the bicep is a supinator so that's a more slacked position it's allowed to stay shorter versus if they go into pronation more tension on it so just um supinated elbow extension um against gravity so there's less load and they're limited by gravity in addition to the tension so they're just not going to do too much and it's just pass through range of motion like i would say doing a short arc to a dowel for flexor tendon just don't work hard at it don't push the end range but then what do you do right like because that's a perfectly good exercise but six minutes later are you doing anything else yeah
Miranda Materi: Yeah, and are you? And are you doing forearm rotation? Mm-hmm.
josh MacDonald: um I would start with like the spatula rotation, right? Super simple. And I like the spatula. I'll have patients say, oh, I can do it without holding an object. I like the visual feedback for them, for them to have an idea of how far they're going, like on a clock face.
josh MacDonald: Like, you know, you can get 11 to one. Can we get 10 to two and and slowly working on that range of motion?
Miranda Materi: Mm-hmm.
josh MacDonald: I'll have them do some early active assist elbow flexion. So the other hand, just kind of passing it through. but teaching them to respect that endpoint of extension and saying this is not the time to shove it further into extension. It's just find and bump up against that end range a little bit, just like, oh there's the endpoint, come back. And I use the phrase like mastering mid-range will improve end range by default.
Miranda Materi: Yeah, that makes sense.
josh MacDonald: Yeah. Yeah. Um, if they, if they're doing great and they get to like week three and they're starting to get a little bit of like scar adhesion stuff, I'll give them a little bit more like gravity eliminated range of motion. So like sitting at a table, if they're tall enough, they might need like an elevated surface so that they're not pulling against gravity, but towel slides on the table coming like, um, into shoulder flexion extension a little bit. So it's like an indirect elbow mover as they push their hands across the table away. and then bring their hands back. I'll have them set the elbow up on the table and do actual elbow extension flexion isolated, all gravity eliminated. So they've got like a towel. If you've got a scooter board, you can put their hand on that's like one of those free rolling ones. That's fantastic for it.
josh MacDonald: Some of those things just to like, let's get a little bit more movement and get away from the simple.
Miranda Materi: Right. Yeah. How do you advance these patients? And then they're like, is that it? That's all therapy is, you know, right?
josh MacDonald: Yeah, yeah.
Miranda Materi: You're like, what am I going to do for your hour of treatment?
josh MacDonald: Right, right. And like a flexor tendon, I may not see them for an hour on their second visit, you know, two, three weeks in. I may not see them for a whole heck of a long time because like that Gale-Groff pyramid, if they're doing great, I don't need to. Like if I can advance the block on their splint to, you know, minus 30 degrees and they're moving well and they're not scarring in aggressively, but they've got a little bit of healthy tension in there.
josh MacDonald: I don't need to do a whole heck of a lot more. Just let them keep moving in their daily life, just lifting restrictions still in place for that arm until they get past that five to six week mark.
Miranda Materi: Right. And I think that's hard for patients to buy in, right? They want to be doing more, especially that young athletic patient that usually has these. They want to be doing more. They're like, what can we do? Why? This is all we're doing. This isn't therapy, you know?
josh MacDonald: Yeah, yeah.
Miranda Materi: What's more I think about putting the brakes on and providing education as to why we're not doing all those other things.
josh MacDonald: Yeah.
Miranda Materi: That's why we're not grabbing dumbbells.
josh MacDonald: And I don't like the... Right, right. I don't like to use the term with patients too much, but I like to kind of scare them a little bit and say like, hey, if we aren't careful with this, you could set yourself back a long way and then it's an even longer road ahead of you. This can be a a two to three month problem and then you move on with your life or this can be a six to eight month problem if we don't kind of follow this early careful protocol.
josh MacDonald: um So, yeah, youre it's usually that younger patient that's going to be out there like hopping on their dirt bike again.
Miranda Materi: Right. And then when you have the patient that's like, I've probably seen more that are not repaired than have been repaired in practice where they come in like, yeah, a year ago, you know, and then you're like, oh man.
josh MacDonald: Yeah. Yeah. Yeah. I've had that for some vice, some proximal bright bicep ruptures. Um, and doctors are like, well, you still got one head intact and you got other, other elbow flexors and shoulder movers. So just leave it. But the distal too, it's like, I, like I try to work through any adhesions they may have if they lack range of motion and then just make them less painful, but we can't reattach it.
josh MacDonald: Um, yeah, you can work on some strength with what muscles they have left intact, but yeah, there's not much we can do.
