Biceps Rupture

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. Ruptures of the proximal biceps tendon make up 90-97% of all biceps ruptures and almost exclusively involve the long head.[11] Proximal tendon ruptures occur at the tendon-labral junction or bony attachment and are typically not associated with a unique mechanism. Distal biceps tendon tears occur at the radial tuberosity and are commonly linked to an excessive eccentric overload.[2]

Shoulder pathology, specifically symptomatic rotator cuff tears, has been reported in 46-82% of patients with proximal biceps tendon pathology.[1]

Frequency

United States

As previously noted, biceps ruptures have been reported in the United States with increasing frequency.

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.[5]

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. At present, no evidence exists for a male or female predisposition to biceps rupture due to anatomic or genetic factors.

Age

Age in biceps rupture may vary considerably, depending on the location of the rupture. Distal biceps tears typically happen between the ages of 35-54 years and have a strong male predominance (95%).[12, 2] In contrast, proximal biceps tendon tears commonly occur in the elderly.

Patients with biceps rupture may report a wide variety of symptoms, including the following:

• Some patients report sudden anterior shoulder pain or elbow pain during activity. This acute pain, frequently described as sharp in nature, may be accompanied by an audible pop or a perceived snapping sensation, depending on the location of the rupture.
• In proximal biceps tears, some people may experience recurrent pain while performing overhead or repetitive activities that require elbow flexion, while others may experience only a nondescript anterior shoulder soreness that may worsen at night. In some patients, pain may diminish when a complete rupture occurs following chronic impingement and irritation.
• In both proximal and distal biceps tendon tears (more so in distal tears), a visible or palpable mass may be appreciated (“Popeye deformity”). However, not all biceps tears, especially those involving the long head of the biceps tendon, demonstrate a palpable mass. A deformity may not be present due to scarring of the rotator interval, the subscapularis tendon, or the tendon in the bicipital groove.

When a proximal or distal 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 ruptures are often the final event in a cascade of impingement and inflammation, testing for impingement syndromes and bicipital tendonitis is always warranted, with a thorough examination made of the upper extremity. An examination can be carried out as follows:

• 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, is often used for this purpose
• Utilization of the “Hook test,” with the patient’s shoulder elevated, elbow flexed, and arm supinated, aides in determining if the distal biceps tendon is intact; ^[13] an inability to “hook” the biceps tendon is considered a positive test for a complete rupture, while reproduction of pain with palpation of the biceps tendon is indicative of a partial tear ^[14]
• Other maneuvers, such as the Speed test and checking for a positive Yergason sign, are used, along with signs of biceps dislocation or instability, to identify patients who may have partial tears or may be predisposed to future rupture

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. Typically, proximal biceps tendon tears occur in the elderly, but younger individuals may suffer a proximal tear following a fall or during heavy weightlifting or sports activities.[12, 2] On the other hand, distal biceps tendon tears typically occur in the middle-aged (aged 35-54 years) population. However, acute traumatic ruptures of the proximal or distal biceps tendon may occur in anyone engaged in predisposing activities.

Ruptures of the proximal biceps tendon make up 90-97% of all biceps ruptures and almost exclusively involve the long head.[11] Repeated insults often lead to fraying of the tendon, with resultant weakness predisposing it to rupture following relatively minor injuries. A distal biceps rupture is typically due to an excessive eccentric overload at the elbow.[2] In that moment, the biceps actively contracts as the elbow is forcibly extended.[13]

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)
• Fluoroquinolone antibiotics
• Cigarette smoking

Biceps tendon rupture or degeneration is frequently 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 an impingement phenomenon.[15, 16, 17]

Vestermark et al found a strong association between acute rupture of the long head of the biceps tendon and rotator cuff disease, determining that evidence of rotator cuff disease existed in 93% of patients with such ruptures (mean age 61.0 y). Most of the rotator cuff disease cases involved full-thickness tears of the supraspinatus tendon.[18]

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).[19]

Most biceps ruptures occur at the tendinous insertion to the bony anchor, proximally and distally.[20, 21]

Distal avulsions from the radius are commonly 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.[22]

In most cases, proximal and distal ruptures can be detected based on history and physical examination alone. The mechanism of injury, a history of pain and/or inflammation, and supportive physical findings (as previously discussed) 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.

