Laith M Jazrawi, MD
Professor of Orthopedic Surgery Chief, Division of Sports Medicine T 646-501-7223
NYU Langone Orthopedic Center 333 E 38th St, New York, NY 10016 T 646-501-7223 F 646-754-9505 www.NewYorkOrtho.com
Post-Operative Instructions Shoulder Arthroscopy, Decompression, and Biceps Tenodesis
DayofSurgery
A. Relax.Dietastolerated.B. Icingisimportantforthefirst5-7dayspost-op.Whilethepost-opdressingisinplace,icingshouldbedone
continuously.Oncethedressingisremovedonthefirstorsecondday,iceisappliedfor20-minuteperiods3-4timesperday.Caremustbetakenwithicingtoavoidfrostbite.Alternatively,CryocufforGame-readyicecuffcanbeusedasperinstructions.
YouwillbecontactedbyEastCoastOrthoticsregardinganicecompressionunittobeusedaftersurgery.Thishelpswithpainandswellingbuttypicallyisnotcoveredbyinsurance.Thecostis$200-300fora2-weekrental.Alternatively,icegelpackswithashoulderorkneesleevecanbeprovidedbythehospitalforaminimalcharge.
C. Painmedicationasneededevery6hours(refertopainmedicationsheet)
FirstandSecondPost-OperativeDay
A. ContinueIcing.B. Painmedicationsasneeded
ThirdPost-OperativeDay
A. Youmayremovesurgicalbandageandshowerthisevening.Apply4”x4”(orsimilarsize)waterproof
bandagestothesewoundspriortoshoweringandwhenshoweringiscompleteapplyfreshones.Youwillneedtofollowthisroutinefor2weeksaftersurgery.
PhysicalTherapy
A. PhysicalTherapyshouldbeginwithinthefirst10daysaftersurgery.Pleasecallyourpreferredfacilitytomakeanappointment.
*Note:Yourshoulderwillbeveryswollen.Itmaytakeaweekorlongerforthistogoaway.Itisalsocommontonoticeburningaroundtheshoulderastheswellingresolves.Ifexcessivebleedingoccurs,pleasenotifyDr.Jazrawi.Callouroffice@646-501-7223option4,option2toconfirmyourfirstpostoperativevisit,whichis
usuallyabout1-2weeksaftersurgery.Ifyouareexperiencinganyproblems,pleasecallourofficeor
contactusviatheinternetatwww.newyorkortho.com.
Dr. Laith M. Jazrawi Chief, Division of Sports Medicine Associate Professor Department of Orthopaedic Surgery
Rehabilitation Guidelines for Biceps Tenodesis
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
Theshoulderhastwoprimaryjoints.Onepartoftheshoulderblade,calledtheglenoidfossaformsaflat,shallowsurface.Thisiscoupledwiththehumerus(shapedlikeagolfball)tomakeupthejoint.Theglenoidlabrumisa”ring”ofcar@lagethatturnstheflatsurfaceoftheglenoidintoaslightlydeepersocket,whichissimilartores@ngagolfballonagolfteeinsteadofatabletop,providingmoreshoulderstability.Anotherpartofthescapula,calledtheacromium,ar@culateswiththeclavicle(collarbone)tomaketheacromioclavicular(AC)joint.Therotatorcuffisagroupoffourmuscles:thesupraspinatus,infraspinatus,teresminor,andsubscapularis.TherotatorcufftendonsaFacharoundthehumeralhead(ball)andconnectthehumerustothescapula.Thelongheadofthebicepsoriginatesfromthetopoftheglenoidfossaandlabrum(topofthegolftee).Itthenrunsthroughagrooveinthehumerus(upperarmbone)tojointheshortheadofthebicepsandinsertsonaboneintheforearm1(SeeFigure1).Becauseofitsposi@on,thelongheadofthebicepsisalsoconsideredtobeasecondarystabilizeroftheshoulderjoint.Thelongheadofthebicepsisatriskofinjuryanddegenera@vechangesduetoitsproximitytotherotatorcuffandtheacromium.Sincethelongheadofthebicepscanactasasecondarystabilizeroftheshoulder,itisalsosubjecttoinjuryduringhighspeedoverheadmovements;repe@@veoverheadmovements;orforcefulshoulderac@[email protected]@onandirrita@onofthebiceptendonitself;aproblemwiththebiceptendoninconjunc@onwithoneoftherotatorcufftendons;ordetachmentofpartofthetendonfromtheaFachmentpoint(SLAPtear).1Biceptendondegenera@onand/ortearingcancausesignificantshoulderdiscomfortanddysfunc@on(SeeFigure2).Abicepstenodesisisasurgicalprocedurewhichmaybeperformedfortreatmentofseveresymptomsinvolvingthebicepstendon,includinginflamma@[email protected]@onoraspartofalargershouldersurgery,includingsurgeryinvolvingtherotatorcuff.Duringthebicepstenodesis,thenormalaFachmentofthebicepstendonontheshouldersocket(glenoidfossa)iscutandreaFachmentofthetendonismadeonthehumerus(upperarmbone).ThistakesthepressureoffthebicepsaFachmentandplacestheaFachmentbelowtheactualshoulderjoint.2Thegoalistoeliminatetheshoulderpaincomingfromthebiceptendon.Differenttechniquesareusedtoperformabicepstenodesis.Thesurgicaltechniquescanbebrokendownintotwocategories:soV@ssuetechniquesandhardwarefixa@ontechniques.Bothtechniquesareeffec@veandchosenbasedonsurgeonpreferenceandpa@entindica@ons.
