Bicipital Tendon Injuries 

Updated: Sep 14, 2018
Author: John P Salvo, Jr, MD, MS; Chief Editor: Harris Gellman, MD 

Overview

Background

The biceps brachii is the most powerful supinator of the forearm; along with the brachialis, it provides elbow flexion. Bicipital tendon injuries of the elbow most commonly occur in the dominant extremity of active men aged 40-60 years, sometimes leading to significant impairment of daily activities. Injuries range from tendinitis to partial tears to complete ruptures.[1, 2] A rupture usually occurs at the insertion of the tendon to the radial tuberosity, resulting in pain and deformity about the elbow, as well as weakness, especially with supination.

Most surgeons agree that the best results are obtained with early surgical intervention and reattachment of the tendon to the radial tuberosity.[3, 4, 5, 6, 7, 8, 9, 10]  Without early surgical repair, chronic weakness and deformity persist. Pain typically resolves in time.

Boyd and Anderson first described a modified two-incision approach for repair of a distal biceps tendon in 1961.[11] The original approach involved subperiosteal dissection on the ulna. This led to an increased incidence of synostosis and heterotopic bone formation.

A modified approach with muscle splitting rather than subperiosteal dissection decreases the incidence of synostosis and heterotopic bone formation. The biceps tendon is secured after the tuberosity is excavated. The tendon is fixed through three drill holes in the tuberosity.

The advent of suture anchors has increased the popularity of the one-incision approach. This approach has the theoretical advantage of a low risk of synostosis. The originally described anterior one-incision extensile approach was associated with radial nerve injury. Today's limited anterior approach has been associated with neurapraxic injuries only.

Anatomy

The biceps brachii travels in the anterior compartment of the arm and is innervated by the musculocutaneous nerve. It is the most powerful supinator of the forearm and also acts as a flexor of the elbow. It has two separate proximal origins: the coracoid process and the bicipital tuberosity of the superior glenoid. Distally, a single tendon inserts on the radial tuberosity after passing through the antecubital fossa. (See the image below.)

Biceps muscle and tendons. Biceps muscle and tendons.

The lacertus fibrosus, an aponeurotic expansion, originates at the musculotendinous junction medially, blends distally with the fascia of the superficial flexor mass, and inserts on the proximal ulna.

The lateral antebrachial cutaneous nerve travels between the brachialis and the biceps brachii and exits the arm in the subcutaneous tissue laterally. It supplies sensation to the lateral aspect of the forearm.

The median nerve courses with the brachial artery and vein medial to the biceps tendon in the antecubital fossa. The artery bifurcates into the radial and ulnar arteries at the level of the radial head. A recurrent branch from the radial artery travels lateral and proximal across the antecubital fossa.

The radial nerve travels laterally between the brachialis and the brachioradialis to enter the antecubital fossa. The superficial branch travels deep to the brachioradialis in the forearm. The deep branch enters the supinator muscle lateral to the radius and becomes the posterior interosseous nerve.

Etiology

Bicipital tendon injuries most commonly occur when an extension force is applied with the elbow in flexed position. This force overpowers the tendon and causes its rupture. It is believed that a degenerative process occurs in the tendon prior to the rupture. This process is evident clinically at the time of surgery with the finding of a bulbous, degenerated end of the tendon. Histologic studies have confirmed the degenerative process. Exactly how partial ruptures are related to this process is unknown. In addition, mechanical and vascular issues contribute.

Epidemiology

The overall frequency of bicipital tendon injuries is not truly known, but such injuries have been reported to occur in 1.2 patients per 100,000 population. Distal biceps tendon rupture has been reported with increasing frequency, but generally is considered to represent only 3% of biceps tendon injuries as a whole. This injury is more common in men and rarely reported in women.

Schneider et al performed a retrospective study of 10 patients who sustained nonsimultaneous bilateral distal biceps brachii tendon ruptures that were repaired surgically.[12] They found that bilateral distal biceps tendon ruptures tended to occur in middle-aged men who commonly participated in weightlifting, manual labor, or sports and who had higher rates of nicotine use (50%) and anabolic steroid use (20%) than the general population. The mean time from the first tendon rupture to the contralateral tendon rupture was 2.7 years (range, 0.5-6.3 years).

Prognosis

Excellent results can be obtained with early surgical intervention. Early direct repair of the tendon to the radial tuberosity gives the best opportunity for full functional recovery. Operative treatment restores supination strength better than nonoperative treatment after distal biceps tendon rupture.[13] Both the two-incision technique and the one-incision technique have yielded excellent results.[14, 15] The choice of technique depends on the surgeon's preference.

