Biceps Rupture Treatment & Management

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.