AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Biceps brachii, one of the dominant muscles of the arm, is involved in functional activities of the upper limb, both as a result of its size and its orientation about both the shoulder and elbow joints. At its proximal attachment, the biceps has 2 distinct tendinous insertions on the scapula from its long and short heads. The short head arises from the coracoid process with the coracobrachialis, while the long head originates from the supraglenoid tubercle and passes over the humeral head within the capsule of the glenohumeral joint. The biceps muscle then continues down the arm within the intertubercular groove covered by a synovial outpouching of the joint capsule. The 2 muscle bellies unite near the midshaft of the humerus and attach distally on the radial tuberosity. The distal tendon blends with the bicipital aponeurosis, which affords protection to structures of the cubital fossa, allowing distribution of forces across the elbow to lessen the pull on the radial tuberosity. The biceps

receivesinnervation via the musculocutaneous nerve (C5, C6) from the lateral cord of the brachial plexus.

Pathophysiology

The biceps muscle and its tendons are some of the most superficial structures of the arm. These structures account for a significant portion of shoulder injuries and a smaller number of elbow injuries. Rupture of the proximal biceps tendon comprises 90-97% of all biceps ruptures and almost exclusively involves the long head. Tendon ruptures typically occur at the bony attachment or tendon-labral junction. The remaining ruptures occur distally at the insertion on the radial tuberosity or, even less commonly, at the short head insertion on the acromion.

Frequency

United States

Biceps tendon ruptures are reported in the United States with increasing frequency. Individuals aged 40-60 years with a history of shoulder problems are experiencing this type of injury most commonly, secondary to chronic wear of the tendon. Younger individuals may rupture the biceps tendon following a traumatic fall, during heavy weightlifting, or during sporting activities (eg, snow boarding, football).

Mortality/Morbidity

Overall consequences of biceps rupture may differ among various demographic groups. The major impairment resulting from proximal biceps rupture involves limitations due to pain during the acute phase, but ultimately it relates to a decrease in strength during shoulder flexion, elbow flexion, and forearm supination. Distal ruptures also result in pain initially, followed by reduced strength in supination, elbow flexion, and grip strength.

Race

No correlation exists between race and incidence of biceps rupture.

Sex

Men are affected more commonly than women, but this may be caused primarily by vocational or avocational factors. The dominant arm is involved more commonly, probably related to its greater proportional use compared with the nondominant side. At present, no evidence exists of predisposition to either male or female due to anatomy or genetic factors.

Age

Age may vary considerably in patients with biceps rupture, but, typically, the patient with rupture caused by impingement or chronic inflammation is in the fourth, fifth, or sixth decade of life. Acute traumatic ruptures may occur in younger individuals or in anyone engaged in predisposing activities.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Patients with biceps rupture may report a wide variety of symptoms, including the following:

• Some report a sudden pain in the anterior shoulder during activity, which may be accompanied by an audible pop or a perceived snapping sensation. This acute pain frequently is described as sharp in nature.
• Others may report recurrent pain while performing overhead or repetitive activities.
• Still others experience a nondescript anterior shoulder soreness that may worsen at night.
• Patients also may be asymptomatic and note only a visible or palpable mass between the shoulder and elbow. Pain actually may diminish when complete rupture occurs following chronic impingement and irritation. Distal ruptures may present in a similar fashion, but symptoms or noticeable masses are located closer to the elbow in most cases.

Physical

When biceps tendon rupture is suggested on the basis of history or mechanism of injury, physical examination should include specific testing of all types of shoulder and elbow pathology within the large list of possible diagnoses. Since biceps rupture is often the final event in a cascade of impingement and inflammation, testing for impingement syndromes and bicipital tendinitis always is warranted. Thorough examination should include evaluation for several possible signs.