Radiography

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

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

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 due to the availability of ultrasonographic training to non-radiologists.[3, 17, 23]

Studies have indicated that complete rupture or dislocation of the long head of the biceps can reliably be identified through ultrasonography.[23, 24] In a systematic review by Belanger et al, high-resolution ultrasonography demonstrated a pooled positive likelihood ratio (LR+) of 38.0 and a negative likelihood ratio (LR-) of 0.24 for bicipital tendon dislocation, along with an LR+ of 35.5 and an LR- of 0.30 for complete biceps ruptures.[25] However, intra-articular or partial thickness tears, as well as degenerative changes, may be more difficult to detect with ultrasonography.[26]

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
• Low cost

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

MRI

Magnetic resonance imaging (MRI) provides the greatest anatomic detail from proximal to distal attachment.[27] The major disadvantage is the higher cost of MRI compared with costs associated with other imaging modalities.

Nontraumatic tendon ruptures, including those of the biceps brachii, show evidence of advanced degeneration. Changes include hypoxic tendinopathy, mucoid degeneration, lipomatosis, and calcifying tendinopathy.[28] 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, non-ruptured (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.[28]

Conservative management

Proximal biceps tendon tears

Initially, 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).

Distal biceps tendon tears

Although it is reasonable to consider an initial course of conservative management in distal biceps tears, the majority of these injuries are treated with surgical fixation. Biomechanical studies have demonstrated significantly decreased strength with supination and elbow flexion (74% and 88% strength compared to the contralateral side, respectively) following conservative management.[13]

Physical and 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 is often shaped by the preferences of a physiatrist or other physician and by intraoperative findings during repair. The typical protocol involves the use of a soft sling immediately following the repair procedure, allowing the patient to take the arm out for light movements and gentle ROM. By 10-14 days postoperatively, 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 in most cases be tolerated. Heavy loading is inadvisable for several months, especially in distal tendon repairs.[29]

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 may often be the first step, followed by more functional activities as they are tolerated.

Therapeutic manipulation

Therapeutic manipulation should be considered as an adjunct modality. Wieting et al described manipulation as “the use of the hands applied to the patient incorporating the use of instructions and maneuvers to achieve maximal painless movement and posture of the musculoskeletal system."[30]

Prior to the application of therapeutic manipulation, a thorough structural examination of the bony, muscular, and fascial alignment must be performed to guide the appropriate type of manipulation. Therapeutic manipulation can be divided into two main categories: direct and indirect techniques. Direct techniques apply a force into the area of restricted motion, while indirect techniques utilize a force opposite the area of restriction.[30]

Direct technique options include muscle energy and high velocity/low amplitude (HVLA), while indirect techniques include, but are not limited to, counterstrain, functional, facilitated positional release, and balanced ligamentous tension. These techniques can be provided to the patient by an appropriately trained physician, by a physiatrist or other physician specialist, or by a non-physician (such as a physical or occupation therapist) with manipulation skills sufficient to address the dysfunction.

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.

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 (Surgical referrals are most often made 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

Proximal biceps tendon tears

Should a patient with a proximal biceps tear fail conservative management or require maximum supination, or if the individual is young/athletic, then surgical management should be a consideration. Additionally, cosmetic concerns may prompt a surgical approach when appearance is unacceptable to the patient following rupture.[7, 8, 9, 10]

The optimal surgical approach, tenotomy versus tenodesis, is not well established and is a subject of debate. Tenotomy of the proximal biceps tendon from the supraglenoid tubercle is indicated in older patients with lower functional demands.[1, 31] A tenotomy is also a simpler, quicker procedure, with a shorter rehabilitation period. However, there are increased risks of cramping, muscle fatigue, and a “Popeye” deformity.[1] Tenodesis is a longer procedure with more postoperative restrictions but is indicated for younger and/or high-demand patients.[1]

A study by Euler et al indicated that open subpectoral tenodesis of the long head of the biceps tendon is a safe and effective means of primary repair for chronic proximal long head tendon ruptures and of revision for such ruptures following failed surgery. The report included 25 patients (18 primary repairs and seven revision surgeries), who were followed up for a mean 3.8 years, with significant improvement seen in a disease-specific, internally derived Subjective Proximal Biceps Score, as well as in the American Shoulder and Elbow Surgeons (ASES) and Short Form–12 Physical Component Summary (SF-12 PCS) scores.[32]

A retrospective cohort study by Aflatooni et al compared patient report outcomes and patient satisfaction for those who underwent proximal biceps tenotomy versus patients who were treated with tenodesis. In the report, 75% of individuals who underwent tenotomy were “very satisfied,” and 95% of patients indicated that they would have the surgery again, while 88% of patients who had a tenodesis were “very satisfied,” with 95% of individuals stating that they would have the procedure again. Interestingly, those who were younger (51.4 years) reported more downsides than did a slightly older population (59.6 years) in the tenodesis cohort.[33]

Distal biceps tendon tears

As previously stated, although it is reasonable to consider an initial course of conservative management in distal biceps tears, the majority of these injuries are treated by surgical fixation.

