Biceps Rupture Workup
- Author: Gary L Branch, DO; Chief Editor: Milton J Klein, DO, MBA more...
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:
Need for experienced interpreters of rarely seen images
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, 10, 14]
Studies have indicated that complete rupture or dislocation of the long head of the biceps can reliably be identified in this manner.[15, 16] (However, intra-articular or partial thickness tears, as well as degenerative changes, may be more difficult to detect with ultrasonography. ) 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
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 attachment ; the major disadvantage is the higher cost of MRI compared with costs associated with other imaging modalities.
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. 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.
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