Biceps tendon rupture

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This image show the biceps brachii from an anterior perspective. The biceps brachii primarily serves to supinate the forearm at the elbow joint. The muscle belly is composed of two heads. The short head is more medial and highlighted in green. The long head is more lateral and highlighted in red. Biceps brachii muscle06.png
This image show the biceps brachii from an anterior perspective. The biceps brachii primarily serves to supinate the forearm at the elbow joint. The muscle belly is composed of two heads. The short head is more medial and highlighted in green. The long head is more lateral and highlighted in red.

A biceps tendon rupture or bicep tear is a complete or partial rupture of a tendon of the biceps brachii muscle. It can affect any of the three biceps brachii tendons - the proximal tendon of the short head of the muscle belly, the proximal tendon of the long head of the muscle belly, or the distal tendon. The characteristic finding of a biceps tendon rupture is the Popeye sign. Patients often report an audible pop at the time of injury as well as pain, bruising, and swelling. Provocative physical exam maneuvers to assess for a rupture include Ludington's test, Hook test, and the Ruland biceps squeeze test. Treatment and prognosis are highly dependent on the site of the injury described in further detail below.

Contents

Signs and symptoms

When a tendon of the biceps brachii ruptures, the muscle belly retracts, meaning that it goes from a lengthened position under tension at two attachments to a shortened position with a single attachment. This shortened position forms a bulge which is referred to as "Popeye's deformity," due to its similarity in appearance to the cartoon character Popeye. [2]

Other signs at the time of injury may include ecchymosis, swelling, and/or a sharp pain accompanied by an audible popping sound. [3] [1] The pain may persist for prolonged periods of time depending on the response to the individualized treatment plan. [1]

Distal tendon rupture will cause significant weakness with respect to forearm supination and flexion, whereas proximal tendon ruptures do not cause significant weakness as a result of their dual proximal tendinous attachments serving as redundancy. [1] [4]

This image shows a biceps brachii tendon rupture on the right arm. The rupture occurred in a proximal biceps tendon, resulting in retraction distally. This is one of the two forms of the "Popeye deformity." BicepstendonRupture - Copy.jpg
This image shows a biceps brachii tendon rupture on the right arm. The rupture occurred in a proximal biceps tendon, resulting in retraction distally. This is one of the two forms of the "Popeye deformity."
This image shows a biceps brachii tendon rupture on the left arm. The rupture occurred in the distal biceps tendon, resulting in retraction of the muscle belly proximally. This is the other form of the "Popeye deformity." Dist. bizepssehnenruptur.jpg
This image shows a biceps brachii tendon rupture on the left arm. The rupture occurred in the distal biceps tendon, resulting in retraction of the muscle belly proximally. This is the other form of the "Popeye deformity."

Diagnosis

History

Patient may describe that they felt a sudden audible popping sound under strenuous load at the time of injury. [3] Immediately after the injury, they may notice some of the signs and symptoms listed in the section above, including pain, ecchymosis, and swelling. [3] [1] Patient with suspected rupture should also be asked about risk factors including corticosteroid use, athletic history, and pre-existing shoulder impingement syndromes or rotator cuff tears. [5]

Physical

Upon physical examination, an initial visual inspection may reveal the "Popeye's deformity," ecchymosis, and swelling. [1] Physical manipulation may reveal weakness in supination and elbow flexion. [4] Provocative physical exam maneuvers include the Hook test, Ludington's test, and the Ruland biceps squeeze test. [1] [5] Given the nature of each exam, the Ludington's test is a provocative physical exam maneuver to palpate for a proximal tendon rupture, whereas the Hook test and the Ruland biceps squeeze test are used to palpate for a distal tendon rupture. [1] [5]

Ludington's test - The patient is asked to place both hands on his head and interlock his fingers. Then he is asked to flex both biceps. Meanwhile, the physician will palpate both bicipital grooves for the proximal tendon of the long head of the biceps. He will be unable to palpate the tendon within the groove on the arm with the ruptured tendon, but will be able to palpate it within the unaffected arm. [5]

Hook test - The physician uses his finger to use a lateral approach to "hook" underneath the patient's flexed distal tendon while the patient is actively flexing his bicep. If the physician cannot hook at least 1 cm underneath the tendon, then the tendon is considered to be ruptured. This test may be misinterpreted if either the bicipital aponeurosis or brachialis tendon is palpated instead of the distal biceps brachii tendon or if there is a partial tear instead of a full tear. [1] For this reason, the test is not sensitive enough to rule out rupture. One review quoted, "It is concluded that the hook test is moderately sensitive at detecting complete DBTR when carried out by skilled clinicians in specialist upper limb clinics. As a single test, it is not sensitive enough to exclude complete DBTR." [6]