• Perform an examination to identify any palpable tenderness along the course of the biceps tendons and muscle belly, including the bicipital groove with the arm in 5-10° of internal rotation.
• Perform range of motion (ROM) testing of the shoulder and elbow.
• Perform complete strength testing of upper limb muscles, especially the biceps.
• Inspect the shoulder and arm contour and compare with the contralateral side.
• • Pay special attention to the region of the bicipital groove, which may show indentation or hollowing when the tendon is absent following a rupture.
  • The Ludington test (or position), in which the hands are clasped behind the head and biceps muscles are flexed, often is used for this purpose.
• Other maneuvers, such as the Speed test, Yergason sign, and signs of biceps dislocation or instability, are used to identify patients who may have partial tears, or who may be predisposed to future rupture.

Causes

• Proximal biceps ruptures generally are caused by insidious inflammation from impingement in the subacromial region and may be the eventual result of chronic microtrauma in this manner. Repeated insults often lead to fraying of the tendon, with resultant weakness predisposing it to rupture following relatively minor injuries.
• Excessive loading or rapid stress upon the tendon, such as in weightlifting, often causes acute ruptures.
• Biceps tendon rupture frequently is associated with rotator cuff trauma in the geriatric population.
• Most ruptures occur at the tendinous insertion to the bony anchor, both proximally and distally.
• • Distal avulsions from the radius commonly are caused by chronic irritation on an irregular surface, such as in persistent cubital bursitis.
  • Acute avulsions are the result of forceful extension of the elbow from a flexed and supinated position.
  • Rare short head rupture may occur with rapid flexion and adduction of the arm during elbow extension activities.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Acromioclavicular joint separation
Impingement syndrome
Humeral fracture
Shoulder dislocation/instability
Aseptic necrosis of the humeral head
Cubital tunnel syndrome (distal)
Radial head fracture (distal)
Septic arthritis
Gout

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Imaging Studies

• In most cases, both proximal and distal ruptures can be detected on the basis of history and physical examination alone. Mechanism of injury, history of pain and/or inflammation, and supportive physical findings discussed above lead to a confident diagnosis in most patients. Several imaging studies can be employed as an extension of the physical examination to rule out other disorders from the lengthy list of possibilities.
• Plain radiographs may reveal hypertrophic spurring or bony irregularities that increase the likelihood of rupture and support a clinical suspicion of this diagnosis. Anteroposterior and axillary films are the most useful views for ruling out fractures in this setting.
• Arthrography has been used for a long time to evaluate tendon ruptures, but it has several drawbacks, including the following:
• • Invasiveness
  • Need for experienced interpreters of rarely seen images
  • Ionizing radiation
  • Possible confusion with concomitant rotator cuff tears
• Ultrasonography of the anterior shoulder can provide a useful and reliable evaluation in many cases and has previously been shown to be superior to arthrography for examination of the biceps tendons. Recently, the use of diagnostic ultrasonography for musculoskeletal indications has received increasing attention. Studies have indicated that complete rupture or dislocation of the long head of the biceps can be reliably identified in this manner (Moosmayer, 2005). Smaller, more portable, and less expensive ultrasonography units have also likely contributed to increased use in the office setting. Other advantages of this modality include the following:
  • Lack of ionizing radiation
  • Painless examination
  • Rapid interpretations
  • Dynamic imaging capability
• Potential disadvantages of ultrasonography include the following:
  • Limited ability to image the intra-articular portion of the tendon, which is the most frequent site of rupture
  • Can be more technically challenging and is highly operator dependent
• MRI provides the greatest anatomic detail from proximal to distal attachment; the major disadvantage is the higher cost of MRI compared with costs associated with other imaging techniques.

