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A ruptured biceps tendon involves the tearing of the fibrous attachment (tendon) for the biceps muscle. The biceps tendon has two attachments at the shoulder (the long head and short head of the proximal biceps tendon) and one at the elbow (distal biceps tendon). Nearly all (90% to 97%) of biceps tendon ruptures occur in the proximal biceps and involve the long head of the biceps tendon (Branch). The remaining ruptures occur in the distal biceps tendon and in the short head of the biceps tendon.
Ruptures can be complete or partial, although partial ruptures are rare. Distal biceps tendon ruptures are more disabling because they result in the complete loss of biceps muscle function. A rupture that occurs at the junction between tendon and bone is called an avulsion and is the most common type of tendon rupture. Ruptures at the junction between tendon and muscle (musculotendinous junction) or within the tendon are very rare.
Most biceps tendon ruptures are caused by a single traumatic incident that usually involves lifting a heavy weight while the elbow is bent at a 90-degree angle. Rupture can also result from activities such as falling forcefully on an outstretched arm or pitching a baseball. An individual’s dominant arm is most likely to be injured. Nontraumatic or chronic rupture refers to a spontaneous rupture in the absence of a traumatic event. This usually occurs in elderly individuals with advanced tendon degeneration. Individuals with degenerative changes of the biceps tendon or who have shoulder impingement syndrome are at risk of developing the condition.
Risk: Laborers and athletes are at higher risk of sustaining a ruptured biceps tendon. Weight lifters who use anabolic steroids are at an increased risk of sustaining a rupture at the musculotendinous junction or within the tendon. Recent studies have suggested that use of certain statin medications may predispose individuals to tendon rupture (Pullatt).
Biceps tendon rupture most often affects people between 40 and 60 years of age, with men affected significantly more often than women (Branch). Risk is increased in middle-aged male athletes and workers whose activities place repetitive strain on the upper arm. Incidence and Prevalence: Biceps tendon rupture is a relatively uncommon injury that is reported to be increasing among middle-aged athletes and laborers in the US (Mazzocca). Approximately 3% of biceps injuries involve distal insertion of the biceps tendon, occurring with an incidence of 1.2 per 100,000 individuals (Mazzocca). |
Source: Medical Disability Advisor
| History: The individual may report a tearing or popping sensation followed by a sudden, sharp pain in the upper arm. The sensation and subsequent pain may have occurred while lifting a heavy object or weight, falling, or participating in a sports activity such as football or snowboarding. Some individuals may complain of forearm pain. Following the episode of severe pain, the individual may feel upper arm discomfort or complete pain relief. Difficulty using the arm and arm weakness may be reported. Grip strength may be decreased and the individual may have difficulty opening doors or using a screwdriver. The individual may have developed shoulder pain that worsens at night. Individuals with a partial rupture may report constant pain and arm weakness. Physical exam: The upper arm may be swollen. Bending the elbow may reveal a lump sometimes called a "Popeye muscle" that is in an abnormal position—either too far up due to rupture of the distal tendon or too far down due to rupture of a proximal tendon. If a lump is not readily apparent, the physician may perform Ludington's test, in which both arms are placed on the head and the contours of the upper arms compared. Defects in the muscle-tendon unit usually are detectable by touch (palpable). If no defect is palpable, then a partial rupture may have occurred. The upper arm and inner elbow (antecubital fossa) may be tender to the touch. Bruising (ecchymosis) may be visible beneath the skin of the upper arm. Muscular strength in the arms and range of motion in the elbow and shoulder may be evaluated. Tests: Diagnosis of a ruptured biceps tendon usually is based on individual history and the physical exam. Specialized tests (e.g., Yergason test and Speed test) may be done to detect the presence of related conditions such as bicipital tendonitis or shoulder impingement syndrome. Imaging studies may be done as an extension of the exam to rule out other disorders. Plain x-rays can rule out fractures or other skeletal abnormalities. Arthrography, ultrasound, and MRI all can help further evaluate tendon ruptures. |
Source: Medical Disability Advisor
| Current practice stresses individualized decisions regarding treatment options, taking into consideration the individual's age, activity level, personal needs, and any comorbid conditions (Branch). Partial ruptures may be treated conservatively or surgically.
Conservative, nonsurgical treatment of biceps tendon rupture consists of rest, strengthening and range of motion exercises, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Ice is applied for the first few days of treatment, followed later by heat therapy.
