BICEPS TENDON RUPTURE
What is the biceps muscle?
The biceps muscle is the large muscle in the front of the upper part of arm. It is the muscle which flexes the arm when making the “muscle man” pose. The biceps is attached at the upper end by two tendons around the shoulder ( called the “long head” and the “short head”) and at the lower end by a single tendon around the elbow.
Which part of the biceps ruptures?
The biceps can rupture at its upper (proximal) end or at its lower (distal) end. Ruptures of the proximal biceps tendon make up about 90% of all biceps ruptures. This nearly always involves the long head of the biceps which normally attaches to the top of the shoulder socket.
In whom does this occur?
Upper or proximal biceps tendon rupture occurs most commonly between the age 40-70 years. These patients usually have a history of shoulder problems and may have rotator cuff tears. The tendon ruptures due to chronic wear and tear. Occasionally younger individuals may rupture the upper biceps tendon following a single incident such as a fall, during heavy weightlifting, or during sporting activities such as football or rugby.
Lower or distal biceps tendon ruptures tend to occur in strength athletes, bodybuilders and heavy manual workers. This is seen in a younger population, usually males , over the age of 30 years. It can be related to steroid use.
What are the symptoms and signs of rupture?
In case of distal rupture, the patient may feel a “pop” in the elbow and pain at the front of the elbow, with bruising and swelling. The biceps muscle may retract up the upper arm resulting in a prominent lump, known as the 'Popeye' sign. This is often visibly different to the other biceps when contracting the muscle.
In case of proximal ruptures, the patient often has a sudden, sharp pain in the upper arm, sometimes accompanied by an audible pop or snap. Bruising is seen from the middle of the upper arm down toward the elbow. There can be pain or tenderness at the shoulder and the elbow accompanied by weakness in the shoulder and the elbow.
A bulge in the upper arm above the elbow (also the “Popeye sign") may appear, with a dent closer to the shoulder.
What effect does the rupture have if not treated surgically?
Other arm muscles can substitute for the torn tendon, usually resulting in full motion at the shoulder and elbow and reasonable function. The major impairment after proximal biceps rupture, once the initial pain settles, is due to a decrease in strength during shoulder flexion, elbow flexion, and forearm supination (as in twisting a screwdriver to tighten a screw). Distal biceps ruptures are also painful initially and also result in reduced strength in elbow flexion (about 30%)and forearm supination (about 40%).
What is the recommended treatment?
Conservative management is considered appropriate for middle-aged or older patients and those with less physically demanding professions. This is particularly true for proximal ruptures. Non-operative involves initial rest and painkillers followed closely by physiotherapy and strengthening exercises for the shoulder and elbow. Conservative therapy can be very effective and is recommended in the majority of patients.
Who needs an operation?
Operative reattachment is indicated for athletes, and those requiring full or nearly full elbow flexion and forearm supination power.
- Distal Rupture:
Early operative repair is the treatment of choice to restore full strength and correct the cosmetic deformity. Repair should be undertaken within 3 weeks of the injury as the tendon can shorten and retract after this time period.
There are many different repair techniques. I favour a two incision approach reattaching the tendon down to the bone. The surgery is done as a daycase. The repair is strong enough to allow movement of the elbow soon after the surgery. However all lifting must be avoided for at least 6 weeks after surgery.
- Proximal Rupture:
Surgical treatment for rupture of the upper end (long head) of the biceps tendon is rarely needed. However, for those requiring full restoration of strength, such as athletes or manual laborers, surgery may be indicated. Surgery may also be offered for those patients with partial tears whose symptoms are not relieved with nonsurgical measures.
Several new techniquess have been developed for repairing the tendon. I perform the surgery either by open or keyhole surgery depending on the individual patient and associated injuries. The aim of the surgery is to re-attach the ruptured tendon back to the humerus bone.
What are the complications?
Complications are generally uncommon and short-lived. They occur in about 5% to 10% of patients and include:
- Numbness and/or weakness in the forearm which usually goes away gradually.
- New bone formation can occur around the site where the distal tendon is reattached to the forearm bone. This can sometimes reduce the ability to twist the forearm. This requires additional surgery.
- Re-rupture of the tendon occurs in less than 5% of patients.
What is the rehabilitation?
After surgery, the operated arm is immobilised in a cast or splint. This is worn for about 3-4 weeks. This is followed by physiotherapy. Return to sports, manual professions and and weightlifting etc is after about 4-6 months.