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[Case Report]

Proximal Biceps Tendon Rupture

Primarily an Injury of Middle Age

Amy M. Carter, MD; Steven M. Erickson, MD

American Medical Society for Sports Medicine
Case Report Series Editor: Kimberly G. Harmon, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 27 - NO. 6 - JUNE 1999


In Brief: A 51-year-old man suffered a rupture of the long-head tendon of the left biceps and a small rotator cuff tear while rock climbing. The typical signs and symptoms of a ruptured long-head biceps tendon include anterior shoulder pain, tenderness in the bicipital groove, and unusual bulging of the injured biceps. The history and physical exam are generally sufficient to make the diagnosis, but x-rays and MRI may be helpful to rule out related disorders. Because the injury is often associated with rotator cuff tendinitis, a complete shoulder exam is necessary. Conservative treatment will enable most patients to regain normal strength.

Ruptures of the proximal and distal tendons of the biceps brachii are more common in patients who are over 50 years old than in younger patients (1). Ruptures of the long-head tendon occur more frequently than those of the short- head or the distal tendon. Long-head tendon ruptures are often associated with rotator cuff tendinitis, which may cause degeneration that predisposes the tendon to rupture (2,3). Repetitive strenuous activity often leads to ruptures of the long-head tendon (4,5). Rupture of the long-head tendon is uncommon in competitive and recreational athletes (6).

A case report demonstrates the typical presentation, diagnosis, and conservative treatment of a ruptured long-head tendon of the biceps in a middle-aged recreational athlete.

Case Report

A 51-year-old right-handed rock climber presented with mild left arm and shoulder discomfort and a bulging deformity of the volar aspect of his left upper arm. He had injured the arm the day before while scaling an indoor rock-climbing wall. When the injury occurred, he had been supporting weight with his left arm, forearm supinated. As he began pulling himself up, he felt a painless "pop" in his left arm but had no other symptoms.

The patient had had "shoulder trouble," but so long ago that he could not recall which shoulder had been involved. Nothing else in the patient's history was remarkable.

Physical exam. The physical examination revealed no significant swelling or ecchymosis of the left upper extremity or shoulder. When the patient flexed his elbows with arms adducted, there was a noticeable deformity of the contracted muscle of the left biceps (figure 1). The deformity was more obvious when the arms were abducted 90° and the elbows flexed (figure 2).

[Figure 1]

The left shoulder had full pain-free range of motion. Rotator cuff and acromioclavicular joint impingement signs were absent. Supraspinatus strength testing and resisted internal and external rotation revealed no pain or weakness.

[Figure 2]

There was mild tenderness over the bicipital groove and the short head of the biceps when the patient, with his elbow extended and forearm supinated, flexed his left shoulder forward against resistance (Speed's test, figure 3). The injured arm was weaker than the uninjured arm when the patient, with forearms supinated, flexed his elbows against resistance from 90°. No other significant weaknesses were evident. The distal biceps tendon was palpable and nontender.

[Figure 3]

Imaging studies. Plain films of the left shoulder and humerus revealed no bony abnormality. Magnetic resonance imaging (MRI) was obtained to rule out a tear of the rotator cuff and short head tendon. The MRI (figure 4) showed no bicipital tendon in the bicipital groove (a defect consistent with inferior retraction of a torn biceps tendon), moderate impingement with hypertrophic changes at the acromioclavicular joint, and a questionable minimal rotator cuff tear with edema.

[Figure 4]

Diagnosis and treatment. The patient was diagnosed as having a complete rupture of the long head of the left biceps.

He was treated conservatively with nonsteroidal anti-inflammatory drugs (NSAIDs), range-of-motion exercises for the shoulder and elbow, and rotator cuff strengthening exercises. He was advised to avoid rock climbing for a week and to limit his activity according to pain and weakness when he resumed.

At 1 week postinjury, he resumed rock climbing at near preinjury levels. He continued his home rehabilitation and gradually included light weights. Six months after the injury, he was rock climbing without any problems and noted weakness only when he did one-arm pull-ups and biceps curls.

