eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions

Biceps Rupture: Differential Diagnoses & Workup

Author: Gary L Branch, DO, Mid-Michigan Orthopedics, Staff Physician, Memorial Healthcare Center.
Coauthor(s): J Michael Wieting, DO, MEd, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Sports Medicine, Associate Director of Physician Assistant Training Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
Contributor Information and Disclosures

Updated: Sep 18, 2009

Differential Diagnoses

Acromioclavicular Joint Separations
Gout
Rotator Cuff Disease
Septic Arthritis

Other Problems to Be Considered

Impingement syndrome
Humeral fracture
Shoulder dislocation/instability
Aseptic necrosis of the humeral head
Cubital tunnel syndrome (distal)
Radial head fracture (distal)

Workup

Imaging Studies

  • In most cases, proximal and distal ruptures can be detected on the basis of history and physical examination alone. The mechanism of injury, a history of pain and/or inflammation, and supportive physical findings (as 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 biceps 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 the examination of the biceps tendons. The use of diagnostic ultrasonography for musculoskeletal indications has received increasing attention.1,9,12 Studies have indicated that complete rupture or dislocation of the long head of the biceps can reliably be identified in this manner.13,14 (However, intra-articular or partial thickness tears, as well as degenerative changes, may be more difficult to detect with ultrasonography.15 ) Smaller, more portable, and less expensive ultrasonography units have likely contributed to the increased use of ultrasonography 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
  • Magnetic resonance imaging (MRI) provides the greatest anatomic detail from proximal to distal attachment16 ; the major disadvantage is the higher cost of MRI compared with costs associated with other imaging modalities.

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.17 Often, evidence of reduced collagen fiber thickness, decreased crimp angle, and disrupted crimp continuity is also present in tendon rupture.

In symptomatic and asymptomatic patients with rupture (not limited to the biceps alone), a healthy tendon composition rarely, if ever, has been encountered. In contrast, nonruptured (control) tendon samples have demonstrated a 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.

More on Biceps Rupture

Overview: Biceps Rupture
Differential Diagnoses & Workup: Biceps Rupture
Treatment & Medication: Biceps Rupture
Follow-up: Biceps Rupture
Multimedia: Biceps Rupture
References
Further Reading
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References

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Keywords

biceps rupture, biceps, biceps tendon, biceps muscle, biceps brachii, tendon rupture, ruptured tendon, tendon ruptures, biceps tendon rupture, bicep tendon rupture, bicep rupture, ruptured bicep, ruptured biceps, ruptured biceps tendon, torn biceps, torn bicep, biceps tear, bicep tear, torn bicep tendon, torn biceps tendon, rotator cuff, rotator cuff tear, tendinopathy, tendinitis, tendonitis, biceps tendinitis, biceps tendonitis, bicipital tendinitis, bicipital tendonitis

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Contributor Information and Disclosures

Author

Gary L Branch, DO, Mid-Michigan Orthopedics, Staff Physician, Memorial Healthcare Center.
Gary L Branch, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Osteopathic College of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

Coauthor(s)

J Michael Wieting, DO, MEd, Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Principles and Practices, Director of Sports Medicine, Associate Director of Physician Assistant Training Program, Department of Osteopathic Principles and Practice, Lincoln Memorial University-DeBusk College of Osteopathic Medicine
J Michael Wieting, DO, MEd is a member of the following medical societies: American Academy of Osteopathy, American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Forensic Examiners, American College of Sports Medicine, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and International Society of Physical and Rehabilitation Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert J Kaplan, MD, James E Van Zandt VA Medical Center, Staff Physician, Department of Rehabilitation Medicine
Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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