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

Biceps Rupture

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

Introduction

Background

Tendon ruptures of the biceps brachii, one of the dominant muscles of the arm, have been reported in the United States with increasing frequency. Ruptures of the proximal biceps tendon make up 90-97% of all biceps ruptures and almost exclusively involve the long head.

Anatomy

Because of its size and its orientation about the shoulder and elbow joints, the biceps muscle is involved in functional activities of the upper limb. 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.1,2 The biceps receives innervation 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. As mentioned, rupture of the proximal biceps tendon comprises 90-97% of all biceps ruptures and almost exclusively involves the long head. Tendon rupture typically occurs 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

As previously noted, biceps rupture has been reported in the United States with increasing frequency. The injury is experienced most commonly by individuals aged 40-60 years with a history of shoulder problems, 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, snowboarding, 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 impairment ultimately relates to a decrease in strength during shoulder flexion, elbow flexion, and forearm supination. Distal ruptures also initially result in pain, followed by reduced strength in supination, elbow flexion, and grip strength.3

Race

No correlation exists between race and the incidence of biceps rupture.

Sex

Men suffer biceps rupture more commonly than do women, but this difference may result primarily from vocational or avocational factors. The dominant arm is involved more commonly, probably because it is used more often than is the nondominant arm. At present, no evidence exists of a male or female predisposition to biceps rupture due to anatomic or genetic factors.

Age

Age may vary considerably in patients with biceps rupture, but typically, the patient with a rupture caused by impingement or chronic inflammation is in the fourth, fifth, or sixth decade of life.4,5,6 Acute traumatic ruptures may occur in younger individuals or in anyone engaged in predisposing activities.

Clinical

History

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

  • Some patients report a sudden pain in the anterior shoulder during activity. This acute pain, frequently described as sharp in nature, may be accompanied by an audible pop or a perceived snapping sensation.
  • Other persons may report experiencing 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 in most of these cases, symptoms or noticeable masses are located closer to the elbow.

Physical

When biceps 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. Because biceps rupture is often the final event in a cascade of impingement and inflammation, testing for impingement syndromes and bicipital tendinitis always is warranted. A 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 º 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 the biceps muscles are flexed, often is used for this purpose.
  • Other maneuvers, such as the Speed test and Yergason sign, are used, along with signs of biceps dislocation or instability, to identify patients who may have partial tears or who may be predisposed to future rupture.

Causes

  • A proximal biceps rupture generally is 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.
  • A tendon rupture due to chronic inflammation can occur in rheumatoid arthritis.
  • Excessive loading or rapid stress upon the tendon, such as in weightlifting, often causes an acute tendon rupture.
  • Biceps tendon rupture or degeneration frequently is associated with rotator cuff trauma in the geriatric population and is often observed at the time of surgery for complete rotator cuff tears. This may be related to impingement phenomenon.7,8,9
  • Most ruptures occur at the tendinous insertion to the bony anchor, proximally and distally:10
    • 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.
  • Impairment of physiologic repair mechanisms by medications (statins) has also been proposed as a potential factor predisposing the tendon to rupture.11

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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