Discussion

Biceps brachii anatomy. The long head of the biceps originates from the supraglenoid tubercle of the scapula and the glenoid labrum and runs through the bicipital groove of the humerus (figure 5) (2). The tendon glides over the humeral head, stabilizing it in the glenoid cavity by preventing superior translation during shoulder abduction (7). The distal tendon insertion on the radial tuberosity allows the biceps muscle to function mainly as an elbow flexor and forearm supinator (2).

[Figure 5]

The long head of the biceps is at risk of injury and degenerative changes because of its mechanical function and proximity to the rotator cuff, bicipital groove, and acromion (8). In fact, ruptures of the long head account for 96% of all biceps brachii injuries, while distal tendon and short head ruptures account for 3% and 1%, respectively (2). The conditions that are most frequently associated with—and probably contribute to—ruptures of the long head of the biceps are rotator cuff pathology, spurs of the bicipital groove, and shoulder instability (6).

Typical symptoms. At the time of long-head tendon rupture, patients often feel a pop but not always pain. At presentation, they may report pain in the anterior shoulder that radiates to the biceps muscle belly or distal humerus (4). In the above case, the climber's discomfort was localized to the anterior shoulder and proximal arm. Repetitive overhead activities and lifting may exacerbate the pain, while rest usually brings relief. The pain may also intensify at night. Patients commonly have a history of injury to the ipsilateral shoulder or of chronic shoulder pain that diminished after the rupture (4). When the patient's only symptom is a chronic ache in the anterior shoulder, diagnosis can be difficult (3,4).

Physical exam. As in this case, most patients present with unusual bulging of the biceps muscle on the affected extremity (3). The differences in the biceps' contours can be observed clearly if the patient interlocks the fingers of both hands on top of the head and flexes the biceps (as in Ludington's test, figure 6) (4).

[Figure 6]

Testing for biceps tendinitis is also important, since a positive finding may rule out a torn tendon. With the patient's arm adducted and in 10° of internal rotation and the elbow flexed 90°, palpation of the proximal biceps tendon may reveal point tenderness in the bicipital groove, indicating probable biceps tendinitis (3,4). The area of tenderness is often found about 3 to 6 cm distal to the anterior acromion.

Strength testing should include Speed's test (figure 3). Weakness can be a sign of tendinitis or of tendon rupture. Biceps strength may be tested more specifically by having the patient adduct the affected arm, hold the elbow at 90° flexion with the forearm supinated, and then flex the elbow against resistance.

Since biceps pathology is often associated with impingement syndromes, the assessment should include a complete exam of the patient's shoulder (4). Most patients who have a ruptured biceps tendon will have full range of motion in both shoulders and elbows (3).

Radiographs and MRI. Diagnosis can usually be made on the basis of the history and physical exam, but imaging may help rule out other conditions. Plain films of the shoulder can be helpful in the evaluation of biceps tendon ruptures thought to be associated with other shoulder pathology. Anteroposterior axillary, supraspinatus outlet, and bicipital groove views should be included (4). The biceps groove view may demonstrate spurring of the groove, indicating chronic inflammation of the bicipital tendon. A supraspinatus outlet view may show evidence of supraspinatus outlet impingement syndrome.

As in the present case, MRI may be useful in assessing biceps tendon anatomy and associated rotator cuff and intra-articular pathology. MRI should be considered in patients who have clinical evidence of an associated rotator cuff tear and in those who choose to have their biceps surgically repaired.

Differential diagnosis. Ruptures of the distal insertion of the biceps tendon, though less common than those of the long head, are associated with more long-term sequelae (9). Other diagnoses to consider include brachialis tendon rupture, biceps tendinitis, biceps tendon subluxation, and rotator cuff pathology.

