Rupture Long Head Biceps

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Definition/Description

A biceps tendon rupture often occur after a sudden contraction of the biceps with resistance to flexion of the elbow and supination of the forearm. This can further be aggravated by the intrinsic degeneration of the tendon release and frictional wear of the tendon belly. This intrinsic degeneration is caused by improper training or fatigue. Inordinate stresses can be placed on the biceps as it attempts to compensate for other muscles. This can lead to attrition and failure, either within the tendon substance or at its origin.

Clinically relevant anatomy

The biceps brachii muscle consists of 2 parts: The long head and the short head. The long head originates at the supraglenoid tubercle and is attached to the dorsal aspect of the radial tuburosity. It runs intra-articularly over the humeral head and follows the bicipital groove distal to the glenohumeral joint. It functions as dynamic stabilizer of the glenohumeral joint, as well as a depressor of the humeral head. The short head is a functions more in elbow flexor, while the long head functions more in forearm supination.

The parts of the tendon differ in shape. The intra-articular part is wide and flat while the extra-articular part is rounder and smaller. The articular portion of the long head of biceps is vascularly supplied by the anterior circumflex artery, mostly to the proximal tendon. The distal portion is fibrocartilaginous and avascular. Soft-tissue stabilizes the extra-articular long head of biceps when it enters the bicipital groove en this is built by fibers of the coracohumeral ligament, superior glenohumeral ligament and parts of the subscapularis tendon.

Epidemiology/Etiology

Epidemiology

Biceps tendon rupture mainly occurs in individuals between 40 and 60 years who already have a history of shoulder problems. It mostly affects the dominant arm. A biceps tendon tear can also occur in younger individuals, but usually after a traumatic fall on an outstretched arm, heavy weightlifting or consistently sport activities such as snowboarding and soccer.

Etiology

Tendon rupture usually results from sudden contraction of the biceps associated with resisted elbow flexion and supination of the forearm. A possible predisposing role is played by intrinsic degeneration of the tendon tissue or frictional wear of the tendon belly.

Risk factors

• Age: Older people have put more years of wear and tear on their tendons than younger people.
• Heavy overhead activities
• Shoulder overuse - repetitive strain injuries:
  • Can lead to additional shoulder injuries, including tendonitis, shoulder impingement, and rotator cuff injuries
  • Having any of these conditions puts more stress on the biceps tendon, making it more likely to weaken or tear
• Smoking: Nicotine use can affect nutrition in the tendon
• Corticosteroids: Linked to increased muscle and tendon weakness
• Gender: More common in men (most likely primarily from vocational or avocational factors)

Characteristics/Clinical presentation

Patients with a long head biceps rupture report a wide variety of symptoms.

• Trauma:
  • Audible pop
  • Sharp anterior shoulder pain with or without snapping sensation
• Pain:
  • With overhead activities
  • Anterior shoulder pain that may get worse at night
• Associated pathologies that may lead to rupture of long head of biceps:
  • Rotator cuff tears
  • Tendonitis
  • Shoulder impingement
• Popeye deformity

Differential diagnosis

• Acromioclavicular joint separations
• Gout
• Rotator cuff disease
• Septic arthritis

Diagnostic procedures

Physical examination

• Special tests:
  • Yergason's test : Positive if pain is reproduced in the bicipital groove during the test

• • Hook test

Special investigations

• MRI
• Ultrasound

These studies can create a good image of soft tissues like the biceps tendon.

Outcome measures

• Disabilities of the Arm, Shoulder, and Hand (DASH), Quick DASH

Examination

Diagnosis can be based on clinical examination (grades of recommendation:B) , based on:

• Inspection of the shoulder and arm contour and compare with the contralateral side

   -  the presence of the classic Popeye sign or a less striking descent of the biceps muscle in the middle part of the arm. (more obvious by contracting the muscle )

• MRI findings in two planes, axial and parasagittal, is required to diagnose accurate a rupture of the biceps tendon.
• Constant score:

     - assesses pain, function, ROM, and strength.

     -  Pain is allotted a maximum of 15 points, activities of daily living (function) 20 points, ROM 40 points, and strength 25 points. The           component scores are summated to achieve a maximum possible total score of 100. A maximum score indicates greater shoulder function.

• Shoulder strength (measured with a MicroFET dynamometer)
• Flexion strength of the forearm(measured with a MicroFET dynamometer)

     -  with the forearm flexed at 90° and the arm adducted to the body, with the hand in full supination

• Perform range-of-motion (ROM) testing of the shoulder and elbow.
•  yergason’s test 
•  speed test

Medical management

There is no consensus about surgical repair.

• Generally they do surgery for young, athletic patients or patients who needs maximum supination strength.
-> Patients lose up to 20% of supination strength but there is rarely impact on ADL.
• Non-operative management is considered appropriate for older patients or patients who do not require a high level of supination strength.

