Rehabilitation of the Ruptured Biceps -

Brachii Muscle of an Athlete

WILLIAM D. BANDY, MA, PT, SCS, ATC,'
VENITA LOVELACE-CHANDLER, PhD, PT, PCS,' ANDREA L. HOLT, P T ~

The purposes of this case study are to report on the successful rehabilitation
program of a college football player diagnosed as having a ruptured biceps brachii
muscle and to discuss the basic rehabilitation concepts used for treatment planning. A
review of the literature indicated agreement that the ruptured biceps brachii is a rare
event, but the pathology does occur, and the opportunity for the clinician to evaluate
and treat the injury may arise. Following a rupture of the biceps brachii muscle, a
Downloaded from www.jospt.org at on May 29, 2022. For personal use only. No other uses without permission.

player was treated conservatively (nonsurgically)using rehabilitation concepts that

included ice during acute phase; heat during chronic phase; submaximal exercise prior
to maximal exercise; multiple angle isometric exercise prior to isotonic and isokinetic
exercise; and functional progression to field activities. The athlete was able to avoid
surgery, successfully return to competition in three weeks, and compete in the final five
Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

football games without reinjury. One year follow-up evaluation revealed that the athlete
had full strength with no residual problems, a finding not commonly reported in
conservatively treated biceps brachii ruptures.

Rupture of the biceps brachii muscle is a
relatively uncommon lesion that may occur in the
long head near its insertionat the glenoid tubercle,
in the muscle belly of one or both heads, at the
musculotendinousjunction, or at the distal tendin-
Journal of Orthopaedic & Sports Physical Therapy®
Opinion as to the proper treatment of the
ruptured biceps brachii varies between surgical
(1, 7, 8, 18, 19) and nonsurgical (conservative)
care (4). Meherin and Kilgore (18) compared sur-
gical (21 patients) to nonsurgical (nine patients)

ous attachment into the radial tuberosity (3). A
review of the literature indicates agreement that
the ruptured biceps brachii is a rare event, but the
pathology does occur, and the opportunity for the
clinician to evaluate and treat the injury may arise
(1, 9, 20).
Sources vary regarding the most frequent
site of the rupture (9, 20). Gilcrest and Albi (9)
report the rupture to occur in the long head 96
percent of the time, the distal tendon three per-
cent of the time, and the short head in one percent
of such cases. Morrey (20) agrees that the r u p
tured biceps brachii muscle is rare but states that
the majority of these ruptures occur at the distal
attachment of the biceps.
Faculty. PhysicalTheraw Department.Uliversily of Central Arkansas.
Conway. AR 72032.
Employed at Donelson Hospttal Sports Mediine in Nashville. TN.
0190401 1pl/l3O4-Ol84$O3.OO/O
THEJOURNAL OF ORTHOPAED~C AND SPORTS PHYSICAL THERAPY
Copyright 0 1991 by The Orthopaedii and Sports Physical Therapy
Sectms of the American Physical Therapy Association
184 BANDY ET AL
treatments by establishing disability ratings for
each patient. The average disability rating for
those treated conservatively was 21.3 percent;
for those treated surgically, it was 7.2 percent.
The authors concluded that surgery was the treat-
ment of choice for the ruptured biceps brachii
muscle.
Comparing surgical (nine patients) to con-
servative (four patients) treatment, Friedman (7)
classified six of the nine surgical patients as "hav-
ing excellent results without reservation," while all
four of the conservativelytreated patients showed
weakness in elbow supination and flexion. The
author concluded that surgical repair is "indicated
to achieve the most satisfactory result possible."
Baker and Bierwagen (1) and Morrey et al (19)
also reported that a ruptured biceps brachii leads
to weakness in strength of elbow flexion and
supination, which may be avoided with appropri-
ate surgery. Morrey et al (19) emphasized that
the primary problem with conservative treatment
is the loss of strength in elbow supination, which
is alleviated with surgery.
JOSPT 13:4 April 1991
 One possible explanation for the failures re-
ported in the literature of the conservatively
treated patients was the rehabilitation program
used. In the study by Morrey et al(19), all patients
who elected not to have operative intervention
were treated with immobilization "until the pain
subsided." They were then instructed in a home
program of isometric strengthening exercises for
elbow flexion. Both Baker and Bierwagen (1) and
Gilcrest (8) described a conservative program that
consisted of sling immobilization for three weeks
followed by active range of motion and progres-
sive resistive exercise. Other authors failed to
describe the rehabilitation program (7, 18).
Carroll and Hamilton (4) suggested that no
functional deficit occurred with nonoperative
treatment of the ruptured biceps brachii. The au-
thors reported that on average, patients treated Figure 1. Mechanism of injury.
conservatively returned to work four weeks after
injury and that the conservative approach to treat- right upper extremity indicated pain with active
ment might be "well adapted in treating this type range of motion with flexion of the elbow. Passive
of injury." The difficulty in interpreting information range of motion to all joints was full, but pain was
elicited with full elbow flexion and extension.
Downloaded from www.jospt.org at on May 29, 2022. For personal use only. No other uses without permission.

