Biceps Tendon Rupture


Article Author:
David Hsu


Article Editor:
Ke-Vin Chang


Editors In Chief:
Shivajee Nallamothu
Matthew Varacallo
Joshua Tuck


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
11/24/2018 11:41:13 AM

Introduction

The biceps tendon consists of 2 heads originating from the coracoid process (short head) and supraglenoid tubercle of the superior labrum (long head). The tendon attaches to the radial tuberosity of the humerus. The biceps tendon is a strong supinator of the forearm and serves as a weak elbow flexor. Some reports also mentioned biceps tendon’s contribution to the stability of the glenohumeral joint. Rupture of the proximal biceps tendon can be treated conservatively, while injury to its distal attachment usually needs surgical intervention. Patients generally recover successfully if they receive a timely diagnosis and treatment.[1][2][3]

Etiology

The etiology of biceps tendon rupture is mainly attributed to a sudden eccentric load on the flexed and supinated forearm, which can result in rupture of the tendon proximal and distal attachments. Risk factors include age, smoking, use of corticosteroids, and overuse.

Epidemiology

The incidence of biceps tendon rupture is around 2.55 per 100,000 patient-years. Most patients (more than 95%) are males, and the injury events usually happen during middle age.

Pathophysiology

Age, overuse, smoking, and corticosteroid contributed to tendon degeneration and later, tendinopathy. A sudden eccentric load may break tendon structures, mostly involving the bony attachment or tendon-labral junction. Furthermore, there is a vascular watershed zone at the distal biceps tendon, and lack of sufficient blood supply also plays a crucial role in potentiating tendon rupture.[4]

Histopathology

The histopathology studies show that the torn biceps tendon exhibit an increase in proteoglycan, collagen type III, matrix metallopeptidase-1, and matrix metallopeptidase-3, disorganized fiber arrangements, which were compatible with the finding of tendinopathy.

History and Physical

Patients suffering from biceps tendon rupture may complain of sudden sharp pain in the anterior forearm following sudden extension on a flexed elbow. They may feel an audible "pop" on the affected arm and pain during resisted flexion or supination. Tenderness is often noted at the superior margin of the muscle belly. Occasionally, there is ecchymosis near the tender point. Pain can persist for weeks to months. Pain may diminish if the tendon is completely torn. The patient may also present with pain during supination. It is important to check whether there is atrophy of shoulder girdle muscle because the biceps tendon disorders are usually associated with rotator cuff pathology.

Physical examination is important for correct diagnosis. In patients with proximal biceps tendon rupture, there will be a bulbous mass in the upper arm with a visible gap proximal to the mass (Popeye sign). Patients also complain of significant pain in resisted flexion or supination. Tenderness at the superior margin of the muscle belly is also present. Clinicians should examine a range of motion of the elbow to evaluate possible incarceration of the biceps tendon stump in the glenohumeral joint.

Patients suffering from distal biceps tendon rupture may have ecchymosis, swelling, and tenderness in the antecubital fossa. If the bicipital aponeurosis (lacertus fibrosus) is involved, the muscle will be retracted to the upper arm and a defect of the distal tendon will be palpated. The hook test can be used to identify the absence of the biceps tendon at its distal insertion. First, the examiner positions the patient's arm in 90 degrees of flexion and then supinates it. Second, the examiner tries to hook the tendon underneath the skin. Intact distal biceps tendon permits the examiner to hook index finger under the biceps tendon.