Figure1Shoulderanatomy
Rehabilitation Protocol After Biceps Tenodesis
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
TheprimarysoV@ssuetechniqueisthe“openkeyholeprocedure”.AnopenkeyholetechniquerelocatesthetendonwithinthegrooveinthehumerusboneaVercuXngitfromitsoriginalloca@onintheshoulder.1Theprocedureinvolvestheproximalend(thepor@onclosesttotheitfromitsoriginalloca@onintheshoulder.)ofthebicepstendonbeingrolledintoaballandthensuturedtogetherasamass.Akeyholeismadeinthegrooveofthehumerus,thetendonmassistheninsertedintothekeyholeandpulleddownwardsothatthetendonmassislockedinplace.3ThePiFtechniqueusestwoneedlestopiercethebiceptendoninoppositedirec@ons.Suturesarethenthreadedthroughtheneedlestomakeasuture.ThisprocedureisrepeatedwiththeneedleplacementreversedtocreatealockingpaFernofthesutures.Aknotisusedtosecurethesuturestothetransverseligamentintheshoulderinsteadoftothebone.4Thehardwarefixa@ontechniquesincludescrewfixa@[email protected]@onthetendonisdetachedandthenplaceinaholemadeatthetopofthebicipitalgroove.Thenaninterferencescrewisplacedoverthetendon,intothebone,toholditinplace.IntheendobuFontechniquethereleasedtendonissecuredtoabuFon,thebuFonisthensecuredbehindthebonebyslidingitintoasmallerholeatthetopofthebicipitalgroove.Imagineadrywalltypeanchorwherethepressureisappliedfromtheinsideout.Appropriaterehabilita@[email protected]@onguidelinesaretailoredtothetypeofprocedureperformed,thereforebelowyouwillfindrehabilita@onguidelinesforsoV@ssuefixa@ontechniquesandrehabilita@[email protected]@onguidelinesarepresentedinacriterionbasedprogression.General@meframesaregivenforreferencetotheaverage,butindividualpa@entswillprogressatdifferentratesdependingontheirage,associatedinjuries,pre-injuryhealthstatus,[email protected]@meframes,restric@onsandprecau@onsmayalsobegiventoprotecthealing@ssuesandthesurgicalrepair/reconstruc@on.