provided by Carroll and Hamilton (4) is that details

of the conservative treatment were omitted.
Although the ruptured biceps brachii muscle
is a relatively rare event, informationon successful
rehabilitation programs for the ruptured biceps
Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Weakness and pain were present with resisted
elbow flexion and shoulder flexion, and a palpable,
visible defect in the middle one-third of the short
head of the biceps brachii muscle was noted with
resisted elbow flexion (Table 1). Strength of all

brachii muscle may be of value to physical thera-

pists. In addition, the description of the rehabili-
tation of this soft tissue injury may help to refute
or strengthen the current philosophy regarding
treatment.
The purposes of this manuscript are to report
on the successful conservative treatment of a
college football player diagnosed as having a r u p
t u r d biceps brachii muscle and to discuss the
basic rehabilitation concepts used for treatment
Journal of Orthopaedic & Sports Physical Therapy®
other muscles appeared within normal limits and
resisted movements were painfree. Ligamentous
laxity tests of the elbow were negative.
Physical therapy evaluation indicated a r u p
ture of the short head of the right biceps brachii
muscle. Immediate treatment consisted of immo-
bilization in a sling, compression wrap, and ice.
Follow-upconsultation by an orthopaedic surgeon
resulted in findings consistent with a diagnosis of
a ruptured biceps brachii muscle. At that time, a

planning.
CLIENT DATA
The initial injury was sustained by an outside
linebacker (21 years old; 6 ft 1 in, 190 Ibs) of a
college football team during the second quarter
of a football game. Review of the client's history
indicated no other injuries during the current sea-
son and no previous history of musculoskeletal
problems of the upper extremity during his athletic
career. While making an "arm tackle" of an op-
posing ball carrier, the client's right upper extrem-
ity was forcibly, horizontally abducted behind his
trunk, while remaining in 90 degrees of shoulder
abduction and full elbow extension (Figure 1). In
this horizontally abducted position, the client used
elbow flexion to pull the opposing player to the
ground. Following the tackle, the client remained
on the ground complaining of severe, sharp pain
in the anterolateral aspect of the arm. He was
eventually escorted to the sidelines.
lmmediate sideline evaluation of the client's
JOSPT 13:4 April 1991 RUPTURED BICEPS BRACHll
decision was made by the physician, physical
therapist, and client to treat the injury conserva-
tively (nonsurgically).
REHABILITATION
Days One to Four Postinjury
Evaluation
During the early part of the first week after injury,
the client presented with acute inflammation, in-
cluding palpable heat, ecchymosis, and swelling
(as indicated by circumferential measurement of
the arm, right vs. left). Swelling was greatest at
the medial aspect of the elbow joint. A similar
injury is pictured in Figure 2.
Passive range of motion again resulted in
pain at the extremes of elbow flexion and exten-
sion but no loss of motion. Resisted elbow flexion
was painful and weak, and the palpable defect
was still present during resisted elbow flexion.
185
 TABLE 1
Results of evaluation, initialinjury through week three
Week 1
Initial Week 2 Week 3
Day 1-4 Day 5-7
Resisted elbow flexion Severe . Severelmod Slight No pain No pain
pain pain pain
Elbow flexion strength 315' 3-415' t t t
Resisted shoulder flexion Moderate Slight pain No pain No pain No pain
pain
Shoulder flexion strength 315' 415' R = U R = L+ R = U
Swelling None Moderate None None None
As tested by Manual Muscle test.
t See Table 2 for objective measures as determined by Cybex test.
$ Less than 10% difference as determined by Cybex test.