There are anti-inflammatory medications that can be used to reduce the underlying inflammatory process that may predispose tendons to rupture. When tendons may be stressed or partially disrupted, anti-inflammatory medications can provide an analgesic effect.(Grades of recommendation = F)

Physiotherapy management

• without surgery:
- we can do mobilizations
- control swelling by cold modalities such as cold packs, ice massage
- against inflammation: NSAIDs except for contraindications
- Preserving ROM:

         - Codman pendulum exercises

         - Functional exercises

• 
After surgery:
- 10 - 14d: soft sling + light exercises for ROM
- 14d - 6 to 8w: functional exercises using pulleys or therapy bands
- after 6 à 8w: moderate loading may be tolerated but heavy loading is prohibited for the first months. (LoE: 3B)

1. surgery

Before the doctor decides to operate, he considered about the advantages and disadvantages. In this situation, the activities of the patiënts , the way of living and the age are important. The operation is often carried out by young people or people who have a hard work, like a carpenter, port worker,… etc. These people need a maximal supination strenght. There will also be operated when some people can’t accept the Popeye malformation. The operation trial ( tenotomy) includes the attaching torn tendon to the bone. The results of the other studies shows us that the function of the muscle fully recovers and that the strength can go back like it was before the rupture. They also see a good cosmetic result. (LoE: 3B)

postoperative (tenotomy) rehabilitation (LoE: 5)

phase 1: passive

• pendulums to warm-up
• passive ROM

week 1

• full passive elbow flexion/ extension
• full passive forearm supination/pronation
• full passive shoulder ROM
• seated scapular retractions
• phase 2: active
• pendulums to warm-up
• active ROM, with terminal stretch to prescribed limits

Phase 2: active
week 2

• full active shoulder ROM, lawn chair progression
• active elbow flexion/ extension
• full ROM allowed
• active forearm supination/pronation
• full ROM allowed

phase 3: resisted

• pendulums to warm-up and continue the program

week 3

• sport cord internal/ external rotation at 30° abduction
• Prone I,T,Y,W
• Sport cord standing forward punch
• Sport cord low rows
• Sport cord bear hugs
• Biceps curls
• Resisted supination/pronation

Phase 4 : weight training
Week 4

• Keep hands within eyesight, keep elbows bent, minimize overhead activities
• Return to activities

       -  Computer after 1-2 weeks
       -  Golf after 4 weeks
       -  Tennis after 8 weeks (LoE: 5)

     2.   conservative treatment

Is more used in older patients and who do not need maximal supination strength in their daily life and work. There are some advantages in comparison with the first treatment. Therefore, this treatment is better tolerated and presents fewer complications. The costs are also lower and because there was no operation, the people can get back to work quicker. But with this choice of treatment the strength is 20% lower then before. But it hasn’t have influence at the ADL activities and that maybe is the reason why people hold off an operation. Also doctors recommend this treatment faster when people are afraid or when the injury is too old.
The treatment takes 4-6 weeks 2-3 times in a week. It consists of mobilization and flexibility exercises to improve the shoulder ROM. After that, there are also strength and stretching exercises. The muscle will also be static trained. At home there will be home exercises. The exercises are extension and flexion and supination en pronation exercises. After a period the pain needs to be lower and the strength have to be better. Most people go back to work after 2-3 weeks but the work is adapted. After 8 weeks the ROM and the strength is back to normal. Normally there aren’t anymore restrictions more but the popeye malformation remains. (LoE: 3B)

Nonoperative rehalitation
Phase1: acute phase
Week 1

• Clinical modalities as needed
• Glenohumeral ROM

       - apply appropriate joint mobilization to restrictive capsular tissues
       - implement wand stretching as indicated
       - supplement with home program
                 - cross-arm stretch
                 - sleeper stretch
                 -  Early scapular strengthening

        -  begin scapular stabilization with instruction in lower trapezius facilitation

phase 2: subacute phase, early strengthening
Week 2

• Continue with modalities and ROM.
• Begin rotator cuff strengthening

        -  sport cord internal/external rotation in 30° abductee
        -  sport cord low rows ( prone, scapular plane abduction (<90°), celling punch, biceps en triceps)

phase 3: advanced strengthening
Week 3

• continue with strengthening

       - resisted PNF patterns
       - sport cord bear hug
       - sport cord reverse fly
       - sport cord IR/ ER at 90° abduction for neuromuscular re- education
       - push-up progression
       - begin 2- arm plyometric exercises advancing to 1-arm exercises
       - weight training

phase 4: return to activities
week 4

• continue with program
• re-evaluation with physician and therapist
• advance to return-to-sport program, as motion and strength allow (LoE: 5)

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