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High Yield Topics

Biceps Tendon Rupture

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Ovid: 5-Minute Sports Medicine Consult, The


Biceps Tendon Rupture
Peter D. Marshall
Christopher C. Madden
Basics
Description
Complete or partial tear of the long bicipital tendon at a proximal or distal location from repetitive microtrauma or acute traumatic injury
Epidemiology
  • Occurs most commonly in middle-aged males as a result of impingement
  • Occurs most commonly concomitantly with rotator cuff disease (eg, tendinopathy, tear) rather than in isolation (1)[C]
  • 90–97% of biceps tendon ruptures are proximal, at the intertubercular sulcus.
  • 3–10% occur distally at the elbow.
Risk Factors
  • Male
  • Age >30 yrs
  • Known bicipital tendinopathy
  • Known rotator cuff tendinopathy or tear (biceps tendon pathologically loaded)
  • Overhead athlete (contributes to anterior shoulder stability with repeated abduction/external rotation)
  • Prior corticosteroid injection into biceps tendon sheath
  • Anabolic steroid use
Commonly Associated Conditions
  • Rotator cuff impingement: Subacromial impingement in combination with repetitive overhead motion, such as with throwing, can lead to proximal biceps tendon degeneration.
  • Superior labrum anterior-to-posterior (SLAP) lesions: Lesions of the superior glenoid labrum from the 10 o'clock to the 2 o'clock position. SLAP lesions may involve the biceps anchor (2)[C).
  • Subscapularis rupture/partial rupture: Following subscapularis tears, the biceps tendon can sublux medially out of the bicipital groove, causing a painful clicking sensation.
  • Rotator interval lesions: The biceps tendon can sublux medially over the lesser tuberosity after tears to the rotator interval, but there usually is an associated subscapularis injury.
Diagnosis
History
  • Mechanism is usually forceful eccentric biceps contraction, and it may be acute or chronic.
  • Pain is usually located more proximal than distal.
  • Prior symptoms are indicative of prior rotator cuff or bicipital tendinopathy.
  • Prior biceps tendon sheath corticosteroid injection is risk factor.
  • An injury with minimal symptoms in elderly patients showing acceptable strength may be managed conservatively.
Physical Exam
  • Proximal rupture:
    • Patient may report a sudden tearing or “pop” in the shoulder.
    • Acute pain (may not be extreme) and later ecchymosis and swelling about the anterior shoulder
    • Visible lump-type of deformity in the mid-upper arm anteriorly, secondary to muscle belly retracting distally (“Popeye sign”)
    • In some cases of chronic shoulder pain, there may be notable improvement after inflammation subsides.
    • Patients with accompanying rotator cuff pathology may complain of overhead pain and weakness and night pain.
    • Inspect for “Popeye sign” deformity in anterior brachium.
    • Ecchymosis may involve entire anterior biceps.
    • Elbow function generally is preserved. Patient may have mild weakness of elbow flexion and supination.
    • Shoulder function may be diminished, and careful evaluation of rotator cuff integrity is advised.
    • Specialized tests for biceps pain include the Speed, Yergason, and Ludington tests.
  • Distal rupture:
    • History is usually of a sudden eccentric load with elbow at 90 degrees of flexion.
    • Acute tearing sensation with sudden loss of elbow flexion and supination strength
    • Pain, ecchymosis, and swelling localized over the antecubital fossa
    • Antecubital fossa with swelling and ecchymosis
    • May visualize absence of distal biceps tendon as it crosses the flexion crease
    • A palpable defect usually can be felt in antecubital fossa.
    • Usually significant losses in strength on resisted elbow flexion and supination
    • A partial rupture may have many of the same features as a complete rupture, but generally the tendon still can be palpated in continuity.
Diagnostic Tests & Interpretation
Imaging
  • Plain films of shoulder are often negative with isolated tendon rupture. They are helpful in ruling out proximal humerus fracture in elderly patients, however.
  • Shoulder MRI confirms diagnosis if clinical exam not straightforward and if rotator cuff pathology is suspected.
  • MRI findings may include absence of the tendon within the intertubercular groove as a result of tendon retraction. Partial rupture may show increased T2-weighted signal extending partially through the tendon (3)[C].
  • Standard elbow x-ray series for distal injuries:
    • Check for avulsion fragment of radial tuberosity.
    • Degenerative changes or lipping at the radial tuberosity can be associated with biceps tendinopathy.

