Abstract
Biceps tendon rupture is either complete or partial disruption of the tendon of the biceps brachii muscle that can occur proximally or distally. Structural and histological considerations need to be taken. A wide variety of treatment modalities are discussed.
Keywords
biceps tendon rupture, distal bicipital tendonitis, proximal bicipital tendonitis, tendonopathy
| Synonyms | |
| |
| ICD-10 Codes | |
| M66.821 | Rupture of tendon of biceps (upper arm), nontraumatic, right |
| M66.822 | Rupture of tendon of biceps (upper arm), nontraumatic, left |
| M66.829 | Rupture of tendon of bicep (upper arm), nontraumatic, unspecified |
Definition
Biceps tendon rupture is either complete or partial disruption of the tendon of the biceps brachii muscle that can occur proximally or distally. The more common proximal ruptures account for 90% to 97% of all biceps ruptures and almost exclusively involve the long head. They are associated with concomitant rotator cuff disease and degenerative joint disease of the shoulder ( Fig. 13.1 ). The incidence is 1.2 per 100,000 patients, with a majority on the dominant side of men who smoke and are in the fourth decade of life. Most cases involve the long head of the biceps (LHB) brachii and are manifested as a partial or complete avulsion from the superior rim of the anterior glenoid labrum. Cadaveric study suggests that the relative avascularity of the LHB tendon may be a risk factor, as seen in many tendons having a “watershed” blood supply. Supplied through its osteotendinous and musculotendinous junctions and, rarely, branches from the anterior circumflex humeral artery traveling in a mesotenon, the LHB tendon has a hypovascular region in the border of two adjacent vascular territories. This region of limited arterial supply, 1.2 to 3 cm from the tendon origin, extends midway through the glenohumeral joint to the proximal intertubercular groove. The distal biceps rupture is relatively uncommon and typically occurs in middle-aged men, although acute traumatic ruptures may occur in younger individuals or in anyone engaged in predisposing activities, such as forceful explosive contraction of the biceps. Patients with a distal biceps tendon rupture carry a risk of at least 8% for a rupture on the contralateral side. This often develops suddenly with stressing of the flexor mechanism of the elbow. Distal biceps rupture usually occurs as a single traumatic event, such as with heavy lifting; it is often an avulsion of the tendon from the radial tuberosity, but it can also occur as a midsubstance tendon rupture.
Symptoms
Proximal ruptures are often asymptomatic and are commonly discovered with awareness of distal migration of the biceps brachii muscle mass, or they may occur suddenly by a seemingly trivial event. Often, individuals will note an acute “popping” sensation. The patient often takes one finger and points directly to the bicipital groove when describing the pain. Edema and ecchymosis may be seen with tendon rupture, but also with other regional pathologic processes. The proximal ruptures are typically less painful, but can be preceded by chronic shoulder discomfort. An acute distal rupture is often associated with pain at the antecubital fossa that is typically aggravated by resisted elbow flexion. The pain is usually sharp initially but improves with time and is often described as a dull ache. Swelling, distal ecchymosis, and proximal migration of the biceps brachii muscle mass accompany this injury with a magnitude dependent on the degree of injury. Younger, healthy patients may often present with a cosmetic rather than a functional complaint.
Physical Examination
As with all musculoskeletal conditions, the physical examination portion of clinical assessment is carried out within the clinical context of functional, not just regional, complaints. Visual inspection of the biceps brachii, including comparison to the contralateral side, is usually the first and most obvious element in the physical examination. Neurosensory, vascular, and even electrodiagnostic medicine exams should be normal. Patients may often present aware of side-to-side changes and may alternate non-dominant for dominant arm activities. Ultrasound assessment of the LHB tendon is now reliable among trained clinicians and is a safe non-invasive modality with virtually no risk that can be incorporated into clinical exam portions of patient assessment. Readers should be aware that as many as 129 shoulder exam maneuvers have been described, many of which overlap or are redundant. However, peer-reviewed systemic review of combined specific tests, that have been used for decades, has yielded a “3-pack” of the O’Brien’s test (downward force distally on the arm while the patient resists with an upward force), throwing test (throwing motion against examiner’s resistance; anterior subluxation may occur), and bicipital tunnel palpation with good inter-rater reliability and possible arthroscopic predictability.