Ruland biceps squeeze test - The patient is asked to place his arm in about 60 to 80 degrees of flexion with support. The physician then squeezes the distal muscle belly and observes for supination of the forearm. Lack of supination is supporting evidence for tendon rupture. [1] [4]

Imaging

X-ray will show nonspecific findings when diagnosing biceps tendon ruptures. [5] Ultrasound is useful for diagnosing acute biceps tendon ruptures in the clinic. [5] MRI, although costly, can be used to distinguish between complete and partial tears, between muscular and tendinous tears, and the degree of muscular retraction. [5] [7]

Causes

Biceps tendon rupture may occur in patients with pre-existing rotator cuff tears or impingement syndromes, during athletic activities, or in the context of overuse, aging, or the use of corticosteroids. [5]

Proximal tendon rupture

The most common tendon to be ruptured is the proximal tendon of the long head. [1] [5] Proximal tendon rupture is not assosiacted with a specific mechanism of injury, rather it more often seen in concurrence with rotator cuff tears or impingement syndromes. [8]

Distal tendon rupture

The mechanism of injury for a distal tendon rupture is forced contraction under eccentric load. [1] [9] A few examples of forced contraction under eccentric load include mixed-grip deadlifts (one forearm pronated and the other supinated, putting the biceps under greater load), preacher curls, and the "kingsmove" technique in armwrestling. Distal tendon ruptures are more common in males than females. [9] Distal tendon tuptures occur more frequently in the dominant arm. [1]

Treatment

A proximal rupture is repaired by anchoring the tendon to a different location on the bone, like the humerus shaft. While this offers stability and improves function, it can also lead to a slightly shorter biceps muscle than the original anatomy. Proximal rupture repair.png
A proximal rupture is repaired by anchoring the tendon to a different location on the bone, like the humerus shaft. While this offers stability and improves function, it can also lead to a slightly shorter biceps muscle than the original anatomy.

Acute rupture of the distal biceps tendon can be treated nonoperatively with acceptable results, [10] but because the injury can lead to 30% loss of elbow flexion strength and 30-50% loss of forearm supination strength, surgical repair is generally recommended. [11] [12] [13] Complete distal biceps tears are commonly treated with re-attachment of the biceps tendon to its native insertion on the tuberosity of the radius using bone tunnels, suture buttons, or suture anchors. [14] [11] [15] Proximal ruptures of the long head of the biceps tendon can be surgically addressed by two different techniques. Biceps tenodesis includes the release of the long head of the biceps tendon off of its insertion on the glenoid and re-attachment by screw or suture anchor fixation to the humerus. Biceps tenotomy consists of a simple release of the long head of the biceps without reattachment to the humerus, allowing the tendon to retract into the soft tissues of the proximal upper arm. [16]

Treatment of a biceps tear depends on the severity of the injury. The muscle will usually heal over time with no corrective surgery. Applying cold pressure and using anti-inflammatory medications will ease pain and reduce swelling. More severe injuries require surgery and post-op physical therapy to regain strength and functionality in the muscle. Corrective surgeries of this nature are typically reserved for elite athletes who rely on a complete recovery. [17] Older patients will be treated by long head bicep tenotomy almost without exception.

Prognosis

Prognosis is dependent on the site of tendon rupture. [1] Proximal tendon ruptures usually allow for a non-operative treatment course with minimal deficits in shoulder flexion, flexion at the elbow, and forearm supination. [1] Distal tendon ruptures often require operative treatment, and can still cause persistent loss of function with regard to flexion at the elbow and forearm supination, especially for chronic cases with significant retraction of the tendon. [7] As mentioned above, distal tendon ruptures are more common in athletes. Athletes who have sustained this injury return to athletics at a high rate regardless of the surgical technique or rehabilitation program. [4] [18] A few reviews have shown that return to activity is independent of surgical approach, athlete age, steroid use, and rehabilitation program. [18] Other reviews have shown that surgical approach does affect time to return to sport. [19] [4] Nonoperative management of distal tendon ruptures results in inferior strength and endurance in flexion at the elbow and forearm supination. [20]

Related Research Articles

<span class="mw-page-title-main">Humerus</span> Long bone of the upper arm

The humerus is a long bone in the arm that runs from the shoulder to the elbow. It connects the scapula and the two bones of the lower arm, the radius and ulna, and consists of three sections. The humeral upper extremity consists of a rounded head, a narrow neck, and two short processes. The body is cylindrical in its upper portion, and more prismatic below. The lower extremity consists of 2 epicondyles, 2 processes, and 3 fossae. As well as its true anatomical neck, the constriction below the greater and lesser tubercles of the humerus is referred to as its surgical neck due to its tendency to fracture, thus often becoming the focus of surgeons.