Histologic Findings

Histologic studies associated with tendon rupture repeatedly have revealed similar results. Nontraumatic tendon ruptures, including those of the biceps brachii, show evidence of advanced degeneration. Changes include hypoxic tendinopathy, mucoid degeneration, lipomatosis, and calcifying tendinopathy. Often, evidence of reduced collagen fiber thickness, decreased crimp angle, and disrupted crimp continuity is also present in tendon ruptures. In both symptomatic and asymptomatic patients with rupture (not limited to biceps alone), a healthy tendon composition rarely, if ever, has been encountered. In contrast, nonruptured (control) tendon samples have demonstrated much lower incidence of degenerative change in large study populations. Although the etiology of degenerative changes remains unclear, this group of subjects may be heterogeneous with multiple factors at work.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

Depending on the individual case scenario, type of facility, and physician preference, patients who have suffered a rupture of the biceps tendon can benefit from physical and/or occupational therapy. Methods of proper rehabilitation for this type of injury are discussed below.

Occupational Therapy

Begin rehabilitation during conservative management with a complete examination of the limb to identify coexisting injuries or complicating factors that may affect treatment. Rest the affected joint in the acute stage, with or without soft immobilization. Control swelling with cold modalities (eg, cold packs, ice massage, hydrotherapy, specialized cold compression units) and treat inflammation with nonsteroidal anti-inflammatory drugs (NSAIDs), barring contraindications.

Postoperative rehabilitation often is shaped by surgeon preferences and intraoperative findings during repair. The typical protocol involves use of a soft sling immediately following the procedure, allowing the patient to take the arm out for light movements and gentle ROM. By 10-14 days, introduce pulleys or therapy bands for ROM and strengthening and advance functional exercises and maintenance of motion until 6-8 weeks. At this point, moderate loading may be tolerated in most cases. Heavy loading is inadvisable for several months, especially in distal tendon repairs.

Early evaluation and treatment by occupational therapy resembles strategies similar to those used in rotator cuff repairs. Emphasize preservation of full ROM at the shoulder, elbow, wrist, and hand with a gradual increase in weight bearing. Codman pendulum exercises often may be the first step, followed by more functional activities as they are tolerated.

Surgical Intervention

Treatment of biceps tendon ruptures is a topic of debate. Several reviews of surgical repair versus conservative (nonoperative) management report conflicting results; neither complete agreement nor general clinical consensus has been reached. Although no concrete evidence provides unconditional support for one treatment protocol, the results of these reviews ultimately may lend credence to the long-standing practice of individualizing treatment to each patient's circumstances.

Generally accepted clinical guidelines advocate surgical repair consisting of tenodesis and subacromial decompression proximally (or anatomic reattachment distally) for young or athletic patients or those who require maximum supination strength. Cosmetic concerns may prompt a surgical approach when appearance is unacceptable to the patient following rupture.

Conservative management is considered appropriate for middle-aged or older patients and for those who do not require a high degree of supination strength in daily activities. This approach involves rest, followed closely by ROM and strengthening exercises for the shoulder and elbow. The number of patients managed conservatively outweighs the number repaired surgically in most practice settings, and this therapy provides an effective and highly tolerable means of treatment. Various follow-up studies report up to 20% loss of supination strength in nonoperative management, although the overall level of impairment rarely impacts activities of daily living (ADL).

Currently, it seems prudent to employ individualized and comprehensive treatment strategies tailored to each patient's needs, consisting of the following:

• Perform a thorough evaluation for coexisting shoulder and elbow pathology.
• Conduct risk/benefit discussions concerning surgical repair according to each patient's needs, desires, age of injury, and other relevant information ascertained. Surgical referrals are made most often for those requiring maximum biceps function or for intolerable pain that limits function.
• Focus appropriate rehabilitation efforts at maximizing functional capacity, regardless of acute management.

Consultations

Surgical consultation and occupational/physical therapy may be necessary.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Anti-inflammatory medications can be used to reduce the underlying inflammatory process that may predispose tendons to rupture. They also may provide an analgesic effect during the early or acute phase of an injury in which tendons may be disrupted partially or stressed. The analgesic effect is most pronounced when anti-inflammatory agents are used in combination with rest and ice following such an injury.

