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 is visible through the formation of a bump of the biceps at the elbow. The rupture of the 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.

Arm abduction is restricted by the inflamed bursa and tendons, reducing the joint space
Cross section of the shoulder depicting the compression of the bursa (red) above the rotator cuff (white) and below the deltoid muscle

Classification

There are various classification systems for a shoulder impingement syndrome.

Stages of subacromial impingement in athletes - Jobe’s Classification
(1989):

Pure impingement with no instability

Primary instability, with capsular and labral injury with secondary impingement, which can be internal or subacromial impingement

Primary instability due to intrinsic ligament laxity with secondary impingement

Pure instability with no impingement.

Grading of impingement changes - Milgrom’s Ultrasound Classification:

Stage 1 Bursal thickness from 1.5 to 2.0 mm

Stage 2 Bursal thickness over 2.0 mm

Stage 3 Partial or full thickness tear of the rotator cuff.

Impingement lesions - Copeland Levy Classification:

This is based on the location of the impingement, either on the acromial or the bursal side.

Acromial side

A0 normal - smooth surface

A1 minor deterioration, haemorrhage or local inflammation

A2 marked scuffing/damage of the undersurface of the acromion and coraco-acromial ligament

A3 exposed bone areas.

Bursal side

B0 normal - smooth surface

B1 minor deterioration, haemorrhage, inflammation

B2 major deterioration of the cuff, partial thickness tear

B3 full thickness tear of the rotator cuff

B4 massive cuff tear.

Two-part proximal humerus fracture

According to the Habermeyer Classification the fractures to the proximal humerus are divided into:

Type 0 one fractured part without dislocation

Type A two-part fracture of the great tuberosity and lesser tuberosity avulsion

Type B involves the humerus “surgical” neck below the femoral head as two-part, three-part and four-part with one or both tuberosities

Type C involves the humerus anatomical neck (between the head and greater tuberosity) as two-part, three-part and four-part with one or both the greater and lesser tuberosities.

These are defined further as:

One-part fractures are non-displaced fractures or fractures with minimal displacement

Two-part fractures only involve a single segment

Three-part fractures involve two segments

Four-part fractures occur when all humeral segments are involved (see image in pathology section)

The injury severity is proportional to the increasing number of fractures.

Three-part proximal humerus fractures

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) 

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