Biceps Rupture 

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

Overview

Practice Essentials

Tendon ruptures of the biceps brachii, one of the dominant muscles of the arm, have been reported in the United States with increasing frequency. Ruptures of the proximal biceps tendon make up 90-97% of all biceps ruptures and almost exclusively involve the long head.

Anatomy

Because of its size and its orientation about the shoulder and elbow joints, the biceps muscle is involved in functional activities of the upper limb. At its proximal attachment, the biceps has 2 distinct tendinous insertions on the scapula from its long and short heads. The short head arises from the coracoid process with the coracobrachialis, while the long head originates from the supraglenoid tubercle and passes over the humeral head within the capsule of the glenohumeral joint (see image below).

Biceps muscle and tendons Biceps muscle and tendons

The biceps muscle then continues down the arm within the intertubercular groove, covered by a synovial outpouching of the joint capsule. The 2 muscle bellies unite near the midshaft of the humerus and attach distally on the radial tuberosity. The distal tendon blends with the bicipital aponeurosis, which affords protection to structures of the cubital fossa, allowing distribution of forces across the elbow to lessen the pull on the radial tuberosity.[1, 2] The biceps receives innervation via the musculocutaneous nerve (C5, C6) from the lateral cord of the brachial plexus.

Diagnosis and management

In most cases, proximal or distal bicep tendon ruptures can be detected on the basis of history and physical examination alone. Physical examination may show the classic "Popeye" muscle bulge of the humerus midshaft with a complete biceps tendon rupture. However, several imaging studies can be employed as an extension of the physical examination to rule out other disorders from the lengthy list of possibilities; these include plain radiography, arthrography, ultrasonography, and magnetic resonance imaging (MRI).

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. 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. Early evaluation and treatment by occupational therapy resemble strategies used in rotator cuff repairs.

Several reviews of surgical repair versus conservative (nonoperative) management report conflicting results; neither a complete agreement nor a general clinical consensus has been reached. 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, 4] Cosmetic concerns may prompt a surgical approach when appearance is unacceptable to the patient following rupture.[5, 6, 7, 8]

Pathophysiology

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. As mentioned, rupture of the proximal biceps tendon comprises 90-97% of all biceps ruptures and almost exclusively involves the long head.[9] Tendon rupture typically occurs at the bony attachment or tendon-labral junction. The remaining ruptures occur distally at the insertion on the radial tuberosity or, even less commonly, at the short-head insertion on the acromion.

Epidemiology

Frequency

United States

As previously noted, biceps rupture has been reported in the United States with increasing frequency. The injury is experienced most commonly by individuals aged 40-60 years with a history of shoulder problems, secondary to chronic wear of the tendon. Younger individuals may rupture the biceps tendon following a traumatic fall, during heavy weightlifting, or during sporting activities (eg, snowboarding, football).[10]

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.[3]

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 than is the nondominant arm. At present, no evidence exists of a male or female predisposition to biceps rupture due to anatomic or genetic factors.

Age

Age may vary considerably in patients with biceps rupture, but typically, the patient with a rupture caused by impingement or chronic inflammation is in the fourth, fifth, or sixth decade of life.[11, 12, 13] Acute traumatic ruptures may occur in younger individuals or in anyone engaged in predisposing activities.

 

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.

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.

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]

 

DDx

Diagnostic Considerations

These include the following:

  • Impingement syndrome

  • Humeral fracture

  • Shoulder dislocation/instability

  • Aseptic necrosis of the humeral head

  • Cubital tunnel syndrome (distal)

  • Radial head fracture (distal)

Differential Diagnoses

 

Workup

Imaging Studies

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.

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.[1, 16, 22]

Studies have indicated that complete rupture or dislocation of the long head of the biceps can reliably be identified in this manner.[23, 24] (However, intra-articular or partial thickness tears, as well as degenerative changes, may be more difficult to detect with ultrasonography.[25] ) 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[26] ; the major disadvantage is the higher cost of MRI compared with costs associated with other imaging modalities.

Histologic Findings

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.[27] 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.

 

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.[13]

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, 4, 28] Cosmetic concerns may prompt a surgical approach when appearance is unacceptable to the patient following rupture.[5, 6, 7, 8]

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

A study by Hinchey et al found a low rate of rerupture 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 modification of the Boyd-Anderson two-incision procedure. Only three biceps (1.6%) reruptured; each incident occurred within 3 weeks of the original repair and appeared to have resulted from patient compliance issues and the exposure of the repairs to excessive force.[29]

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.[30] 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.

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 study, early failures occurred in just 2 of 170 distal biceps tendon ruptures (1.2%) treated with the procedure.[31]

However, a smaller study (14 patients), by Caekebeke et al, suggested that the need for interference screws to strengthen the repair 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.[32]

A study by Euler et al indicated that open subpectoral long head of the biceps (LHB) tenodesis is a safe and effective means of primary repair for chronic proximal LHB tendon ruptures and of revision for proximal LHB tendon ruptures following failed surgery. The study included 25 patients (18 primary repairs and seven revision surgeries) who were followed up for 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.[33]

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, range of motion, and subjective patient rating. The study involved 46 patients, with a mean postoperative follow-up of 2.1 years.[34]

A literature review by 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%.[35]

Consultations

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

 

Medication

Medication Summary

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

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.

 

Follow-up

Further Outpatient Care

See the list below:

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

Further Inpatient Care

See the list below:

  • 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.

Deterrence

See the list below:

  • The pathophysiology of biceps rupture often is 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.[14, 15]

  • 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.

Complications

See the list below:

  • Possible surgical complications

  • Contractures due to excessive immobilization

  • Heterotopic ossification[36]

Prognosis

See the list below:

  • 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.

Patient Education

See the list below:

  • 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.

 

Questions & Answers

Overview

What is biceps rupture?

What is the anatomy relative to biceps rupture?

How is biceps rupture diagnosed and treated?

What is the pathophysiology of biceps rupture?

What is the prevalence of biceps rupture in the US?

What is the mortality and morbidity associated with biceps rupture?

What is the racial predilection of biceps rupture?

What are sexual predilections of biceps rupture?

Which age groups are at highest risk for biceps rupture?

Presentation

What are the signs and symptoms of biceps rupture?

Which physical findings are characteristic of biceps rupture?

What causes proximal biceps rupture?

What causes biceps rupture?

Where do most biceps rupture occur?

DDX

Which conditions should be considered in the differential diagnosis of biceps rupture?

What are the differential diagnoses for Biceps Rupture?

Workup

What is the role of imaging studies in the diagnosis of biceps rupture?

What is the role of radiography in the diagnosis of biceps rupture?

What is the role of arthrography in the diagnosis of biceps rupture?

What is the role of ultrasonography in the diagnosis of biceps rupture?

What is the role of MRI in the diagnosis of biceps rupture?

Which histologic findings are characteristic of biceps rupture?

Treatment

What is the role of physical therapy in the treatment of biceps rupture?

What is the role of occupational therapy in the treatment of biceps rupture?

How is biceps rupture treated?

What is included in the surgical treatment of biceps rupture?

What is the efficacy of surgery for the treatment of biceps rupture?

Which specialist consultations are beneficial to patients with biceps rupture?

Medications

What medications are used in the treatment of biceps rupture?

Which medications in the drug class Nonsteroidal anti-inflammatory drugs are used in the treatment of Biceps Rupture?

Follow-up

What is included in outpatient care for biceps rupture?

What are the indications for inpatient rehabilitation of biceps rupture?

How is biceps rupture prevented?

What are the possible complications of biceps rupture?

What is the prognosis of biceps rupture?

What is included in patient education about biceps rupture?