Evaluation

Diagnosis is often clinically made, while imaging is helpful when the diagnosis is unclear or partial rupture is considered. Three criteria described for diagnosis:

  1. History of a single traumatic event
  2. Grossly palpable and visible signs of proximal retraction of the distal end of the biceps
  3. The weakness of flexion of the elbow and supination of the forearm

Partial ruptures may present with similar, but subtle, symptoms and physical presentation is usually less a significant weakness or no palpable defect, sometimes leading to delayed diagnosis. Ultrasound is an inexpensive, noninvasive tool to reveal the absence of tendon. Radiographs generally cannot aid in diagnosis; however, it is helpful to survey for other accompanying conditions, confirm the absence of another bony pathology, or sometimes reveal radial tuberosity hypertrophy or occasional avulsion fracture of the tuberosity. MRI is rarely necessary for diagnosis, but it is helpful to distinguish between the following: 

  • Complete versus partial tear
  • Muscle substance versus tendon tear
  • Degree of retraction

Treatment / Management

Rupture of the biceps tendon affects the strength of elbow flexion and supination. There is no absolute indication of surgical intervention. However, an operation is recommended for patients who want to have better recovery and to return to sports.[5][6][7]

Rupture of the Proximal Biceps Tendon (Long Head) 

The non-surgical treatment is usually sufficient for proximal tendon rupture. However, residual cosmetic deformity and intermittent cramps may persist. For surgical intervention, biceps tenodesis is the most common procedure. The early surgical technique involves the transfer of the biceps tendon to the coracoid process, which includes dissection of soft tissue to expose the coracoid process. Now, keyhole tenodesis is the preferred option due to its less invasiveness. The deltopectoral approach can expose the bicipital groove. A knot is then formed from the tendon and is delivered through the keyhole. Newer implants include interference screws and bio-absorbable suture anchors which can be placed either through the open or arthroscopic approach to secure the tendon in the subpectoral space. All the approaches as mentioned above are reported to achieve good clinical outcomes. However, until now, there is limited data to show the superiority of the surgical intervention to the non-surgical approach.

Rupture of the Distal Biceps Tendon  

Most surgeons recommend operative treatments for rupture of the distal biceps tendon to regain the maximal strength of elbow flexion and forearm supination and to effectively relieve pain in the antecubital fossa. Patients with low physical demands and multiple comorbidities are more suitable for conservative treatments. If the bicipital aponeurosis is intact, the functional deficits due to biceps rupture can be minimized.

Surgical repair of the distal biceps tendon can be divided into 2 methods. The non-anatomic approach indicates sutures of the ruptured biceps tendon to the brachialis, which is a simple and efficient way to regain flexion strength. The anatomic approach indicates reinsertion of the ruptured tendon on the radial tuberosity, which is reported to have better effects of restoring the strength of elbow flexion and forearm supination. 

There are 2 incision techniques for surgical exploration of the torn distal biceps tendon.

Anterior Single-Incision Technique

Incision: From antecubital fossa

  • The most common complication is the injury to the lateral antebrachial cutaneous nerve. Sometimes the radial nerve or posterior interosseous nerve might be damaged.
  • Less common heterotopic ossification and synostosis compares to dual incision technique.

Dual-Incision Technique

  • The method is developed to avoid injury to a radial nerve or posterior interosseous nerve.
  • It includes a smaller anterior incision over the antecubital fossa and a second posterolateral elbow incision
  • The dual-incision technique is more common to develop synostosis and heterotopic ossification than the single incision approach.

Differential Diagnosis

The diagnosis of the biceps tendon rupture remains challenging. The investigator should bear in mind that biceps tendon injury usually coexists with rotator cuff disorders and shoulder girdle instability. 

Differential diagnosis includes:

  • Rotator cuff disease
  • Shoulder dislocation/instability
  • Impingement syndrome
  • Humeral/radial head fracture

Prognosis

Timely diagnosis and successful operation are the keys to correct muscle deformity and to regain strength or forearm supination and flexion. The non-operative treatment of distal biceps tendon rupture usually leads to acceptable outcomes and the strength of supination can be gradually restored.

Postoperative and Rehabilitation Care

There are different rehabilitation protocols used after surgical repair of biceps tendon rupture. Generally, limited active or passive elbow extension and supination are suggested at the early period post operation. Strengthening exercise of the shoulder and wrist should also be incorporated in the post-operation rehabilitation protocol.

