Biceps Rupture Treatment & Management

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

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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]

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Consultations

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

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