Drug Category: Nonsteroidal anti-inflammatory drugs

Administered in this setting to reduce the pain and inflammation associated with acute or chronic impingement, overuse syndromes, or injuries to muscles and tendons.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients with biceps rupture, especially those hospitalized for repair, rarely need inpatient rehabilitation.
• Without adequate social support, presence of other functional impairments or medical comorbidities may necessitate admission for compensatory strategies and/or adaptive equipment training.
• Following admission, these patients should progress much like their counterparts with outpatient or in-home therapy.

Further Outpatient Care

• Patients with biceps tendon ruptures, whether treated conservatively or with surgical repair, frequently are referred to outpatient facilities for physical or occupational therapy. See Occupational Therapy.

Deterrence

• Pathophysiology of biceps tendon rupture often is related intimately to chronic irritation, inflammation, and impingement; therefore, prevention of ruptures is accomplished best when the patient can avoid repetitive maneuvers and activities that predispose to tendinitis, bursitis, and rotator cuff injuries.
• Avoidance of falls with direct trauma to the muscle or tendon and reduction of incidents of rapid, heavy loading of the muscle (especially with the elbow flexed and forearm supinated) also may be helpful in decreasing the likelihood of rupture.

Complications

• Possible surgical complications
• Contractures due to excessive immobilization
• Heterotopic ossification

Prognosis

• Overall prognosis for biceps tendon ruptures is good for both surgical repair and conservative management. Both approaches generally result in adequate functional return to performance of ADL, as well as to most vocational and recreational pursuits.
• Strength deficits existing before and after repair vary.
• Factors such as comorbid disorders, concomitant injuries, age, and time since rupture may affect eventual functional level outcomes.

Patient Education

• Educate patients on the importance of stretching in preparation for athletic or exertional activities and providing proper care of resultant injuries.
• Warn patients that long-term or frequent steroid injections may weaken local tendons in the region of the injection.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Few medical/legal issues surround rupture of the biceps. Diagnosis usually is apparent on physical examination and can be confirmed readily by MRI when in doubt. Significant permanent disability rarely results.
• • Failure to exercise caution when evaluating or treating persons with upper limb injuries, pain symptoms, or functional impairments who require maximum strength and/or motion for vocational pursuits
  • Failure to diagnose or treat rupture of the biceps adequately in this setting may lead to lost wages, disability claims, and unemployment

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Agrawal V, Stinson, MJ. Case Report: Heterotopic ossification after repair of distal biceps tendon rupture utilizing a single-incision endobutton technique. J Shoulder Elbow Surg. Jan-Feb 2005;14(1):107-9.
• Ahovuo J, Paavolainen P, Slatis P. Diagnostic value of sonography in lesions of the biceps tendon. Clin Orthop. Jan 1986;(202):184-8. [Medline].
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• Moosmayer S, Smith HJ. Diagnostic ultrasound of the shoulder--a method for experts only? Results from an orthopedic surgeon with relative inexpensive compared to operative findings. Acta Orthop. Aug 2005;76(4):503-8.
• Neer CS. Cuff tears, biceps lesions and impingement. In: Shoulder Recontruction. Philadelphia, Pa: WB Saunders; 1990:. 71-137.
• Phillips BB, Canale ST, Sisk TD, et al. Ruptures of the proximal biceps tendon in middle-aged patients. Orthop Rev. Mar 1993;22(3):349-53. [Medline].
• Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg. May-Jun 1999;7(3):199-207. [Medline].
• Refior HJ, Sowa D. Long tendon of the biceps brachii: sites of predilection for degenerative lesions. J Shoulder Elbow Surg. Nov-Dec 1995;4(6):436-40. [Medline].
• Reid DC. Shoulder region. In: Sports Injury Assessment and Rehabilitation. 1st ed. New York, NY: Churchill Livingstone; 1992:. 943-50.
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• Spivak JM, Di Cesare PE, Feldman DS. Biceps tendon injuries. In: Orthopaedics: A Study Guide. New York, NY: McGraw-Hill; 1999:. 593-4.
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Article Last Updated: Jan 24, 2007