Resisted shoulder flexion was strong, eliciting
only slight pain (Table 1).
Treatment Goals
Downloaded from www.jospt.org at on May 29, 2022. For personal use only. No other uses without permission.
the changes that occur with isometric exercise
are relatively specific to the joint angle at which
the exercise takes place (13, 16). To ensure an
effective exercise program, the isometric exer-

cises were performed by the client at several

The treatment program was initiated with the
goals of decreasing inflammation, (swelling, ec-
chymosis, palpable heat, and pain), maintaining
full range of motion, and diminishing less of
Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
points in the range of motion (multiple angle iso-
metrics).
Although ecchymosis and swelling were
present after injury, the early intervention allowed

strength during healing. An additional goal was to inflammation to be minimized. The swelling and
educate the client regarding the criteria for deter- discoloration dissipated in less than a week, even
mining ability to return to competition. though the injury was relatively severe.

Treatment Description Days Five to Seven Postinjury

Daily treatment during this early rehabilitation
phase consisted of:
A. Ice prior to the treatment.
B. Active flexion and extension range of mo-
Journal of Orthopaedic & Sports Physical Therapy®
Evaluation
Evaluation of the patient at the end of the first
week indicated no pain with passive range of

tion exercises of the elbow.
C. Resisted exercise to shoulder flexion and
abduction using low weight (2 Ibs)and high
repetitions.
D. Multiple angle isometric exercise (painfree)
to elbow flexors using high repetitions of
submaximal contractions (Figure 3).
E. Ice after treatment.
F. Sling use was discontinued the fourth day
after injury.
Rationale for Treatment
Assessment and treatment were started immedi-
ately following injury. Knight (15) reported that ice
and compression were most effective if initiated
immediately after the injury occurred.
The early use of isometric exercise in the
acute stage has been shown to minimize muscle
atrophy and aid in the removal of the effusion (17,
23), which otherwise could cause a reflexive de-
crease in strength (6, 22). Research indicates that
186
motion, decreased pain with resisted elbow flex-
ion, and no pain with resisted shoulder flexion
(Table 1). The palpable defect was still present in
the arm with resisted elbow flexion. Circumfer-
ential measurements of the arm were equal be-
tween right and left, indicating no swelling. Ecchy-
mosis had begun to disappear.
Treatment Goals
The goals of treatment for the latter part of the
first week were to promote healing (decrease
pain, influence proper collagen deposition, in-
crease blood flow) and to increase strength in
preparation for more aggressive isokinetic exer-
cise and functional activities.
Treatment Description
Daily treatment consisted of:
A. Hot pack to biceps brachii muscle area
prior to treatment.
B. Resisted exercise to shoulder flexion and
BANDY ET AL JOSPT 13:4 April 1991

