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

Biceps Rupture: Treatment & Medication

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

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

Begin rehabilitation during conservative management of the biceps rupture, with a complete examination of the limb to identify coexisting injuries or complicating factors that may affect treatment. 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.

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.

Adult

200-800 mg PO qid

Pediatric

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

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

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

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

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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