Miranda Materi: Yeah, that's typically what I do. And yeah, tell them, you know, you're not going to have that big bulk, you know, there that you used to have or you had before.
josh MacDonald: Yeah. Yeah. um And it can cause some other like downstream problems with compensations and they start using like flexor, flexor tendon mass at the medial elbow to pull a little bit more. And so you can get some other like associated soft tissue things going on, but we just try to talk about mechanics a little bit and making sure that they're You know, these are guys who are ah guys I say because it's usually guys to get the injury, but these are patients who like to be active and physical.
Miranda Materi: had a
josh MacDonald: And so you're not going to get them to stop doing if it's powerlifting or working out of the gym, whatever it is that caused that rupture weekend warrior athlete or gardener whatever, like they're going to do that.
josh MacDonald: You just try to say, like, hey, just respect the limitation and the discomfort.
Miranda Materi: Well, I think the other thing that people don't know that that the biceps is not the only elbow flexor, right? The job is primarily to supinate.
josh MacDonald: Right.
Miranda Materi: So you're really providing education too on like, hey, this job is to turn your palm up. You know, you can do that with, you know, your shoulder. We just want to make sure you're not hiking your shoulder. I think it's just a lot of education on anatomy and how our bodies move.
josh MacDonald: Yeah, yeah. i um Side note, I had a distal bicep rupture probably 10 years ago, 12 years ago, something like that. Had the surgery for it. Didn't realize it until a week in. It just thought it had a stinger in a hockey game kind of thing and had the repair. And now probably what, maybe 12 years later, I still have tension and tightness during certain movements. Like just today, I was turning a screwdriver with that right hand doing supination.
josh MacDonald: and still feel some tension in there. So I tell patients like it's it's okay, you're going to feel some tension long term, even if you had the repair, like it's just a shorter unit than it was originally and shorter than it should be. So it's okay to have those things down the road.
Miranda Materi: Was there an option not to repair yours? Like.
josh MacDonald: um There was, I could have chosen that, um but I was active enough. The doctor that I worked with and he did a fantastic job with it. I had very, like I was able to do my own recovery for it. He said, you know, you're active enough. It's a simple enough procedure. Let's just go ahead and do it and then you can move on with life and not have to worry about it.
josh MacDonald: So, and I'm glad I did it. Definitely. I would, I would suggest someone who wants to stay active to go ahead and do it.
Miranda Materi: Yeah.
josh MacDonald: um The button was super secure, healthy healing, all that.
Miranda Materi: Yeah. And then when I have that patient, I don't know, they probably came in like two months ago and they didn't, they had no clue that their bicep had ruptured a distal biceps rupture. And, um, so we were like talking about it and I was like, how many years afterwards can you go in and like graft it or repair it?
Miranda Materi: You know, if there is such a thing as doing simple weight repair. And I, I didn't know, I was like, you need to go back to the, you know, go back to your orthopedic surgeon and explore what the options are. Cause they would know a lot of those factors better than I would.
josh MacDonald: Yeah. Interestingly, the surgeon that I worked with, I went in a week after it happened by the time I was able to get in to see him. And he said, i can do surgery in one week on on a Friday.
josh MacDonald: But if we don't do it before the two week mark, there's no point in doing it because it will have retracted enough that I can't pull it back down into position.
Miranda Materi: Oh, interesting.
josh MacDonald: So it would have taken a more significant grafting procedure. He just pulled my bicep tendon down and reattached it with the button. But he said after two weeks, it will be so short and tight that I won't be able to get it back down and there's no point in doing the surgery. So, yeah.
Miranda Materi: Well, there you go. There's the answer.
josh MacDonald: Yeah. Yeah. So I would say pretty short leash. Yeah. Yeah.
Miranda Materi: Yeah, yeah. It sounds like you need to get in and get it repaired right away if that does happen.
josh MacDonald: Yeah. Now that was a long time ago. So maybe things have changed and they could do like lengthening, like tendon lengthenings and and get it intact. And maybe there's options, but yeah, you're not talking a year.
Miranda Materi: yeah right yeah this guy was a year ago yeah
josh MacDonald: Yeah. Yeah. Yeah. All right. Well, hopefully that helps if you have a patient come into your clinic with a distal bicep rupture or some kind of similar diagnosis, just some ideas and it kind of how it helps to think of things as an alternate for a flexor tendon injury or if it's triceps extensor tendon injury. So hopefully that helps.