Downloaded from www.jospt.org at on May 29, 2022. For personal use only. No other uses without permission.
Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®
Figure 2. A biceps rupture. (From "The Elbow and
Its Disorders" by B. F. Morrey, by permission of Mayo
Foundation.)
abduction with increased weight (4 Ibs)
and high repetitions.
C. Multiple angle isometric exercise to elbow
flexion using high repetitions of maximal
contractions.
D. Active range of motion to elbow flexors
with no weight.
E. Ice after treatment.
JOSPT 13:4 April 1991 RUPTURED BICEPS BRACHll
Figure 3. Isometric exercise to elbow flexors.
Rationale for Treatment
Treatment goals for the end of the first week were
accomplished by applying heat before each treat-
ment and increasing resistance in all exercises.
Hot packs act to relax the patient, decrease pain,
and increase superficial blood flow (24). Knight
and Londeree have suggested that the most effi-
cient mechanism for increasing blood flow to the
muscle is active resistive exercise (14). Active
resistance exercise has also been shown to influ-
ence organized collagen deposition to assist the
healinq of the muscle iniury
. . (23).
.
iring a resistance training program, the
muscle becomes stronger in response to the a p
plication of increasing amounts of resistance (11).
The increase in strength of the muscle is a result
of both adaptations at the muscle fiber levei
as well as the ability of the nervous system to re-
cruit motor units involved in activation of the
muscle (2).
Week Two Postinjury
Evaluation
Evaluation indicated all resisted movements of the
right elbow and shoulder to be painfree, with slight
weakness present during resisted elbow flexion
(Table 1). No swelling was present, only slight
ecchymosis was observed, and the same palpable
defect was present with resisted elbow flexion.
At the end of the first week of rehabilitation,
strength testing of the upper extremity using the
CybexdDII lsokinetic Dynamometer (Cybex, Divi-
sion of Lumex, Inc., 2100 Smithtown Ave., Ron-
konkoma, NY 11779) indicated a 37 percent dif-
ference between the right and left elbow flexors
at a test speed of 60°/sec (Table 2) and a 15
percent difference at 180°/sec (right side weaker).
Rightlleft differences between the muscles of el-
bow extension, shoulder flexion/extension, shoul-
der abduction/adduction tested at speeds of 60
187
 TABLE 2
Strength evaluation of elbow flexion and extension at 60°/sec
One Week Postinjury Two Weeks Postinjury
Right Left Difference Riht
Flexion 38' 60 37% 50
Extension 66 68 3% 66
' Measured in ft Ibs of peak torque.
and 180°/sec were less than 10 percent and were
considered within normal limits.
Treatment Goals
The goals of the second week of rehabilitation
were to promote continued healing (influence
proper collagen deposition, increase blood flow,
and decrease pain) and continue to increase
strength of the biceps brachii muscle. An addi-
tional goal was to maintain strength and endur-
ance of the lower extremity muscle groups while
the right upper extremity received treatment.
Downloaded from www.jospt.org at on May 29, 2022. For personal use only. No other uses without permission.
Treatment Description
Daily treatment progressed to include:
Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
A. Hot pack to biceps brachii area prior to
treatment.
B. Resisted exercise to shoulder flexion and
abduction (5-6 Ibs).
C. Resisted exercise to elbow flexion using
low weights (2 Ibs) and high repetition.
D. Shoulder press/pull and chest press/pull
on the Omni Tron Total Power Machinem
(Hydra-Fitness Industries, Inc., P.O. Box
599, Belton, TX 76513), which is a variable
Journal of Orthopaedic & Sports Physical Therapy®
resistance hydraulic device (Figures 4 and
5). The client exercised at fast, medium,
and slow speeds of contraction by setting
the aperture at 1, 3, and 5, resPectivel~-
The Total Power Machine was utilized
for the exercise Program instead of the
Figure 4. Shoulder press/pull on Total Power Ma-
'.
chine.
188 BANDY ET AL
Three Weeks Postinjury
Left Dierence Riht Left Dierence
60 17% 58 62 6%
68 3% 65 68 4%
Figure 5. Chest press/pull on Total Power Machine.
Cybex II because of equipment accessibil-
ity. These exercises progressed from sub-
maximal contractions at the beginning of
the second week to maximal contractions
at the end of week two.
E. Ice after treatment.
F. Patient was allowed to participate in agility/
running drills with football team wearing no
pads, emphasizing no contact and no use
of his right upper extremity.
Rationale for T~~~~~~~~
The strength training program utilized a progres-
sion of submaximal to maximal exercise. In addi-
tion, the patient progressed from isometric exer-
cise in the acute stage to isotonic exercise as
effusion dissipated and, lastly, to isokinetic exer-
