BICEPS TENDON TEAR
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related talks: biceps tendonitis; rotator cuff tear; SLAP tear
What is a Biceps Tendon Tear?
The bicep tendon usually tears near the elbow (the front of elbow called the "antecubital fossa") causing a lot of pain and little arm weakness.
It tears when the arm is straightened too fast or with too much force, causing the tendon (which can only stretch slowly) to snap like a rubber band. Similar to an old rubber band that has less spring, and can break apart, its believed in medicine that healthy tendons do not tear, but rather have underlying degeneration that puts them at risk for this sudden tear. The injury usually occurs when a person is trying to lift something too heavy and 90% of the time it occurs in men in their 40s and 50s.
Sometimes the tendon itself doesnt tear but rips off from its attachment to the bone. This is called an "avulsion fracture" because a small chip of bone gets pulled off with the tendon. Its like pulling a plant out of the ground, and them stem doesnt break rather its roots come out.
Lets quickly review the anatomy of your arm. The biceps is the "popeye muscle" (from the cartoon), located in the front of your arm. This muscle flexes (bends) your elbow and rotates your forearm. It got the name biceps because its actually made of two ("bi", like "bicycle") muscles that originate in the shoulder (glenoid rim and coracoid) and insert on the forearm (radial tuberosity).
How is a torn Biceps tendon diagnosed?
When someone tears their bicep muscle they often hear or feel a "pop". It will happen suddenly, usually when you are trying to lift something heavy with your arms. People will immediately feel pain and swelling in the crease of their elbow. The biceps muscle itself can retract and the muscle will bunch up in the middle of your arm, and almost look like its being flexed (this is because its no longer being held out to length by its attachments to bone so it recoils like window-blinds that are suddenly pulled up). This is called a "popeye sign".
In a healthy arm you can actually feel the bicep tendon in the crease of your elbow, and you can hook a finger around it. When the bicep tears, you cannot feel this tendon (its gone). This is a common test used by doctors, called a "Hook Test".
Sometimes the tendon only partially tears, and it can be difficult to separate a partial tear from a complete tear. Sometimes its obvious on the hook test that the tendon is totally gone, but other times, you can sorta-kinda-maybe feel the tendon, and its not clear how bad the injury is (extra fibers of the tendon, called the Lacertus Fibrosis, may remain attached to the arm and prevent the muscle from retracting). In this case its recommended to get an MRI of the elbow to look directly at the tendon to see the injury.
Doctors also get an MRI in many cases where the biceps tendon is clearly torn to look at where the tear occurred, how far the tendon recoiled up the arm, and see if any other injuries occurred. The MRI can be very helpful for surgical planning (more on that below).
How is a Torn Biceps Tendon treated?
A biceps tear can be treated with or without surgery. It depends on the activity level of the person and whether they are willing to undergoing surgery.
Nonoperative treatment consists of literally doing nothing beyond controlling the immediate post-tear pain. People can return to their activities as tolerated and most pain resolves after a few days to weeks. Losing your bicep muscle may cause some lost strength in elbow flexion (bending the arm) and forearm supination (the motion of turning a doorknob or screwdriver). It may also cause increased fatigue in these movements (your arm gets tired more easily with elbow flexion and supination). While biomechanic studies suggest that up to 30% elbow flexion and 50% supination is lost, most people don't notice a major difference between their arms (with many people reporting no difference in strength). Therefore, many people dont want to go through a surgery (which has risks of complication) and a 3 month rehabilitation program to regain a small (if any) amount of strength.
With that said, many younger and active people are unwilling to lose arm strength and elect to have the tendon repaired. Surgery involves tying the tendon back to the forearm bone using various techniques like Endobutton, or interference screws, or suture anchors. The arm is immobilized for 2 weeks after surgery, and then a rehab program is started.
What is the long term outcome?
Nonoperative treatment may lead to some initial notable decreased strength, however with time the surrounding muscles (notably the brachialis and the supinator) will pick up the slack. By 6 months to a year, many people don't notice a difference.
Surgery can restore a lot of this strength, however, the arm still may never return to its full strength. In addition, this surgery has historically had a relatively high complication rate, with risk of injury to a branch of the radial nerve (the PIN), or the Lateral Antebrachial Cutaneous nerve. Also, post-operative stiffness is always a concern with elbow surgery. Recent advances in surgical technique and techology has significantly lowered the risks of surgery. However, there is a saying that "no injury can't be made worse by surgery", which is meant as a disclaimer that all surgeries have a risk of complication, some of which can be significant, and therefore its critical for people to weight the pros and cons of any treatment approach.
1) Kannus P et al. Histopathological changes preceding spontaneous rupture of a tendon. A controlled study of 891 patients. JBJS 1991; 73: 1507-25. full article. degeneration precedes all tendon ruptures.
2) Seiler JG 3rd et al. The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impoingement. J Shoulder Elbow Surg 1995; 4: 149-56. full article. etio rupture.
3) O'Driscoll SW et al. The hook test for distal biceps tendon avulsion. Am J Sports Med 2007; 35: 1865-9. full article. effective test, better than MRI.
4) Giuffre BM, Moss MJ. Optimal positioning for MRI of the distal biceps brachii tendon: flexed abducted supinated view. AJR Am J Roent 2004; 182: 944-6. full article. mri effective for dx.
5) Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. JBJS 1985; 67: 414-7. full article. nonop is weaker over 1 yr postop.
6) Kelly EW et al. Complications of repair of the distal biceps tendon with the modified two-incision technique. JBJS 2000; 82: 1575-81. full article. 2-incision 30% complication elbow pain,stiff,paresthesia.
7) Kelly EW et al. Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision. J Shoulder Elbow Surg 2003; 12: 456-61. full article. single incision less complication.
8) Miyamoto RG et al. Distal biceps tendon injuries. JBJS 2010; 92: 2128-38. full article. review.
9) McKee MD et al. Patient-oriented functional outcome after repair of distal biceps tendon ruptures using a single-incision technique. J Shoulder Elbow Surg 2005; 14: 302-6. full article. low complication, good outcome 64 pt. by one surgeon.