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

Biceps Rupture

Gary L Branch, DO, Mid-Michigan Orthopedics, Staff Physician, Memorial Healthcare Center.
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

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

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.

Treatment

Rehabilitation Program

Physical Therapy

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. The proper rehabilitation methods for this type of injury are discussed in the next section.

Occupational Therapy

Postoperative rehabilitation often is shaped by surgeon preferences and intraoperative findings during repair. The typical protocol involves the 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; advance functional exercises and maintain and advance ROM 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.⁶

Early evaluation and treatment by occupational therapy resemble strategies 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 a complete agreement nor a 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 for persons who require maximum supination strength.³ Cosmetic concerns may prompt a surgical approach when appearance is unacceptable to the patient following rupture.^18,19,20,21

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. Conservative therapy provides an effective and highly tolerable means of treatment; in most practice settings, the number of patients who are managed conservatively is greater than the number who undergo surgical repair. Various follow-up studies have reported that in nonoperative management, patients lose up to 20% of their supination strength, 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. Such strategies consist of the following:

• A thorough evaluation for coexisting shoulder and elbow pathology
• Risk/benefit discussions concerning surgical repair, according to each patient's needs, desires, age of injury, and other relevant information that has been ascertained (Surgical referrals are made most often for patients requiring maximum biceps function or for individuals who are suffering intolerable pain that limits function.)
• A focus on appropriate rehabilitation efforts aimed at maximizing functional capacity, regardless of acute management

In a surgical study involving 23 patients, 10 of whom were either professional athletes or highly physically active, Grégory et al reported promising results from an endoscopic procedure in which a suture anchor was used to repair distal biceps tendon ruptures.²² The investigators found that 22 of the patients were satisfied with the surgery's results, with 20 patients returning to preinjury jobs and sports. Following surgery, the mean loss of pronation and supination among patients was 8.6º and 5º, respectively. One patient suffered a severe neurologic complication, necessitating a second surgical procedure.

Consultations

Surgical consultation and occupational/physical therapy may be necessary in cases of biceps rupture.

Medication

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, when tendons may be stressed or partially disrupted. Following such an injury, the analgesic effect is most pronounced when anti-inflammatory agents are used in combination with rest and ice.

Nonsteroidal anti-inflammatory drugs

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

Ibuprofen (Motrin, Ibuprin)

Representative member of propionic acid group of NSAIDs; ibuprofen has been extensively studied with regard to indications, side effects, and interactions. It is the first-line medication in situations in which NSAIDs are indicated, due to its long track record and high degree of familiarity among clinicians; used here to represent NSAIDs in general.

Dosing

Adult

200-800 mg PO qid

Pediatric

5-10 mg/kg PO; not to exceed 40 mg/kg/d

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; history of allergic reactions to NSAID class or to aspirin

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Pregnancy category D in third trimester; GI ulceration, bleeding, and perforation associated with chronic or long-term use; few or no warning signs prior to ulceration or perforation; need careful risk/benefit assessment
Severe allergic reactions possible
Caution in persons with nasal polyps, aspirin allergy, reactive airway diseases, history of angioedema
Caution with renal impairment (monitor kidney function)
Associated with fluid retention and edema, prompting caution in persons with cardiovascular disease
Associated with reversible inhibition of platelet aggregation and prolongation of bleeding time; avoid in persons with coagulation defects and in combination with anticoagulants
Caused elevation of some liver enzymes in previous studies; identify signs or symptoms of liver dysfunction with use of NSAIDs
Associated with aseptic meningitis
Possibility of febrile reactions, blurred vision, or scotomas

Follow-up

Further Inpatient Care

• Patients with biceps rupture, especially those who have been hospitalized for repair, rarely need inpatient rehabilitation.
• Without adequate social support, the 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 rupture, whether treated conservatively or with surgical repair, frequently are referred to outpatient facilities for physical or occupational therapy. (See Occupational Therapy.)

Deterrence

• The pathophysiology of biceps rupture often is intimately related to chronic irritation, inflammation, and impingement; therefore, patients can best prevent ruptures by avoiding repetitive maneuvers and activities that predispose to tendinitis, bursitis, and rotator cuff injuries.^7,8
• The avoidance of falls in which direct trauma to the muscle or tendon occurs and the reduction of incidents of rapid, heavy loading of the muscle (especially with the elbow flexed and the forearm supinated) also may be helpful in decreasing the likelihood of rupture.

Complications

• Possible surgical complications
• Contractures due to excessive immobilization
• Heterotopic ossification²³

Prognosis

• The overall prognosis for biceps tendon ruptures is good for surgical repair and for conservative management. Both approaches generally result in adequate functional return to the 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 on the need to provide 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

Medicolegal Pitfalls

• Few medical/legal issues surround biceps rupture. Diagnosis usually is apparent on physical examination, and when there is doubt, the diagnosis can readily be confirmed by MRI. 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 - This may lead to lost wages, disability claims, and unemployment.

Multimedia

Media file 1: Biceps muscle and tendons

References

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Keywords

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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.

Related eMedicine topics:
Bicipital Tendonitis
Biceps Tendinopathy
Elbow and Forearm Overuse Injuries
Rotator Cuff Disease
Rotator Cuff Injuries
Rotator Cuff Injury
Rotator Cuff Pathology
Shoulder, Rotator Cuff Injury (MRI)
Shoulder, Rotator Cuff Injury (Ultrasonography)

Clinical guidelines:
ACR Appropriateness Criteria® chronic elbow pain. American College of Radiology - Medical Specialty Society. 1998 (revised 2008). 8 pages. NGC:006997

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