cise at a variety of speeds as the client's condition
allowed. By using this progression (submaximal
to maximal, isometric to isotonic to isokinetic), all
strength training was performed without pain.
This exercise progression has been previously
suggested to be a safe and effective strength
training program for the rehabilitation of other
musculoskeletal pathologies (5, 10, 17, 21).
Week Three Postinjury
Evaluation
After two weeks of rehabilitation, the client's eval-
uation indicated no pain with any resisted motions
JOSPT 13:4 April 1991
 and a slight strength deficit (17 percent deficit by
isokinetic testing at 60°/sec) in right elbow flexion.
The defect in the middle one-third of the short
head of the biceps brachii muscle was still present
during resisted elbow flexion.
Strength testing indicated a 17 percent right1
left difference in the elbow flexors (right side
weaker) at a test speed of 60°/sec (Table 2).
Strength differences were below 10 percent for
the muscles that perform elbow flexion/extension
at 180°/sec and shoulder flexion/extension and
abduction/adduction at 60 and 180°/sec.
Treatment Goals
The primary goals of the third week of rehabilita-
tion were two-fold: first, to prevent loss of
strength (exercising 2 times a week); and second,
to monitor functional progression to full contact
activities (daily).
Downloaded from www.jospt.org at on May 29, 2022. For personal use only. No other uses without permission.
Treatment Description
The client performed the following program two
times a week:
A. Exercise on a Total Power Machine as
previously described using maximal con-
Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
tractions at a variety of contraction
speeds.
6. Use of Thera-Band@(The Hygenic Corpo-
ration, 1245 Home Ave., Akron, OH
44310) using diagonal patterns.
C. Resisted exercise to elbow flexion.
Daily treatment consisted of functional return
to competition beginning with agility drills and
pass coverage. Treatment progressed from tac-
Journal of Orthopaedic & Sports Physical Therapy®
kling drills to brief scrimmaging to full contact
practice, and, finally, to participation in a football
game at the end of the third week of rehabilitation.
Rationale for Treatment
One week was spent on the client's functional
return to competition. Two weeks after rehabili-
tation, this client presented full range of motion,
rightlleft strength differences less than 10 per-
cent, and no pain with resisted movements (sug-
gesting a normal clinical evaluation); however, the
athlete was not ready to return to the specific
demands of playing linebacker in a competitive
football game. The emphasis of rehabilitation
needed to be shifted from the clinic to the field
using functional progression.
Kegerreis et al (12) defined functional pro-
gression as "a planned, progressively difficult se-
quence of exercise designed to meet the specific
needs of each injured athlete and to return him or
her to activity as soon as possible without risking
reinjury." A continuum of activities was con-
JOSPT 13:4 April 1991 RUPTURED BICEPS BRACHll
structed so that easier activities were correctly
and painlessly performed before attempting more
difficult activities requiring stress to the injured
area. The client was evaluated at each step, and
if pain occurred during any activity, the client was
held at that level on the continuum or regressed
until the activity could be performed painlessly.
"As an athlete's rehabilitation progresses, (the
athlete) is permitted to advance along a contin-
uum, starting a new task after completing the
previous one. Overlap will occur, but functional
tasks may not be eliminated from the program
until each is successfully performed" (12).
Functional progressionof this patient enabled
the transition from clinic to a competitive football
game to occur safely and efficiently. Strength
testing one day prior to participation in the football
game indicated rightlleft differences below 10 per-
cent for elbow flexion and extension at test
speeds of 60 and 180°/sec (Table 2).
Weeks Four to Six Postinjury
Treatment consisted of program continuance two
times a week and frequent monitoring for return
of symptoms. The client reported no return of
symptoms and was able to play in the season's
four remaining scheduled games.
FOLLOW-UP EVALUATION
Follow-up strength testing of shoulder flexion1
extension and elbow flexionlextension at 60 (Ta-
ble 3) and 180°/sec was performed at four
months and one year following injury. Strength
remained consistent for all tests and the rightlleft
difference remained below 10 percent.
Previous case studies have reported the oc-
currence of residual strength deficits in elbow
supination in follow-up evaluations. (NOTE: elbow
pronation/supinationdata was not collected prior
to the one year follow-up.) Therefore, at the one
year follow-up, strength of elbow supinationlpro-
