Proximal versus distal biceps tendon ruptures: When to refer

Issue: BCMJ, vol. 59 , No. 2 , March 2017 , Pages 85 WorkSafeBC

Proximal and distal ruptures both involve the biceps brachii but have potential for very different outcomes. Biceps tendon ruptures tend to occur in middle-age men, although they can also occur in younger patients. Approximately 96% involve the long head, 3% the distal, and 1% the short head of the biceps.


Proximal and distal ruptures both involve the biceps brachii but have potential for very different outcomes. Biceps tendon ruptures tend to occur in middle-age men, although they can also occur in younger patients. Approximately 96% involve the long head, 3% the distal, and 1% the short head of the biceps.[1,2]

Anabolic steroid use, tendinopathy, or a rotator cuff tear may predispose patients to a rupture. Mechanisms of injury include heavy lifting activities and traumatic falls. When associated with tendinopathy, minimal force may be involved.

Proximal biceps tendon ruptures usually present with acute pain, swelling, and bruising in the upper arm and shoulder, and possibly a Popeye sign with the muscle belly retracted distally.[3] Patients may describe hearing or feeling a pop. Acute strength loss has been estimated at 30% elbow flexion; however, there is usually no appreciable chronic weakness.[4] Some patients may experience fatigue cramping, mild flexion/supination weakness, and cosmetic deformity. Surgical repair (tenodesis) may be indicated in young, active patients unwilling to accept cosmetic deformity, or in patients whose occupation makes them unable to tolerate minimal weakness or fatigue cramping (e.g., carpenters). Multiple systemic reviews looking at tenotomy versus tenodesis, however, have been unable to show any functional improvement, only cosmetic.[5,6]

Distal ruptures generally present with bruising and swelling in the antecubital fossa, and patients often describe a painful popping sound or sensation at the time of injury. There may be a reverse Popeye deformity, with the muscle belly retracted proximally. The hook test—an elbow is held at 90 degrees of flexion and the forearm supinated while an examiner attempts to hook the tendon by pushing a flexed finger across the antecubital fossa from lateral to medial—is considered the most sensitive and specific test for distal biceps tendon rupture. Comparing the contralateral side can be helpful. Distal ruptures are generally treated surgically, as non-operative management results in a decrease of 30% to 50% supination and 20% flexion strength.[7-9] Patients should be referred to the local orthopaedic surgeon on call. Ruptures that are more than 4 weeks old are considered chronic and may be more difficult to fix, require graft, and have less predictable outcomes.

In summary, the vast majority of proximal biceps tendon ruptures tend to do well with conservative management. Patients who are young and active, unwilling to accept cosmetic deformity, or unable to tolerate mild fatigue cramping may be referred for a surgical opinion. Distal biceps tendon ruptures are treated with surgery in an urgent manner and should be referred to the local orthopaedic surgeon on call.

For more information or assistance with a worker patient with a proximal or distal biceps tendon rupture, please contact a medical advisor in your nearest WorkSafeBC office.
—Derek Smith, MD, FRCSC
WorkSafeBC Orthopaedic Specialist Advisor

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This article is the opinion of WorkSafeBC and has not been peer reviewed by the BCMJ Editorial Board.


References

1.    Carter AN, Erickson SM. Proximal biceps tendon rupture: Primarily an injury of middle age. Phys Sportsmed 1999;27:95-101.
2.    Gilcreest EL. The common syndrome of rupture, dislocation, and elongation of the long head of the biceps brachii: An analysis of one hundred cases. Surg Gynecol Obstet 1934;58:322-339.
3.    McFarland EG, Borade A. Examination of the biceps tendon. Clin Sports Med 2016;35:29-45.
4.    Elser F, Braun S, Dewing CB, et al. Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy 2011;27:581-592.
5.    Tangari M, Carbone S, Gallo M, Campi A. Long head of the biceps tendon rupture in professional wrestlers: Treatment with a mini-open tenodesis. J Shoulder Elbow Surg 2011;20:409-413.
6.    Eakin JL, Bailey JR, Dewing CB, Provencher MT. Subpectoral biceps tenodesis. Oper Tech Sports Med 2012;20:244-252.
7.    Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am 1985;67:414-417.
8.    Thomas JR, Lawton JN. Biceps and triceps ruptures in athletes. Hand Clin 2017;33:35-46.
9.    Schmidt CC, Brown BT, Sawardeker PJ, et al. Factors affecting supination strength after a distal biceps rupture. J Shoulder Elbow Surg 2014;23:68-75.

Derek Smith, MD, FRCSC. Proximal versus distal biceps tendon ruptures: When to refer. BCMJ, Vol. 59, No. 2, March, 2017, Page(s) 85 - WorkSafeBC.



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