Surgical treatment involves either reattaching the torn section of the tendon to bone (tenodesis) or cutting the tendon to produce a complete tear and treating as for an avulsion. Avulsion of the long head of the biceps tendon usually is treated conservatively because the injury causes only minor functional changes. However, athletes or other particularly active individuals may not tolerate any loss of function and will request that a tenodesis be performed. Avulsion of the distal biceps tendon is treated with tenodesis using a metal stitch (suture) anchor.
Rupture of the musculotendinous junction or rupture within the body of the tendon is treated surgically (tendinoplasty) by a ligament augmentation device or a simple folding or tucking (plication) method. Following surgery, the arm is maintained in a bent position for 4 to 5 days. |
Source: Medical Disability Advisor
| Overall prognosis is good for both surgically repaired and conservatively treated biceps tendon ruptures. Both treatments generally allow for adequate functional return to activities of daily living and to most previous vocational and recreational activities. The extent of any residual strength deficits will vary, but may reach 20% in individuals treated conservatively (Branch). Surgical outcomes are optimal when surgery is performed within 4 weeks of injury (Stretanski).
Conservative treatment of partial tendon ruptures generally has a good outcome. Surgical reattachment of a partially ruptured tendon to bone has a poorer success rate; cutting the tendon and treating it as an avulsion produces a better outcome than reattachment.
Tenodesis of either proximal or distal biceps tendon avulsion injuries has an excellent outcome and restoration of normal arm strength is common. Rupture at the musculotendinous junction or within the tendon has a poorer outcome. Simple plication of the tendon is not reliable. Use of a ligament augmentation device has a slightly better outcome but is still associated with an incomplete recovery. |
Source: Medical Disability Advisor
| Note on research and authorship Treatment and rehabilitation for a ruptured biceps tendon will vary based on whether the rupture is proximal or distal.
Proximal tendon ruptures tend to be degenerative and are most commonly managed conservatively. If symptoms are painful, modalities such as heat and cold can be used (Braddom). If function is impaired, the cause of the dysfunction needs to be identified and appropriate treatment initiated. Strengthening and range of motion exercises for the involved upper extremity may be beneficial. Individuals should be instructed in a home exercise program that they should continue independently, while being checked periodically by the therapist.
Distal tendon ruptures are most commonly managed operatively (Aldridge; Bernstein; Brunner). Postoperatively, the elbow is splinted at 90°, with the duration of immobilization determined by the physician's protocol. Unless contraindicated, hand and shoulder range of motion exercises on the involved side may be encouraged. After the splint is removed, at about 6 to 8 weeks postoperatively, gentle range of motion exercises are started and progressed as tolerated (Bernstein). Special attention focuses on regaining full elbow extension and supination. Modalities such as heat and cold may help control pain and swelling (Braddom). After several weeks of supervised rehabilitation, the therapist may give individuals a home exercise program to continue independently. After approximately 12 weeks postoperatively, strengthening exercises can be started and progressed as tolerated. The final goal is to restore the pre-injury functional status.
An ergonomic workplace assessment may be indicated for individuals following a ruptured biceps tendon injury to reduce risk factors that may strain the arm. The treating physician should determine when heavy loading of the tendon is advised (Burkhart). |
| FREQUENCY OF REHABILITATION VISITS | | Nonsurgical and Surgical ‡ | |
| Physical or Occupational Therapist | | Up to 12 visits within 6 weeks | |
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| ‡ Note on Nonsurgical and Surgical Guidelines: If surgically managed, rehab usually begins after tissue healing, about 6 to 8 weeks after surgery. |
| The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice. |
Source: Medical Disability Advisor
| Proximal biceps tendon ruptures are frequently associated with impingement syndrome or rotator cuff tears. Decreased strength may persist following initial recovery. Frozen shoulder (adhesive capsulitis) is a potential complication. Left untreated, partial distal biceps tendon rupture can cause median nerve compression. |
Source: Medical Disability Advisor
| Depending on work duties, the individual may need to be temporarily or permanently reassigned. The individual with a ruptured biceps tendon may be temporarily unable to lift and carry heavy objects, operate equipment, or perform other tasks that require lifting, carrying, pushing, or pulling against resistance using the injured arm. If the dominant arm or hand was affected, the individual may be unable to write legibly or type well. These individuals may require a temporary or permanent reassignment of duties. Individuals with a proximal tendon rupture treated conservatively will have a permanent loss of muscle strength. If weight bearing is an important component of the individual's job duties, permanent reassignment is necessary.