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Differential Diagnosis
  • Proximal rupture:
    • Superior labral lesion (ie, SLAP tear)
    • Subscapularis injury
    • Rotator cuff/rotator interval injury
    • Biceps tendon subluxation (rupture of transverse ligament)
    • Long head of biceps tendinitis or tendinosis; onset usually insidious
    • Greater or lesser tuberosity fractures may occur following shoulder dislocation.
  • Distal rupture:
    • Distal biceps tendinitis or tendinosis; onset usually insidious
    • Partial distal biceps tendon rupture
    • Anterior capsule strain; occurs with hyperextension injuries, and tenderness is more diffuse anteriorly.
    • Coronoid process fractures directly tender over coronoid process; no palpable biceps defect
    • Lateral antebrachial cutaneous nerve entrapment syndrome
    • None of these problems demonstrates absence of a palpable biceps tendon in the antecubital fossa.
    • Partial ruptures can be difficult to diagnose, and MRI often is required.
Treatment
  • Proximal rupture:
    • Acute immobilization in posterior elbow splint with the elbow at 90 degrees for comfort and forearm in full supination; add sling for comfort.
    • Younger patients should begin immediate shoulder and elbow passive range of motion (ROM) exercises.
    • Strengthening can begin in 4–5 wks or when there is resolution of pain (4)[C].
    • Return to unrestricted activities after 2–3 mos
    • Patients over 50 yrs of age may require longer period of immobilization prior to strengthening rehab.
    • Younger patients may prefer surgical treatment (tenodesis) for cosmetic reasons or to return to their previous level of functioning.
    • Most patients are older and will have little to no change in elbow flexion/supination strength; they may opt for surgery, however, if there is additional rotator cuff pathology.
  • Distal rupture:
    • Acute management is the same as for proximal injuries.
    • Trial of nonoperative treatment for partial ruptures and elderly or sedentary patients
    • Most patients require surgical repair because there is more significant loss of elbow flexion and supination strength and endurance with distal injuries.
Additional Treatment
Additional Therapies
  • The main complaint after conservative management of biceps tendon ruptures, especially distal ruptures, is loss of elbow flexion and forearm supination strength, especially endurance.
  • Most young people and athletes require surgical repair of complete biceps tendon injuries. Many advocate surgical repair of partial ruptures in this population, especially if the ruptures are distal.
References
1. Phillips BB, Canale ST, Sisk TD, et al. Ruptures of the proximal biceps tendon in middle-aged patients. Orthop Rev. 1993;22:349–353.
2. Rodosky MW, Harner CD, Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med. 1994;22:121–130.
3. Zanetti M, Weishaupt D, Gerber C, et al. Tendinopathy and rupture of the tendon of the long head of the biceps brachii muscle: evaluation with MR arthrography. AJR Am J Roentgenol. 1998;170:1557–1561.
4. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii: operative versus non-operative treatment. J Bone Joint Surg Am. 1985;67:414–417.
Additional Reading
Anzel SH, Covey KW, Weiner AD, et al. Disruption of muscles and tendons: an analysis of 1,014 cases. Surgery. 1959;45:406–414.
Mariani EM, Cofield RH, Askew LJ, et al. Rupture of the tendon of the long head of the biceps brachii: surgical versus nonsurgical treatment. Clin Orthop. 1988;228:233–239.
Rokito AS, McLaughlin JA, Gallagher MA, et al. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg. 1996;5:73–75.
Codes
ICD9
  • 727.62 Nontraumatic rupture of tendons of biceps (long head)
  • 840.8 Sprain of other specified sites of shoulder and upper arm


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