Pearls and Other Issues

Chronic biceps tendon rupture is defined as tendon tear for more than 4 weeks. Chronic rupture may be due to missed diagnosis or failure of conservative treatment. Partial tear or other coexisting pathology may complicate the diagnosis. High-resolution ultrasound is helpful in differentiating partial and complete tears of the biceps tendon.

Enhancing Healthcare Team Outcomes

Biceps tendon rupture is a relatively common disorder that is chiefly seen in people with repetitive lifting activities. The patient often first presents to the emergency department, urgent care clinic or to the primary care provider, which may include a nurse practitioner.  The key to prevention of this injury is to educate the patient on modifying the risk factors. After the injury is diagnosed, work specific or sports specific training is often recommended before returning to the original activity. For most patients fill recovery is possible within 8-12 weeks. [8][9](Level V)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Biceps Tendon Rupture - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the most sensitive study in differentiating between a partial versus complete distal biceps tendon rupture?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 60-year-old patient was digging a hole when he heard a snap and felt pain in his upper arm. Which of the following is not a likely presentation?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which component of the biceps is most commonly ruptured?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 26-year old was playing neighborhood football when he fell. He complains of a painful soft-tissue mass in the anterior aspect of the arm. On exam, there is decreased strength during flexion and supination of the forearm. What is the recommended treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient was lifting weights and suddenly developed pain in his anterior shoulder. Within a few minutes, he noticed a mass on the upper arm between the shoulder and elbow. On exam, he is found to have palpable tenderness along the upper forearm and his range of motion of the shoulder and elbow are limited. The Ludington and speed tests are both positive. What is the best study to make a diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Biceps Tendon Rupture - References

References

van der Vis J,Janssen SJ,Haverlag R,van den Bekerom MPJ, Functional outcome in patients who underwent distal biceps tendon repair. Archives of orthopaedic and trauma surgery. 2018 Nov     [PubMed]
Witkowski J,Królikowska A,Czamara A,Reichert P, Retrospective Evaluation of Surgical Anatomical Repair of Distal Biceps Brachii Tendon Rupture Using Suture Anchor Fixation. Medical science monitor : international medical journal of experimental and clinical research. 2017 Oct 17     [PubMed]
Castricini R,Familiari F,De Gori M,Riccelli DA,De Benedetto M,Orlando N,Galasso O,Gasparini G, Tenodesis is not superior to tenotomy in the treatment of the long head of biceps tendon lesions. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2018 Jan     [PubMed]
Thomas JR,Lawton JN, Biceps and Triceps Ruptures in Athletes. Hand clinics. 2017 Feb     [PubMed]
Yao C,Weng W,Zhou X,Poonit K,Yang J,Lin D,Sun C,Yan H, Individual Treatment of Delayed Distal Biceps Tendon Rupture: Case Report and Literature Review. Annals of plastic surgery. 2018 Oct 9     [PubMed]
Ribeiro LM,Almeida Neto JI,Belangero PS,Pochini AC,Andreoli CV,Ejnisman B, Reconstruction of the distal biceps tendon using semitendinosus grafting: Description of the technique. Revista brasileira de ortopedia. 2018 Sep-Oct     [PubMed]
Lang NW,Bukaty A,Sturz GD,Platzer P,Joestl J, Treatment of primary total distal biceps tendon rupture using cortical button, transosseus fixation and suture anchor: A single center experience. Orthopaedics     [PubMed]
Tarallo L,Lombardi M,Zambianchi F,Giorgini A,Catani F, Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach. BMC musculoskeletal disorders. 2018 Oct 10     [PubMed]
Frank RM,Cotter EJ,Strauss EJ,Jazrawi LM,Romeo AA, Management of Biceps Tendon Pathology: From the Glenoid to the Radial Tuberosity. The Journal of the American Academy of Orthopaedic Surgeons. 2018 Feb 15     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Surgery-Orthopaedic. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Surgery-Orthopaedic, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Surgery-Orthopaedic, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Surgery-Orthopaedic. When it is time for the Surgery-Orthopaedic board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Surgery-Orthopaedic.