Future or recurrent injury in the workplace may be deterred by avoiding or minimizing repetitive movements and activities that cause chronic irritation and inflammation to the arms and shoulders, predisposing individuals to tendinitis, bursitis, or rotator cuff injuries (Branch). An ergonomic evaluation of the workplace may be beneficial in preventing future or recurrent injuries. Caution in avoiding falls and direct trauma to the arms, along with reducing rapid, heavy loading of the muscle also may help to decrease the likelihood of ruptured biceps tendons. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function. |
Source: Medical Disability Advisor
| If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case. Regarding diagnosis:
- Did individual sustain a traumatic injury to the arm?
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Did individual report a tearing or popping sensation followed by a sudden, sharp pain in the upper arm?
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Does individual have difficulty using the arm?
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Is arm weak, particularly when gripping objects?
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Is the upper arm swollen?
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Does bending the elbow reveal a lump where one should not be?
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Has diagnosis been confirmed and other conditions ruled out with x-rays, arthrography, ultrasound, and/or MRI?
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Was rupture distal or proximal?
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Was rupture partial or complete?
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Is there evidence of other arm injuries?
Regarding treatment:
- Did individual seek out medical treatment in a timely manner?
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What type of conservative treatment was provided?
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Has individual been compliant with conservative treatment regimen?
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Was surgical treatment required? If so, what procedure was performed?
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Has individual been compliant with physical therapy and home exercise program?
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Has individual followed guidelines regarding restrictions on arm movements and weight bearing?
Regarding prognosis:
- When did the rupture occur? Was there a lengthy delay before the individual sought medical intervention?
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Was the dominant or nondominant arm affected?
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Has arm strength and mobility been completely restored? If not, how great is the deficit?
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Has individual developed adhesive capsulitis or nerve compression?
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Will use of the arm be affected by complications or comorbid conditions?
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Source: Medical Disability Advisor
| Aldridge, J. W., et al. "Management of Acute and Chronic Biceps Tendon Rupture." Hand Clinic 16 3 (2000): 497-503. National Center for Biotechnology Information. National Library of Medicine. 14 Nov. 2008 <PMID: 10955222>.Bernstein, A. D., M. J. Breslow, and L. M. Jazrawi. "Distal Biceps Tendon Ruptures: A Historical Perspective and Current Concepts." American Journal of Orthopedics 30 3 (2001): 193-200. National Center for Biotechnology Information. National Library of Medicine. 14 Nov. 2008 <PMID: 11300127>. Braddom, Randolph L. Physical Medicine and Rehabilitation. 2nd ed. Philadelphia: W.B. Saunders, 2000. Branch, Gary L., and J. Michael Wieting. "Biceps Rupture." eMedicine. Eds. Robert J. Kaplan, et al. 12 Sep. 2008. Medscape. 6 Mar. 2009 <http://emedicine.medscape.com/article/327119-overview>. Brunner, F. "Distal Biceps Tendon Ruptures--Experiences with Soft Tissue Preserving Reinsertion by Bone Anchors." Swiss Surgery 5 4 (1999): 186-190. National Center for Biotechnology Information. National Library of Medicine. 14 Nov. 2008 <PMID: 10467875>. Burkhart, S. S., C. D. Morgan, and W. B. Kibler. "Shoulder Injuries in Overhead Athletes. The 'Dead Arm' Revisited." Clinics in Sports Medicine 19 1 (2000): 125-158. National Center for Biotechnology Information. National Library of Medicine. 14 Nov. 2008 <PMID: 10652669>. Mazzocca, A. D. "Distal Biceps Rupture." Orthopedic Clinics of North America 39 2 (2008): Pullatt, R. C., et al. "Tendon Rupture Associated with Simvastatin/Ezetimbe Therapy." American Journal of Cardiology 100 1 (2007): 152-153. National Center for Biotechnology Information. National Library of Medicine. 6 Mar. 2009 <PMID: 17599460>. Stretanski, Michael F. "Biceps Tendon Rupture." Frontera: Essentials of Physical Medicine and Rehabilitation. Eds. Walter R. Frontera, et al. 2nd ed. Philadelphia: Saunders, Elsevier, 2008. |
Source: Medical Disability Advisor
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