Surgical fixation can be divided into two types: anatomical and non-anatomical. The anatomical approach can then be further divided into a single- versus double-incision technique.

The non-anatomical approach involves suturing the ruptured biceps tendon to the brachialis, while the anatomical approach consists of reinsertion of the distal biceps tendon on the radial tuberosity.[2] The single-incision technique occurs over the anterior aspect of the elbow, just inferior to the antecubital fossa, with the elbow in hypersupination[2, 34] The dual-incision technique involves a small anterior incision over the antecubital fossa and another in the posterolateral aspect of the elbow in a muscle-splitting fashion between the extensor carpi ulnaris and the supinator musculature, with the forearm in pronation.[2, 34]

Complications of the anterior approach include damage to the lateral antebrachial cutaneous nerve, while complications involving the posterior approach include heterotopic ossification or synostosis.

Hinchey et al found a low rate of re-rupture following primary repair of distal biceps tendon ruptures. The study, which had a 12-month follow-up period, involved 190 distal ruptures, with 172 of them repaired using the Mayo Clinic modification of the Boyd-Anderson two-incision procedure. Only three biceps (1.6%) re-ruptured; each incident occurred within 3 weeks of the original repair and appeared to have resulted from patient compliance issues and exposure of the repairs to excessive force.[35]

An additional topic of discussion regarding surgical options of a distal biceps rupture is the type of fixation. A retrospective study by Cusick et al indicated that cortical suspensory fixation (employing a cortical button) used in conjunction with an interference screw can effectively repair distal biceps tendon ruptures, with such surgery showing a low rate of early failure (ie, failure within the first 12 weeks). In the report, early failures occurred in just two of 170 distal biceps tendon ruptures (1.2%) treated with the procedure.[36]

However, a smaller study (14 patients), by Caekebeke et al, suggested that the need for interference screws to strengthen the attachment of a ruptured distal biceps tendon to the radial tuberosity and reduce the chance of osteolysis of the radius may be questionable. At minimum 2-year follow-up after distal tendon repair using a transosseous cortical button, the study found just partial closure of the radial bony tunnel (averaging 64% of the initial volume). Such partial closure, according to the investigators, may reduce the likelihood of osteolytic complications such as radius fracture and hardware failure.[37]

In a study of EndoButton versus transosseous suture repair of the distal biceps tendon (both carried out using a two-incision approach), Recordon et al reported that the clinical outcomes of both surgical methods were comparable in terms of pain, supination strength, ROM, and subjective patient rating. The study involved 46 patients, with a mean postoperative follow-up of 2.1 years.[38]

Endoscopic techniques are useful in determining the extent of a tendon tear. 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. 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.[39]

A study by Luciani et al reported that suture anchor reinsertion of a ruptured distal biceps brachii tendon, employing a single incision, demonstrated good functional results at 5-year follow-up, with few complications found. At 3- and 5-year postsurgical follow-up, the ruptured limb showed no significant difference from the contralateral arm with regard to strength and fatigue in flexion-supination.[40]

Behun et al indicated that partial tears of the distal biceps tendon can be effectively repaired surgically, including through completion of the tendon tear and anatomic repair of the rupture to the radial tuberosity. Satisfactory clinical outcomes from surgery reached 94%.[41]

A study by Goedderz et al of short-term complications in distal biceps rupture repair reported that diabetes is a risk factor for readmission, the risk ratio (RR) being 4.238. Smoking and age of 60 years or older were determined to be risk factors for nonhome discharge (RRs = 3.006 and 4.150, respectively), while class 2 (moderate-risk) obesity, chronic obstructive pulmonary disease, and inpatient surgery were found to be risk factors for surgical complications (RRs = 4.120, 21.981, and 8.606, respectively).[42]

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

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.

Class Summary

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.

Patients with biceps rupture, whether treated conservatively or with surgical repair, frequently are referred to outpatient facilities for physical or occupational therapy. (See Physical and occupational therapy.)

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.

The pathophysiology of biceps rupture is often 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.[15, 16]

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.

These include the following:

• Possible surgical complications
• Contractures due to excessive immobilization
• Heterotopic ossification ^[43]

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.

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.