<span class="mw-page-title-main">Rotator cuff</span> Group of muscles

The rotator cuff is a group of muscles and their tendons that act to stabilize the human shoulder and allow for its extensive range of motion. Of the seven scapulohumeral muscles, four make up the rotator cuff. The four muscles are:

<span class="mw-page-title-main">Biceps</span> Muscle on the front of the upper arm

The biceps or biceps brachii are a large muscle that lies on the front of the upper arm between the shoulder and the elbow. Both heads of the muscle arise on the scapula and join to form a single muscle belly which is attached to the upper forearm. While the biceps crosses both the shoulder and elbow joints, its main function is at the elbow where it flexes the forearm and supinates the forearm. Both these movements are used when opening a bottle with a corkscrew: first biceps screws in the cork (supination), then it pulls the cork out (flexion).

<span class="mw-page-title-main">Brachioradialis</span> Muscle of the upper limb

The brachioradialis is a muscle of the forearm that flexes the forearm at the elbow. It is also capable of both pronation and supination, depending on the position of the forearm. It is attached to the distal styloid process of the radius by way of the brachioradialis tendon, and to the lateral supracondylar ridge of the humerus.

<span class="mw-page-title-main">Median nerve</span> Nerve of the upper limb

The median nerve is a nerve in humans and other animals in the upper limb. It is one of the five main nerves originating from the brachial plexus.

<span class="mw-page-title-main">Upper limb</span> Consists of the arm, forearm, and hand

The upper limbs or upper extremities are the forelimbs of an upright-postured tetrapod vertebrate, extending from the scapulae and clavicles down to and including the digits, including all the musculatures and ligaments involved with the shoulder, elbow, wrist and knuckle joints. In humans, each upper limb is divided into the arm, forearm and hand, and is primarily used for climbing, lifting and manipulating objects.

Bicep curls are a group of weight training exercises in which a person bends their arm towards their body at the elbow in order to make their biceps stronger.

<span class="mw-page-title-main">Musculocutaneous nerve</span> Nerve in the arm

The musculocutaneous nerve is a mixed branch of the lateral cord of the brachial plexus derived from cervical spinal nerves C5-C7. It arises opposite the lower border of the pectoralis major. It provides motor innervation to the muscles of the anterior compartment of the arm: the coracobrachialis, biceps brachii, and brachialis. It provides sensory innervation to the lateral forearm. It courses through the anterior part of the arm, terminating 2 cm above elbow; after passing the lateral edge of the tendon of biceps brachii it is becomes known as the lateral cutaneous nerve of the forearm.

<span class="mw-page-title-main">Triceps</span> Muscle on the back of the upper arm

The triceps, or triceps brachii, is a large muscle on the back of the upper limb of many vertebrates. It consists of 3 parts: the medial, lateral, and long head. It is the muscle principally responsible for extension of the elbow joint.

<span class="mw-page-title-main">Coracobrachialis muscle</span> Muscle of the upper arm

The coracobrachialis muscle is a muscle in the upper medial part of the arm. It is located within the anterior compartment of the arm. It originates from the coracoid process of the scapula; it inserts onto the middle of the medial aspect of the body of the humerus. It is innervated by the musculocutaneous nerve. It acts to adduct and flex the arm.

The pronator teres is a muscle that, along with the pronator quadratus, serves to pronate the forearm. It has two origins, at the medial humeral supracondylar ridge and the ulnar tuberosity, and inserts near the middle of the radius.

<span class="mw-page-title-main">Supinator muscle</span> Muscle of the forearm in humans

In human anatomy, the supinator is a broad muscle in the posterior compartment of the forearm, curved around the upper third of the radius. Its function is to supinate the forearm.

<span class="mw-page-title-main">SLAP tear</span> Medical condition

A SLAP tear or SLAP lesion is an injury to the superior glenoid labrum that initiates in the back of the labrum and stretches toward the front into the attachment point of the long head of the biceps tendon. SLAP is an acronym for "Superior Labrum Anterior and Posterior". SLAP lesions are commonly seen in overhead throwing athletes but middle-aged labor workers can also be affected, and they can be caused by chronic overuse or an acute stretch injury of the shoulder.

