Phase I: Protection and Early Mobilisation (0–2 Weeks)

Immobilisation:

• Arm supported in a sling full-time for 2 weeks, including during sleep

• In certain circumstances repair/reconstruction supported by a backslap for the first 2 weeks

Precautions:

• No active elbow flexion or supination

• No lifting, pushing, or pulling with the operative arm

• Avoid combined shoulder abduction and external rotation to reduce biceps tension

• Keep surgical site clean and dry

Therapy:

• Initiate passive elbow flexion and extension in a gravity-neutral or assisted position within pain-free range

• Begin passive forearm supination/pronation with elbow flexed to 90°

• Active wrist and hand ROM

• Ice and elevation for swelling control

Criteria to Progress:

• Pain and swelling are controlled

• Wound healing is satisfactory

• Patient demonstrates compliance with precautions and exercises

Phase II: Controlled Motion Phase (2–6 Weeks)

Immobilisation:

• Continue sling for protection when not performing exercises

• Wean sling gradually by the end of week 6

Precautions:

• No resisted elbow flexion or forearm supination

• Avoid carrying any objects heavier than a cup of tea (<500 g)

• Protect repair from forceful or eccentric loading

Therapy:

• Continue passive ROM; gradually increase active-assisted ROM as tolerated

• Begin gentle active elbow extension and supination, avoiding resistance

• Scar management and soft tissue massage as needed

• Maintain full shoulder, wrist, and hand mobility

Criteria to Progress:

• Near full active elbow ROM

• Pain-free ACTIVE ROM without compensatory patterns

• Compliance with therapy and no signs of repair strain

Phase III: Strengthening Initiation (6–12 Weeks)

Precautions:

• No resisted elbow flexion or supination until week 12

• Avoid sudden forceful movements or loading

Therapy:

• Begin submaximal isometric biceps and forearm muscle contractions

• Progress to light isotonic resistance for shoulder, triceps, and wrist musculature

• Emphasise neuromuscular control and kinetic chain stability

• Scapular and postural strengthening

Criteria to Progress:

• Full, pain-free ROM

• Sufficient control and strength for functional tasks

• Surgeon approval for progressive loading

Phase IV: Progressive Strengthening and Functional Return (3–6 Months)

Precautions:

• Avoid eccentric overloads until strength is near baseline

• Do not lift more than 5 kg until 6 months postoperative

Therapy:

• Begin progressive resistance training for biceps and supinators

• Incorporate functional strength training and endurance exercises

• Sport- or work-specific retraining

• Emphasise bilateral coordination and muscle balance

Criteria to Discharge:

• Full strength and ROM compared to the contralateral side

• Patient meets job or sport-specific demands

• Cleared by treating surgeon

General Recommendations

Work:

• Office/desk work may resume after 2–4 weeks if pain is well controlled

• Manual labour should be deferred until 3–6 months depending on job demands

Driving:

• It is important that you are medically fit to return to driving and you feel safe to control the vehicle and take evasive action if needed.

Sports and Leisure:

• Lower-limb activities may resume as comfort allows.

• Light upper limb activities may resume from approximately 4–6 weeks.

• Progressive return to gym and functional activities from 8–12 weeks.

• Resisted elbow flexion and supination loading from approximately 10–12 weeks.

• Heavy lifting, pulling, and higher-demand activities from 6 months or longer with full recovery and surgeon clearance.

Disclaimer: This protocol is intended as a general rehabilitation guide only. Rehabilitation progression should always be individualised and may be modified by A/Prof Ernstbrunner and the treating rehabilitation team based on the patient’s clinical progress, surgical findings, and individual circumstances.