Biomechanically, the cortical button has been shown to have the highest tensile load to failure.[16] Clinically, however, good outcomes have been reported with the use of all types of fixation.[17, 18, 19] There is no consensus that one type of fixation is better than another.

Delayed repair or reconstruction is more difficult than early treatment. Late repair may result in long-term weakness and loss of motion as a consequence of the chronicity of the injury. However, late reconstructions can be performed safely with improvement in functional outcomes.[20]

Freeman et al retrospectively compared the outcome of 18 patients with 20 distal biceps tendon ruptures managed nonoperatively with historical controls from six published series of operatively treated patients.[21] The median supination and elbow flexion strengths for the injured arm in the nonoperative group were 63% and 93% of those for the contralateral arm, compared with values of 92% and 95% for the historical controls that had been treated surgically.

Patients in this study had satisfactory outcomes overall, with median scores on the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire of 85, 95, and 9, respectively.[21] The authors concluded that nonoperative treatment of distal biceps tendon ruptures may yield acceptable outcomes with modestly reduced strength, especially supination.

Nesterenko et al measured isokinetic strength and endurance in elbow flexion and forearm supination in both arms of nine patients with an untreated unilateral complete distal biceps tendon rupture; one additional patient underwent isokinetic testing only.[22] Peak torque was found to be significantly lower in involved limbs regarding both flexion and supination, but no significant differences were found in the fatigue index between involved and uninvolved limbs for flexion or supination. The authors noted that although nonoperative treatment is rarely recommended for complete distal biceps tendon ruptures, when it is selected, rehabilitation should concentrate on improving strength, not endurance.

Cil et al studied an immediate active range-of-motion (ROM) protocol after modified two-incision distal biceps tendon repair in 21 patients with acute ruptures.[23] After repair, the arms were placed in a sling for 1-2 days, followed by immediate active range of motion. For the first 6 weeks, the elbow was allowed activities of daily living, with a 1-lb weightlifting restriction.

Mean follow-up extension was 0º, and mean follow-up flexion was 141º on the operated arm, with supination of 74º and pronation of 75º. Mean DASH score was 3.6±3.6; mean follow-up isometric flexion strength was 5%; and the power (dynamic strength) of flexion was 12% greater on the operated side.[23] However, on the operated arm, follow-up isometric supination strength was 9% less and the power of supination was 11% less. According to the authors, the modified two-incision distal biceps repair allows a safe immediate active ROM protocol with early return of nearly full ROM and strength.

 

Presentation

History

Bicipital tendon ruptures most commonly occur in the dominant extremity in men aged 40-60 years (average patient age, ~50 years). Patients often have a history of acute pain in the antecubital fossa and typically give a history of either lifting or holding something heavy with the elbow flexed immediately prior to the injury. Patients may or may not have a history of previous elbow pain. This pain, if present, may be related to tendon degeneration or a previous partial tear.

The acute pain is accompanied by deformity in the antecubital fossa due to tendon retraction. An obvious deformity indicates rupture of the tendon and the lacertus fibrosus. Some patients also have swelling, ecchymosis, or both in the antecubital fossa, typically over the medial proximal forearm. Initially, they may have weakness with flexion due to pain. This symptom may subside in a few days as the swelling decreases, but weakness with supination does not subside. If the tendon is completely ruptured but the lacertus fibrosis is intact, little deformity may be present.

Physical Examination

On examination, tenderness may be noted in the antecubital fossa, in addition to deformity due to the tendon retraction. If the lacertus fibrosus is not ruptured, the deformity is not as pronounced, but it can still be appreciated on comparison with the opposite extremity. The deformity is accentuated with resisted supination with the elbow in flexion.

 

Workup

Imaging Studies

Plain radiography is a necessary part of a complete evaluation. Radiographs can reveal a bony avulsion from the radial tuberosity, but they are often negative. Mild-to-moderate underlying degenerative changes are not a contraindication for reconstruction of acute tears.[24]

Magnetic resonance imaging (MRI) can be helpful in cases of partial rupture of the tendon or in cases of chronic disruption or when the diagnosis is uncertain, but it otherwise has not been considered essential for the diagnosis and treatment of acute injuries. However, some feel that MRI may be the optimal imaging modality for distal biceps tendon tears.[25]

Ultrasonography (US) has been suggested as potentially useful for the evaluation of traumatic distal biceps brachii tendon injuries. In a study of 120 patients with traumatic injuries of this type, de la Fuente et al compared US results with MRI results when surgery was indicated and with MRI and surgical results when surgery was indicated.[26]  For major injuries, US had a slight but statistically significant advantge over MRI; however, for minor injuries, no clear advantage was apparent.

