Biceps Rupture Clinical Presentation

Updated: Apr 10, 2018
  • Author: Gary L Branch, DO; Chief Editor: Milton J Klein, DO, MBA  more...
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Presentation

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.

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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 5-10º of internal rotation; look for the "Popeye sign," a distal anterior humeral regional bulging of the biceps muscle.

  • 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.

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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. Additional causes of chronic inflammation with associated predisposition to tendon rupture include the following:

  • Diabetes mellitus
  • Chronic kidney disease
  • Chronic steroid use
  • Systemic lupus erythematosus (SLE)
  • Fluorquinolone antibiotics
  • Cigarette smoking

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. [14, 15, 16]

A prospective study by Vestermark et al found a strong association between acute rupture of the long head of the biceps tendon (LHBT) and rotator cuff disease, determining that evidence of rotator cuff disease existed in 93% of the LHBT rupture patients (mean age 61.0 y). Most of the rotator cuff disease cases involved full-thickness tears of the supraspinatus tendon. [17]

The association between biceps rupture and rotator cuff disease was also explored by Kowalczuk et al, who, in a retrospective study, found that of 116 patients with proximal long head biceps rupture, 99 (85%) displayed supraspinatus or subscapularis tendon tearing. Patients with rotator cuff pathology had a significantly higher mean age (63.3 y) than did those without it (54.2 y). The investigators also found that the supraspinatus tendons had a higher incidence of full-thickness tears than did the subscapularis tendons (44% vs 21%, respectively). [18]

Most biceps ruptures occur at the tendinous insertion to the bony anchor, proximally and distally [19, 20] :

  • 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. [21]

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