nation was tested on the Cybex at speeds of 30
and 120°/sec. Results of testing indicated right/
left strength difference below five percent at both
test speeds.
SUMMARY
This case study illustrates a nonsurgical (conserv-
ative) treatment that allowed an athlete to return
to full competition three weeks after rupturing the
biceps brachii muscle. Follow-up assessment one
year later indicated that the palpable defect in the
middle one-third of the short head of the biceps
brachii muscle persisted, but no residual deficits
in strength, endurance, or range of motion ex-
isted. The rehabilitation program successfully
combined basic rehabilitation concepts (ice to
189
 TABLE 3
Follow-up strength evaluation of elbow flexion and extension at 60°/sec
Four Months Postinjury
Right Left Diefence
Flexion 66' 66 0%
Extension 62 66 6%
Measured in ft Ibs of peak torque.
acute injury and heat to chronic injury; submaxi-
ma1 exercise prior to maximal exercise; multiple
angle isometric exercise prior to isotonic and iso-
kinetic exercise; and functional progression to
field activities) and presented rationale for the use
of these concepts in rehabilitation of other mus-
culoskeletal injuries. 0 13. Knapik JA. Mawdsley RH. Ramos MU: Angular specificity and test
The authors thank Amy Irwin Tank for drawing Fgure 1 and Eve
Sherwood for typing.
REFERENCES
Downloaded from www.jospt.org at on May 29, 2022. For personal use only. No other uses without permission.
1. Baker BE. Bierwagen D: Rupture of the distal tendon of the biceps
brachii. J Bone Joint Surg (Am) 67:414-417.1985
2. Bandy WD.LovelaceChandlwV, McKiirick-Bandy B: Adaptation
of skeletal muscle to resistance traming. J Orthop Sports Phys
Ther. 12:248-255,1990
3. Brashear HR. Raney R: Handbook of Orthopedc Surgery. 10th
Ed. CV Mosby. St Louis, 1986
Copyright © 1991 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
4. Carroll RE. Ham~ltonLR: Rupture of the biceps brachii-a art-
servative method of treatment. J Bone Joint Surg (Am) 49:1016.
1967
5. Davies 6):Use of i s o k i i t i i in rehabiliation of selected surgical
knees. In: Davies GJ (ed). Rehabilitationof the Surgical Knee, pp
77-99. Cy Press. Ronkonkoma. NY. 1984
6. De Andrade J. Grant C. Dixon A: Joint distension and reRex
inhib~tionIn the knee. J Bone Joint Surg (Am) 47:313-322.1965
7. Freidman E: Rupture of the distal biceps tendon. Report on 13
cases. JAMA 184:60-63.1963
8. Gilcrest EL: The common syndrome of rupture. dislocation. and
elongation of the long head of the biceps brachii. An analysis of
one hundred cases. Surg Gynecol Obstet 58:322-340.1934
9. Gllcrest EL, Alb~P: Unusual lesions of muscles and tendons of the
Journal of Orthopaedic & Sports Physical Therapy®
shoulder girdle and upper arm. Surg Gynecol Obstet 68:903-917.
BANDY ET AL
One Year Postinjury
Riht Left Diefence
66 62 6%
68 72 5%
1939
10. Gwld JA. Davies GJ: Orthopedic and sports rehabiliatiion art-
cepts. In: Gwld JA. Davies GJ (eds). Orthopedic and Sports
Physical Therapy. pp 181-198. CV Mosby. St Louis. 1985
11. Hellebrandt FA. Houtz SJ: Mechanisms of muscle trainmg in man.
Experimental demonstration of the overload principle. Phys Ther
Rev 36:371-376.1956
12. Kegerre~sS. Malone T. McCanoll J: Functional progressions: An
aid to athletic rehabilitation. Phys Sportsmed 12:67-71. 1984
mode specificity of isMnetric and isokinetc strength training. J
Orthop Sports Phys Thw 5:58-65.1983
14. Kn~ghtKL. Londeree BR: Comparisons of Mood Row m the ankk
of uninjured subjects during therapeutic applications of heat. cold.
and exercise. Med Sci Sports Exerc 12:76-80. 1980
15. Kn~ghtK: Cryotherapy: Theory. Technique and Physiology. Chat-
tanooga Corp. Chattanooga. TN. 1985
16. Llndh M: Increase of muscle strength from isometric quadriceps
exercises at different knee angles. Scand J Med 11:33-36. 1979
17. Malone TR. Blackbum TA. Wallace LA: Knee rehabilitation. Phys
Ther 60:1602-1610.1980
18. Meherm JM. Kilgore ES: The treatment of ruptures of the distal
biceps brachii tendon. Am J Surg 99:636-640.1960
19. Morrey BF. Askew W, An K, et at: Rupture of the distal tendon of
the blceps brachii. J Bone Joint Surg (Am)67:418-421.1985
20. M w e y BF: Tendon injuries about the elbow. In: Money BF. The
Elbow and Its Disorders. pp 452-463. WB Saunders. Philadelphia.
1985
21. N~tzA: Physical therapy management of the shoulder. Phys Ther
66:1912-1919.1986
22. Stratford P: EMG of the quadriceps femoris mu* in s u b j j s
with normal knees and acutely effused knees. Phys Ther 62:279-
283.1982
23. Wallace LA: Rehabilitation following patellofemoral surgery. Irl:
Davies GJ (ed). Rehabilitation of the Surgical Knee. pp 45-68. Cy
Press. Ronkonkoma. NY. 1984
24. Wh~tneySC: Physical Agents: Heat and cold modalities. In: Scully
RM. Bames MR. Physlcal Therapy. pp 865-867. JB Lippincon.
Philadelph~a.1989
JOSPT 13:4 April 1991