A biceps tendon rupture or bicep tear is a complete or partial rupture of a tendon of the

biceps brachii muscle The biceps or biceps brachii (, "two-headed muscle of the arm") is a large muscle that lies on the front of the upper arm between the shoulder and the elbow. Both Muscle head, heads of the muscle arise on the scapula and join to form a single ...

. It can affect any of the three biceps brachii

tendon A tendon or sinew is a tough band of fibrous connective tissue, dense fibrous connective tissue that connects skeletal muscle, muscle to bone. It sends the mechanical forces of muscle contraction to the skeletal system, while withstanding tensi ...

s - the proximal tendon of the short head of the

muscle belly Anatomical terminology is used to uniquely describe aspects of skeletal muscle, cardiac muscle, and smooth muscle such as their actions, structure, size, and location. Types There are three types of muscle tissue in the body: skeletal, smooth, a ...

, 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. __TOC__

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 Popeye the Sailor Man is a fictional cartoon character created by E. C. Segar, Elzie Crisler Segar. Other signs at the time of injury may include

ecchymosis A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur clo ...

, swelling, and/or a sharp pain accompanied by an audible popping sound. The

pain Pain is a distressing feeling often caused by intense or damaging Stimulus (physiology), stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sense, sensory and emotional experience associated with, or res ...

may persist for prolonged periods of time depending on the response to the individualized treatment plan. Distal tendon rupture will cause significant weakness with respect to forearm

supination Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relativ ...

and

flexion Motion, the process of movement, is described using specific anatomical terminology, anatomical terms. Motion includes movement of Organ (anatomy), organs, joints, Limb (anatomy), limbs, and specific sections of the body. The terminology used de ...

, whereas proximal tendon ruptures do not cause significant weakness as a result of their dual proximal tendinous attachments serving as redundancy. BicepstendonRupture - Copy

Diagnosis

History

Patient may describe that they felt a sudden audible popping sound under strenuous load at the time of injury. Immediately after the injury, they may notice some of the signs and symptoms listed in the section above, including

, and swelling. Patient with suspected rupture should also be asked about risk factors including

corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invo ...

use, athletic history, and pre-existing

shoulder impingement syndrome Shoulder impingement syndrome is a syndrome involving tendonitis (inflammation of tendons) of the rotator cuff muscles as they pass through the subacromial space, the passage beneath the acromion. It is particularly associated with tendonitis of th ...

s or

rotator cuff tear Rotator cuff tendinopathy is a process of senescence. The pathophysiology is mucoid degeneration. Most people develop rotator cuff tendinopathy within their lifetime. As part of rotator cuff tendinopathy, the tendon can thin and develop a defec ...

Physical

Upon

physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...

, an initial visual inspection may reveal the "Popeye's deformity,"

, and swelling. Physical manipulation may reveal weakness in

and elbow

. Provocative physical exam maneuvers include the Hook test, Ludington's test, and the Ruland biceps squeeze test. 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. 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. Hook test - The physician uses his finger to use a

lateral Lateral is a geometric term of location which may also refer to: Biology and healthcare * Lateral (anatomy), a term of location meaning "towards the side" * Lateral cricoarytenoid muscle, an intrinsic muscle of the larynx * Lateral release ( ...

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 The bicipital aponeurosis (also known as lacertus fibrosus) 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. Structure The bici ...

brachialis The brachialis (brachialis anticus) is a muscle in the upper arm that flexes the elbow. It lies beneath the biceps brachii, and makes up part of the floor of the region known as the cubital fossa (elbow pit). It originates from the anterior aspec ...

tendon is palpated instead of the distal biceps brachii tendon or if there is a partial tear instead of a full tear. 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." 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.

Imaging

X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

will show nonspecific findings when diagnosing biceps tendon ruptures.

Ultrasound Ultrasound is sound with frequency, frequencies greater than 20 Hertz, kilohertz. This frequency is the approximate upper audible hearing range, limit of human hearing in healthy young adults. The physical principles of acoustic waves apply ...

is useful for diagnosing acute biceps tendon ruptures in the clinic.

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...

, although costly, can be used to distinguish between complete and partial tears, between muscular and tendinous tears, and the degree of muscular retraction.

Causes

Biceps tendon rupture may occur in patients with pre-existing

s or impingement syndromes, during athletic activities, or in the context of overuse, aging, or the use of

Proximal tendon rupture

The most common tendon to be ruptured is the proximal tendon of the long head. Proximal tendon rupture is not assosiacted with a specific mechanism of injury, rather it more often seen in concurrence with

s or impingement syndromes.

Distal tendon rupture

The mechanism of injury for a distal tendon rupture is forced contraction under

eccentric Eccentricity or eccentric may refer to: * Eccentricity (behavior), odd behavior on the part of a person, as opposed to being "normal" Mathematics, science and technology Mathematics * Off- center, in geometry * Eccentricity (graph theory) of a ...

load. A few examples of forced contraction under eccentric load include mixed-grip

deadlift The deadlift is a strength training exercise in which a weight-loaded barbell is lifted off the ground to the level of the hips, with the torso perpendicular to the floor, before being placed back on the ground. It is one of the three powerlifting ...

s (one forearm pronated and the other

supinated Motion, the process of movement, is described using specific anatomical terms. Motion includes movement of organs, joints, limbs, and specific sections of the body. The terminology used describes this motion according to its direction relati ...

, putting the biceps under greater load), preacher curls, and the "kingsmove" technique in

armwrestling Arm wrestling (also spelled "armwrestling") is a sport in which two participants, facing each other with their bent elbows placed on a flat surface (usually a table) and hands firmly gripped, each attempt to "pin" their opponent's hand by forcing ...

. Distal tendon ruptures are more common in males than females. Distal tendon tuptures occur more frequently in the dominant arm.

Treatment

Acute rupture of the distal biceps tendon can be treated nonoperatively with acceptable results, 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. 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. 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. 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. Older patients will be treated by long head bicep tenotomy almost without exception.

Prognosis

Prognosis is dependent on the site of tendon rupture. Proximal tendon ruptures usually allow for a non-operative treatment course with minimal deficits in shoulder flexion, flexion at the elbow, and forearm supination. 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. 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. A few reviews have shown that return to activity is independent of surgical approach, athlete age, steroid use, and rehabilitation program. Other reviews have shown that surgical approach does affect time to return to sport. Nonoperative management of distal tendon ruptures results in inferior strength and endurance in flexion at the elbow and forearm supination.

References

{{DEFAULTSORT:Biceps tendon rupture Dislocations, sprains and strains Sports injuries