Biceps Tendon Rupture

Ovid: 5-Minute Sports Medicine Consult, The

Biceps Tendon Rupture
Peter D. Marshall
Christopher C. Madden
Complete or partial tear of the long bicipital tendon at a proximal or distal location from repetitive microtrauma or acute traumatic injury
  • 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.
  • 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
  • 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.


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.
  • 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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