 

Treatment

Approach Considerations

Most surgeons agree that the vast majority of bicipital tendon ruptures benefit from early surgical repair. Indications for surgical intervention include a complete tendon rupture, with or without lacertus fibrosus rupture, in an otherwise healthy, cooperative, and active individual. Acute ruptures are best treated early, within 8 weeks of the injury. Chronic injuries may necessitate reconstruction or augmentation of the tendon, a much more complicated procedure.[4] Partial tears are often treated with a period of nonoperative management, followed by surgery if symptoms remain, but the efficacy of nonoperative management in this setting has not been well studied.[27]

Surgical repair of a bicipital tendon rupture has few contraindications. Contraindications include the presence of little functional impairment from the injury, medical contraindications for a surgical procedure, and a sedentary or uncooperative patient. A relative contraindication is chronic disruption. Because of tendon retraction and muscle contraction, it is difficult or impossible to reattach the tendon anatomically to the radial tuberosity. In these situations, delayed reconstruction using autograft or allograft tissue is required, and the outcome is less dependable.

With early repair, success rates with either the two-incision or the one-incision technique (see Surgical Therapy) are high. The use of multiple drill holes instead of a high-speed burr to excavate the radial tuberosity should improve outcomes by decreasing the incidence of synostosis. The one-incision approach will continue to advance with the development of more anatomic repair techniques. In theory, a greater emphasis on anatomic repair of the distal biceps tendon to the bicipital tuberosity may improve supination, endurance strength testing, and functional outcomes.

Surgical Therapy

Early surgical intervention for complete ruptures provides the best results. Two techniques are commonly used: the two-incision (modified Boyd-Anderson) technique and the one-incision technique.[5, 28, 29]

The two-incision technique, which Boyd and Anderson described in 1961, is the one more commonly employed; however, with the advent of suture anchors, the single-incision technique is becoming more popular. An advantage of the two-incision technique is potentially stronger fixation to the radial tuberosity. The most common complication is heterotopic bone, which can create a mechanical block to motion. As a result, this bone may have to be removed surgically. Another reported complication is injury to the posterior interosseous branch of the radial nerve.[30]

The one-incision technique has the obvious advantage of involving fewer incisions. Fixation usually is achieved with suture anchors, cortical buttons, or interference screws placed into the radial tuberosity. The most common complication with the current one-incision technique is lateral antebrachial nerve neurapraxia.

A clinical trial comparing the single- and double-incision techniques showed no significant difference in outcomes between the two types of surgery.[31]

Preparation for surgery

A thorough history, physical examination, and radiographic workup should be completed prior to surgery. Range of motion (ROM) and stability of the elbow should be assessed.

Operative details

Examination with the patient under anesthesia is essential to surgery in any extremity. Surgery should be performed by using a tourniquet placed as high on the arm as possible. After standard sterile preparation and draping, the limb is exsanguinated and the tourniquet inflated.

Two-incision technique

With the two-incision technique, a small incision in the antecubital fossa (~3-4 cm) is made in the flexion crease. Dissection is taken through the fascia, and the biceps tendon is easily identified. Sometimes, a "milking" maneuver must be performed to deliver the tendon into the wound. Once the tendon is identified, it is prepared for fixation. The tendon invariably has bulbous degeneration at the rupture site. Once the bulbous degeneration is resected, two nonabsorbable braided 5-0 sutures are placed in a Bunnell or Krakow fashion to secure the tendon.

A curved Kocher or Kelly clamp is used to mark the second incision. The clamp is placed through the sheath of the biceps tendon and curved toward the radius with the forearm in supination. Great care is taken not to disturb the periosteum of the ulna to prevent synostosis. The clamp is used to tent the skin dorsally after it passes by the radial tuberosity. Once the clamp is past the tuberosity, the forearm is placed in pronation. Pronation of the forearm protects the radial nerve.

A 4- to 6-cm incision is made over the tip of the clamp. The dissection is taken down through the fascia of the common extensor and supinator and down to the radial tuberosity, which is cleared of overlying soft tissue. The tuberosity can be excavated with a high-speed burr. D'Arco et al described a better technique in 1998.[6] In their method, the radial tuberosity is prepared with multiple drill holes in an oval fashion and then excavated with small, curved curettes. This approach avoids creating the bone dust from the burr that may lead to synostosis.