<span class="mw-page-title-main">Bicipital aponeurosis</span> Distal end of the biceps muscle

The bicipital aponeurosis is a broad aponeurosis of the biceps brachii, which is located in the cubital fossa of the elbow. It separates superficial from deep structures in much of the fossa.

<span class="mw-page-title-main">Elbow</span> Joint between the upper and lower parts of the arm

The elbow is the region between the upper arm and the forearm that surrounds the elbow joint. The elbow includes prominent landmarks such as the olecranon, the cubital fossa, and the lateral and the medial epicondyles of the humerus. The elbow joint is a hinge joint between the arm and the forearm; more specifically between the humerus in the upper arm and the radius and ulna in the forearm which allows the forearm and hand to be moved towards and away from the body. The term elbow is specifically used for humans and other primates, and in other vertebrates it is not used. In those cases, forelimb plus joint is used.

<span class="mw-page-title-main">Median nerve palsy</span> Medical condition

Injuries to the arm, forearm or wrist area can lead to various nerve disorders. One such disorder is median nerve palsy. The median nerve controls the majority of the muscles in the forearm. It controls abduction of the thumb, flexion of hand at wrist, flexion of digital phalanx of the fingers, is the sensory nerve for the first three fingers, etc. Because of this major role of the median nerve, it is also called the eye of the hand. If the median nerve is damaged, the ability to abduct and oppose the thumb may be lost due to paralysis of the thenar muscles. Various other symptoms can occur which may be repaired through surgery and tendon transfers. Tendon transfers have been very successful in restoring motor function and improving functional outcomes in patients with median nerve palsy.

<span class="mw-page-title-main">Neer Impingement Test</span> Medical test

The Neer Impingement Test is a test designed to reproduce symptoms of rotator cuff impingement through flexing the shoulder and pressure application. Symptoms should be reproduced if there is a problem with the supraspinatus or biceps brachii. This test is also associated with the Hawkins-Kennedy Test and Jobe's Test.

<span class="mw-page-title-main">Medial knee injuries</span> Medical condition

Medial knee injuries are the most common type of knee injury. The medial ligament complex of the knee consists of:

Yergason's test is a special test used for orthopedic examination of the shoulder and upper arm region, specifically the biceps tendon.

<span class="mw-page-title-main">Stay apparatus</span>

The stay apparatus is an arrangement of muscles, tendons, and ligaments that work together so that an animal can remain standing with virtually no muscular effort. It is best known as the mechanism by which horses can enter a light sleep while still standing up. The effect is that an animal can distribute its weight on three limbs while resting a fourth in a flexed, non-weight-bearing position. The animal can periodically shift its weight to rest a different leg, and thus all limbs are able to be individually rested, reducing overall wear and tear. The relatively slim legs of certain large mammals, such as horses and cows, would be subject to dangerous levels of fatigue if not for the stay apparatus.

References

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  2. ↑ Yoshida, Naoki; Tsuchida, Yoshihiko (2017-11-16). ""Popeye" Sign". New England Journal of Medicine. 377 (20): 1976. doi:10.1056/NEJMicm1704705. ISSN   0028-4793. PMID   29141167.
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  10. ↑ Freeman CR, McCormick KR, Mahoney D, Baratz M, Lubahn JD (October 2009). "Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group". The Journal of Bone and Joint Surgery. American Volume. 91 (10): 2329–34. doi:10.2106/jbjs.h.01150. PMID   19797566.
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  17. ↑ "Bicep tear - Muscular Injuries". Sports Medicine Information.
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  19. ↑ Holt, Jarred; Preston, Gordon; Heindel, Koan; Preston, Heather; Hill, Gregory (2019-11-01). "Diagnosis and Management Strategies for Distal Biceps Rupture". Orthopedics. 42 (6): e492–e501. doi:10.3928/01477447-20190723-05. ISSN   1938-2367. PMID   31355900. S2CID   198966693.
  20. ↑ Looney, Austin M.; Day, Jonathan; Bodendorfer, Blake M.; Wang, David; Fryar, Caroline M.; Murphy, Jordan P.; Chang, Edward S. (April 2022). "Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis". Journal of Shoulder and Elbow Surgery. 31 (4): e169–e189. doi:10.1016/j.jse.2021.12.001. ISSN   1532-6500. PMID   34999236. S2CID   265986114.
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