Figure2aNormallongheadofbicep.Themusclehasasmootharcfromtheshouldertotheelbow
Figure2bandFigure2cTornlongheadofbicep.Themusclehasretractedtowardtheelbow
Rehabilitation Protocol After Biceps Tenodesis
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
Goal o Sling immobilization to be worn at all times for showering and rehab under guidance of PT
o Goals: full passive flexion/extension at elbow and full shoulder AROM
Range of Motion o PROMàAAROMàAROM of elbow as tolerated without resistance (allows biceps tendon to heal into new insertion on the humerus without being stressed), AROM of shoulder (no restriction )
o Encourage pronation/supination without resistance
Therapeutic Exercises
o Grip strengthening o Heat/Ice before and after PT sessions
Goals o Discontinue sling immobilization
Range of Motion Exercises
o Being AROM of elbow with passive stretching at end ranges to maintain/increase elbow/biceps flexibility
Therapeutic Exercises
o Begin light isometrics with arm at side for rotator cuff and deltoid – can advance to bands as tolerated
o Begin light resistive biceps strengthening at 8 weeks
Phase I (Surgery to 4 weeks after surgery)
Phase III (4 to 12 weeks following surgery)
Range of Motion Exercises
o Progress to full AROM of elbow without discomfort
Therapeutic Exercises
o Continue and progress with Phase II exercises o Begin UE ergometer o Begin sport-specific rehabilitation o Return to throwing at 3 months o Throwing from a mound at 4.5 months o Return to sports at 6 months if approved
Rehabilitation Protocol After Biceps Tenodesis
333 38th St. ▪ New York, NY 10016 ▪ (646) 501 7047 ▪ newyorkortho.com!
References 1.KruppRJ,KevernMA,GainesMD,KotaraS,SingletonSB.LongHeadoftheBicepsTendonPain:[email protected]&SportsPT.Feb2009;39(2):55-70.2.RomeoAA,MazzoccaAD,TauroJC.ArthroscopicBicepsTenodesis.Arthroscopy.Feb2004;20(2):206-213.3.OzalayM,etal.MechanicalStrengthofFourDifferentBicepsTenodesisTechniques.Arthroscopy:JourArthro&RelatedSurg.Aug2005;21(8):992-998.4.Lopez-VidrieroE,Cos@cRS,FuFH,RodoskyMW.BiomechanicalEvalua@onof2ArthroscopicBicepsTenodesis:Double-AnchorVersusPercutaneousIntra-Ar@cularTranstendon(PITT)Techniques.AmJourSportsMed.2010;38(1):146-152.5.SlenkerNR,LawsonK,CiccoXMG,DodsonCC,CohenSB.Bicepstenotomyversustenodesis:clinicaloutcomes.Arthroscopy.2012Apr;28(4):576-82.doi:10.1016/j.arthro.2011.10.017.Epub2012Jan28.6.BurnsJP,BahkM,SnyderSJ.Superiorlabraltears:repairversusbicepstenodesis.JShoulderElbowSurg.2011Mar;20(2Suppl):S2-8.doi:10.1016/j.jse.2010.11.013.
Laith M Jazrawi, MD
Professor of Orthopedic Surgery Chief, Division of Sports Medicine T 646-501-7223
NYU Langone Orthopedic Center 333 E 38th St, New York, NY 10016 T 646-501-7223 F 646-754-9505 www.NewYorkOrtho.com
Rehabilitation Protocol: Biceps Tenodesis Name:____________________________________________________________Date:_________Diagnosis:_______________________________________________________DateofSurgery:______________________
PhaseI(Weeks0-4)• SlingimmobilizationtobewornatalltimesexceptforshoweringandrehabunderguidanceofPT• RangeofMotion–PROMàAAROMàAROMofelbowastoleratedwithoutresistance(allowsbiceps
tendontohealintonewinsertiononthehumeruswithoutbeingstressed),AROMofshoulder(norestriction)
o Goals:fullpassiveflexion/extensionatelbowandfullshoulderAROMo Encouragepronation/supinationwithoutresistanceo Gripstrengthening
• Heat/IcebeforeandafterPTsessions
PhaseII(Weeks4-12)• Discontinueslingimmobilization• RangeofMotion
o BeginAROMofelbowwithpassivestretchingatendrangestomaintain/increaseelbow/bicepsflexibility
• TherapeuticExerciseo Beginlightisometricswitharmatsideforrotatorcuffanddeltoid–canadvancetobandsastoleratedo Beginlightresistivebicepsstrengtheningat8weeks
• ModalitiesperPTdiscretion
PhaseIII(Months3-6)• RangeofMotion–ProgresstofullAROMofelbowwithoutdiscomfort• TherapeuticExercise
o ContinueandprogresswithPhaseIIexerciseso BeginUEergometero Beginsport-specificrehabilitationo Returntothrowingat3monthso Throwingfromamoundat4.5monthso Returntosportsat6monthsifapproved
• ModalitiesperPTdiscretionComments:Frequency:______timesperweek Duration:________weeksSignature:_____________________________________________________Date:___________________________