Ludington’s test is a recommended position in which to observe differences in the contour and shape of the biceps ( Fig. 13.2 ). Diagnosis of complete ruptures is relatively easy; patients often come in aware of the biceps muscle retraction. Partial ruptures exist along a spectrum and can be more difficult to diagnose. The clinician should also assess for the presence of ecchymosis or swelling as a sign of acute injury. Palpation for point tenderness will often reveal pain at the rupture site. An effort should also be made to determine whether the rupture is complete by palpation and observation of the tendon. Thorough assessment of the shoulder and elbow should be made for range of motion and laxity. Yergason and Speed tests were originally intended to examine the long head of biceps, but are also used in conjunction to detect superior labral anteo-posterior (SLAP) lesions of the glenoid labrum. They are accurate for predicting pathology of the biceps/labral complex, but are not very specific to a particular structure. Tests which are used in the assessment of bicipital tendinitis are also recommended (see Chapter 12 ). Posterior dislocation of the LHB tendon has been reported and may share some common physical examination findings, but not muscle retraction.
In patients with inconsistent physical examination findings and questionable secondary gains, the American Shoulder and Elbow Surgeons subjective shoulder scale, a standardized scale of shoulder function with patient and physician components, has demonstrated acceptable psychometric performance for outcomes assessment in patients with shoulder instability, rotator cuff disease, and glenohumeral arthritis.
It is important to examine the entire shoulder and to keep in mind that it is a complex, inherently unstable, well-innervated joint that tends to function, and fail, as a unit; therefore, additional lesions that are the true pain generator may be evident. One study looking at shoulder magnetic resonance findings showed no statistical relationship between the level of disability and either biceps tendon rupture or biceps tendinopathy; rather, disability was linked to supraspinatus tendon lesions and bursitis.
A thorough neurologic and vascular examination is performed, and findings should be normal in the absence of concomitant problems. Caution should be used with strength testing or end-range motion to avoid worsening of an incomplete tear.
Functional Limitations
The functional limitations are generally relatively minimal with proximal biceps rupture, and the patient’s concern is often centered around cosmetic considerations. More significant weakness of elbow flexion and supination is noted after a distal tendon disruption. Pain can be acutely limiting after both situations, but is typically more of a problem in distal rupture. The primary role of the biceps brachii is supination of the forearm. Elbow flexion is functional by the action of the brachialis and brachioradialis. A degree of residual weakness with supination and elbow flexion, particularly after distal tendon rupture, can cause functional impairment for individuals who perform heavy physical labor. Fatigue with repetitive work is also a common complaint with nonsurgically treated distal tendon ruptures. The LHB is thought to play a role in anterior stability of the shoulder; this is an issue for people who perform overhead activities (such as lifting, filing, and painting), powerlifting (in which the final 10% of strength is crucial), and nonsports activities in which the appearance of symmetry is important (such as modeling or bodybuilding).
Diagnostic Studies
The diagnosis of biceps brachii rupture is often made on a clinical basis alone. Magnetic resonance imaging (MRI) is helpful in confirming the diagnosis and assessing the extent of the injury, but it should be performed in the flexed elbow, abducted shoulder, and forearm supinated (FABS) position to obtain a true longitudinal view; it is particularly useful in partial ruptures. MRI studies can also assess concomitant rotator cuff disease. Diagnostic ultrasound has grown in applicability and portability. It may have a role in demonstrating not only proximal, but also distal biceps tendon partial tears, ruptures, bifurcation, subluxation, and the rotator cuff. Diagnostic ultrasound may be more cost-effective as an initial screening tool when no surgical injuries are suspected. Imaging of the entire insertion site as well as of elbow structures should be performed in distal ruptures. Plain radiographs sometimes show hypertrophic bone formation related to chronic degenerative tendon abnormalities as a predisposition to rupture. Radiographs are also obtained in acute traumatic cases to rule out fractures and to identify developmental variants. Electrodiagnostic medicine consultation for possible peripheral nerve damage should be considered in cases with evidence of lower motor neuron findings or where the distribution of weakness is not fully accounted for by pain. Attention should be paid to median neuropathy at the elbow and, although it is technically difficult, to lateral antebrachial cutaneous nerve studies.
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