Treatment. Treatment of a ruptured long head is usually conservative as described in the present case. The immediate goals of treatment are the maintenance of shoulder range of motion and the reduction of inflammation and pain with the use of NSAIDs, rest, and ice. Subsequently, strengthening exercises for the shoulder and elbow flexors can be added. Any associated pathology of the biceps or shoulder also needs to be treated to speed the patient's return to activity. Most studies have shown no significant deficits in forearm supination or elbow flexor strength in long-term follow-up of nonoperative management (2,10).

Some authors (3,10) recommend operative treatment in younger patients who require supination strength in activities such as carpentry or auto mechanics. In addition, some athletes choose to have a ruptured long head surgically repaired in order to restore symmetry to the biceps muscle belly (2). The best surgical results are achieved when the repair—usually a biceps tenodesis—is performed within 3 to 4 weeks of the injury. Tenodesis involves attaching the proximal tendon to the proximal humerus to restore a normal contour to the biceps belly and symmetry with the contralateral biceps.

Summing Up

Ruptures of the biceps tendon are most common in middle-aged patients, but this injury should also be considered in the differential diagnosis of upper-extremity complaints in young competitive or recreational athletes. A thorough evaluation of these athletes should include common associated shoulder pathologies such as rotator cuff tendinitis. Conservative therapy usually allows patients to resume their activities without significant deficits.

References

  1. Moorman CT, Silver SG, Potter HG, et al: Proximal rupture of the biceps brachii with slingshot displacement into the forearm. J Bone Joint Surg (Am) 1996;78(11):1749-1752
  2. Strauch RJ, Michelson H, Rosenwasser MP: Repair of rupture of the distal tendon of the biceps brachii: review of the literature and report of three cases treated with a single anterior incision and suture anchors. Am J Orthop 1997;26(2):151-156
  3. Warner JJ, McMahon PJ: The role of the long head of the biceps brachii in superior stability of the glenohumeral joint. J Bone Joint Surg (Am) 1995;77(3):366-372
  4. Curtis AS, Synder SJ: Evaluation and treatment of biceps tendon pathology. Orthop Clin North Am 1993;
    24(1):33-43
  5. Richards AM, Moss AL: Biceps rupture in a patient on long-term anticoagulation leading to compartment syndrome and nerve palsies. J Hand Surg (Br) 1997;22(3):411-412
  6. Kannus P, Natri A: Etiology and pathophysiology of tendon ruptures in sports. Scand J Med Sci Sports 1997;7(2):107-112
  7. Benjamin M, Ralphs JR, Newell RL, et al: Loss of the fibrocartilaginous lining of the intertubercular sulcus associated with rupture of the tendon of the long head of biceps brachii. J Anat 1993;182(pt 2):
    281-285
  8. Refior HJ, Sowa D: Long tendon of the biceps brachii: sites of predilection for degenerative lesions. J Shoulder Elbow Surg 1995;4(6):436-440
  9. Rokito AS, McLaughlin JA, Gallagher MA, et al: Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg 1996;5(1):73-75
  10. Demuynck M, Zuker RM: Biceps tendon rupture after successful reinnervation: a case report. Acta Orthop Belg 1995;61(1):55-58

The American Medical Society for Sports Medicine (AMSSM) is a forum for primary care sports medicine physicians. Dr Carter is a family practice resident at Saint Francis Hospital in Beech Grove, Indiana, and Central Indiana Sports Medicine at Ball Memorial Hospital in Muncie, Indiana. Dr Erickson is a primary care sports medicine physician at Arizona State University in Phoenix. Dr Harmon is a primary care sports medicine physician at the University of Washington and a clinical instructor in the Department of Family Practice at the University of Washington Medical School, both in Seattle. She is a member of the American College of Sports Medicine, the American Academy of Family Practice, and the AMSSM. She holds a certificate of added qualifications in sports medicine and is a member of the editorial board of The Physician and Sportsmedicine. Address correspondence to Amy M. Carter, MD, 3165 Birdsong Dr, Greenfield, IN 46140; e-mail correspondence to [email protected].


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