Biceps tendon rupture
Healthy, short (L) and long (R) biceps tendons proximal to the shoulder joint

Definition

A rupture of the biceps tendon refers to the severing of the short or long head of the biceps tendon in proximity of the shoulder joint, or the distal end of the biceps tendon near the elbow.

A rupture to the biceps tendon can be located to the proximal (L) or distal (R) side

Pathology

The biceps muscle is the largest muscle of the upper arm, which is used when bending the arm or lifting weights. The biceps tendons connect the biceps muscle to the shoulder and the elbow. The upper biceps tendon has two endings, one that connects to the glenoid (long head, right) and the other to the coracoid process (short head, left). The lower part of the biceps has one tendon inserting to the elbow. 

The rupture of any section of the biceps tendon can be complete or partial. The long head of the biceps tendon is more frequently subjected to rupture than the short head. A complete tear of the proximal long head biceps tendon is visible through the formation of a bump of the biceps at the elbow. The rupture of the distal biceps tendon is located near the elbow. In this case the biceps muscle retracts towards the shoulder joint. The patient is unable to flex the elbow and has difficulties to supinate (turn hand upwards). A rupture to the biceps tendon can be determined by other pathologies including chronic biceps tendonitis, shoulder impingement and rotator cuff injury.

Colles' fracture with bone displacement seen before (left) and after closed reduction (right) in a cast

Classification

The fractures of the distal radius are defined with various classification systems including the AO (Arbeitsgemeinschaft fuer Osteosynthese) system. They relate to the mechanisms of injury and bone fracture characteristics and provide a guideline towards suitable treatments. The most frequent types of distal radius fracture are:

No 1.

Colles’ fracture is the most common type of fracture in which the distal bone of the radius tilts upwards following an outer bending of the wrist as it happens when falling on the hand

Smith’s fracture or reversed Colles’ fracture occurs when the distal portion of the radius tilts downwards following the inward bending of the wrist

Barton fracture is an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint

Chauffeur fracture is an intra-articular fracture of the radial styloid process, also known as Hutchinson fracture or backfire fracture.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Bodybuilding can lead to biceps tendon rupture

Causes

A repetitive and prolonged use of the shoulder and upper arm may fray the biceps tendons. This leads to the development of tendon inflammation or tendonitis, followed by an initial partial tear, possibly leading to a complete rupture of the tendon when executing a sudden and strenuous movement. A tendon rupture severely impairs the use of the arm. The causes leading to a biceps tendon rupture are: 

Tear of the rotator cuff

Shoulder instability

Joint stiffness particularly of the elbow

Lack of, or excessive training

Inadequate warm up

Weakness of the muscles

Tightness of the biceps

Carpentry work involving heavy weight lifting can cause a biceps tendon rupture

Risk factors

A rupture to the biceps tendon is more frequent in males above 35 years of age. Sports and professions involving strenuous activities of the shoulders and arms represent the main risk factors for this pathology. In addition, the ageing process per se with the weakening of all tendons and muscles is a significant risk factor for biceps tendon rupture. Professions and sports posing risk for his pathology include:

Weightlifting

Swimming

Tennis

Baseball

Carpentry

 

The so called "Popeye arm" due to the retraction of the biceps following proximal rupture

Symptoms

Symptoms of a biceps tendon rupture include:

Sudden, sharp pain sometimes accompanied by a snap or pop

Formation of bruise extending to the lower arm

Presence of a hump especially when contracting the arm

Weakness of the arm and shoulder

Impairment in rotating the arm

All these symptoms are less evident with partial tear of the biceps tendon.

On MRI the partial ruptured distal tendon (red) is visible with fluid accumulation (blue) around.

Diagnosis

Medical examination begins by acquiring patient's health history including a description of the injurious event that may have caused a biceps tendon rupture. Evident signs for biceps tendon rupture include: 

complete tear forming a “Popeye muscle” (proximal tear) 

in partial tear, biceps contraction causing pain 

tear of the distal biceps tendon causes a gap in the front of elbow. 

The examiner will also assess for possible concomitant injuries: rotator cuff tear, impingement, and biceps tendonitis. X-rays are advised to identify potential changes in the bones of the shoulder if additional pathologies are suspected. MRI and ultrasound aid the classification in complete or partial tear of the biceps tendon.

Treatment

Application of ice pads helps to reduce swelling and inflammation

Nonoperative treatment

Conservative treatment is the most frequent option even in complete tear of the biceps tendons. It is recommended the following:

Rest from any sport activities

Application of ice pads

Administration of NSAIDs

Physical therapy

 

A horse trainer underwent surgery to repair the ruptured distal biceps tendon

Surgical treatment

If severe deformity or weakness occur or in case of specific professions, surgery is required. The procedure consists in re-attaching the tendon to the bone. When the rupture of the biceps tendon has occurred weeks before the diagnosis, the tendon needs to be retrieved surgically prior to being attached to the bone.

 

Physiotherapy is recommended to restore function of the biceps tendon/muscle

Rehabilitation

Rehabilitative treatment for a biceps tendon rupture involves:

Initial arm immobilisation with a sling

Ice or heat applications

Exercise to gain flexibility and strength of the biceps muscle

Massage to increase blood flow

Stretching to improve flexibility of the biceps muscle and tendon.

Taping is useful to prevent recurrent biceps tendon rupture

Prevention

Preventing recidivism of biceps tendon rupture consists in modifying a number of behaviours such as:

Postural support

Shoulder/arm taping

Warm up and stretching before sport activities

Maintain a regular exercise regime

Use of appropriate training techniques