After the tuberosity is prepared, three drill holes are made along the lateral margin of the tuberosity. The tendon is then delivered from the anterior wound to the tuberosity. This step can be expedited by placing a passing stitch when the curved clamp is removed from the biceps tendon sheath. The tendon is delivered into the tuberosity, and the sutures are tied, securing the tendon. Finally, the wound is closed in layers.

One-incision technique

Single-incision techniques through an anterior approach have become increasingly popular. With the one-incision technique, a larger, anterior incision may be necessary to safely expose the bicipital tuberosity and avoid neurovascular injury.

Care is taken to avoid excessive retraction on the surrounding neurologic structures, specifically the posterior interosseous nerve (PIN) and the lateral antebrachial cutaneous nerve. If a nerve palsy of the PIN develops, it is usually traction-related and resolves with time.[32] The distal biceps tendon can be secured to the bicipital tuberosity from the anterior incision with different types of fixation devices.

Three types of fixation devices have been successfully used to repair biceps tendon injuries with the one-incision technique, as follows:

  • Suture anchors [33]
  • Cortical buttons [34]
  • Interference screws [17]

Anchors are inserted into the radial tuberosity, and sutures from an eyelet on the anchor are passed into the biceps tendon. With cortical-button and interference-screw techniques, the tendon stump is delivered into a bone trough. The screw provides fixation with interference fit of the tendon and the surrounding bony socket, whereas the cortical button provides fixation over a bone bridge on the opposing cortical bone. When the cortical button is used, care must be taken to avoid drilling distal and radial to minimize risk of injury to the PIN.[35]

Lacertus fibrosus transfer

Caputo et al published a case series of 12 patients with distal biceps tendon injuries who were treated with an operative approach that used a transfer of the lacertus fibrosus to augment the tendon repair.[36] The authors concluded that in cases of distal biceps tendon injuries where operative management is indicated and the lacertus fibrosus intact, this approach can yield predictable outcomes without the complications associated with autograft or allograft tendon reconstruction.

Adjunctive botulinum toxin

The use of botulinum toxin A as an adjunct to repair of distal biceps tendon ruptures has been described. In a retrospective review of 14 patients who underwent 15 distal biceps tendon repairs (12 acute, 2 chronic, 1 chronic partial), all of whom were injected intraoperatively with a mixture of 100 U of botulinum toxin and 10 mL of normal saline, Khalil et al reported no intraoperative complications.[37] All patients were discharged home on the day of surgery, and the average DASH score at latest follow-up (mean 32.9 months) was 4.9 (range, 0.0-12.5). In all cases, return of function of paralyzed muscle was noted before final follow-up. 

Postoperative Care

Whether the two-incision or the one-incision technique is used, the elbow should be immobilized in 90° of flexion and slight supination for 7-10 days for the patient's comfort. Outpatient physical therapy begins with gentle ROM. A hinged ROM brace can help initially block the terminal 30° of flexion to protect the repair. This angle is gradually increased to full extension. Pronation and supination should be initiated early in therapy.

Complications

The most common complication from a two-incision approach is heterotopic bone formation. This complication can be minimized by avoiding use of a burr to excavate the radial tuberosity, decreasing the amount of bone dust created. In addition, by avoiding disruption of the ulnar periosteum, the risk of synostosis can be minimized.

The most common complication from a one-incision approach is nerve palsy.[38] Most of these palsies are transient in nature and completely resolve. They are best avoided by minimizing traction on the nerve.

Proponents of the one-incision technique argue that there is a lower risk of radioulnar synostosis and heterotopic ossification. Proponents of the two-incision technique argue that there is a lower risk of neurovascular injury and a more anatomic repair of the biceps to the radial tuberosity is possible.

Cadaveric studies have shown that a two-incision technique more adequately restores the original footprint more adequately than a one-incision technique does.[39] Postoperative magnetic resonance imaging (MRI) has shown that single-incision techniques can cause anterior tendon reattachment, which can be associated with a decrease in supination strength.[40]

There are complications specific to the newer types of fixation. High rates of bone resorption have been observed with bioabsorbable screws made out of poly-L-Lactide (PLLA), though there was no correlation with clinical outcomes.[41] Transient PIN palsy, persistent radial nerve palsy, disengagement of the button, and heterotopic ossification have been reported with the use of cortical-button fixation.[42]

Long-Term Monitoring

Unrestricted motion can usually be achieved by 6-8 weeks after surgery. Full, unrestricted resistance activities should be delayed at least 4 months.