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.
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 (see image below).
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.
Diagnosis and management
In most cases, proximal or distal bicep tendon ruptures can be detected on the basis of history and physical examination alone. However, several imaging studies can be employed as an extension of the physical examination to rule out other disorders from the lengthy list of possibilities; these include plain radiography, arthrography, ultrasonography, and magnetic resonance imaging (MRI).
Depending on the individual case scenario, the type of facility, and physician preference, patients who have suffered a rupture of the biceps tendon can benefit from physical and/or occupational therapy. 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. Early evaluation and treatment by occupational therapy resemble strategies used in rotator cuff repairs.
Several reviews of surgical repair versus conservative (nonoperative) management report conflicting results; neither a complete agreement nor a general clinical consensus has been reached. Generally accepted clinical guidelines advocate surgical repair consisting of tenodesis and subacromial decompression proximally (or anatomic reattachment distally) for young or athletic patients or for persons who require maximum supination strength. [3, 4] Cosmetic concerns may prompt a surgical approach when appearance is unacceptable to the patient following rupture. [5, 6, 7, 8]
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.
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).
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. 
No correlation exists between race and the incidence of biceps rupture.
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 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. [10, 11, 12] Acute traumatic ruptures may occur in younger individuals or in anyone engaged in predisposing activities.
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