Rupture Long Head Biceps

Original Editor - Cynthia Meert

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Introduction

anterior shoulder anatomy shows long head of biceps

A torn long head of biceps, also known as a rupture of the long head biceps tendon, is a common shoulder injury that typically affects individuals between 40 and 60 years old, often with a history of shoulder problems. The long head of biceps tendon originates at the supraglenoid tubercle of the shoulder blade and attaches to the radial tuberosity of the forearm. It plays a crucial role in shoulder stability and helps depress the humeral head.

This injury usually occurs at the tendon-labral junction or the bony attachment near the shoulder. It can result from acute trauma, such as falls or heavy lifting, or develop gradually due to repetitive use and age-related degeneration. In many cases, a torn long head of biceps is associated with other shoulder conditions, particularly rotator cuff tears.

A characteristic sign of this injury is the "Popeye deformity," where the biceps muscle appears more prominent due to the tendon's detachment. Patients may experience sharp anterior shoulder pain, sometimes accompanied by an audible pop or snapping sensation. Pain often worsens with overhead activities and at night..

Pathophysiology

Coronal section of the tendon of long head of biceps.

The LH 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 stabiliser of the glenohumeral joint, as well as a depressor of the humeral head. The proximal tendon rupture in most cases occurs at the tendon-labral junction or the bony attachment.

Epidemiology

1. Biceps tendon rupture mainly occurs in individuals between 40 and 60 years who already have a history of shoulder problems.
2. It mostly affects the dominant arm.
3. 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.
4. Studies show up to 93% of cases occur alongside rotator cuff tears.

Etiology

1. LHB rupture is generally not due to a unique mechanism of injury but is highly correlated with rotator cuff disease.
2. Risk factors include age, smoking, obesity, use of corticosteroids, and overuse. Rare causes include the use of quinolones, diabetes, lupus, and chronic kidney disease.

Characteristics/Clinical presentation

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

• Audible pop
• Sharp anterior shoulder pain with or without snapping sensation
• Trauma

• 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

Viewing

Watch this 90 second video for a good visualisation of the injury.

Diagnostic procedures

Physical examination

• Assessment of the shoulder and arm contour:(+) Popeye sign; Descent of the biceps muscle in the middle part of the arm (more obvious with contraction)
• Muscle power: Shoulder and elbow
• Range of motion (ROM): Shoulder and elbow
• Special tests: Yergason's test: Positive if pain is reproduced in the bicipital groove during the test; Speeds test; Lift-off test, Belly-press test, Bear hug test.

Special investigations

• MRI: Axial and parasagittal planes needed Ultrasound Scans

Outcome measures

• Disabilities of the Arm, Shoulder, and Hand (DASH), Quick DASH; Constant-Murley score

Conservative Management

Anti-inflammatory medications can be used to reduce the underlying inflammatory process that may predispose tendons to rupture. When tendons are stressed or partially disrupted, anti-inflammatory medications can be used as analgesia.

Conservative management: Physiotherapy

Conservative management of a long head biceps tendon rupture through physiotherapy typically involves a comprehensive rehabilitation approach. The main goals are to decrease pain and swelling, restore range of motion, improve strength, and gradually return the patient to normal activities. Here's a summary of the conservative physiotherapy management:

1. Initial phase (Days 1-14):

• Use of a standard sling for comfort
• Application of elastic wrap over the upper arm for support
• TENS unit for pain management
• Gentle rhythmic stabilization exercises
• Initiation of scapular stabilization exercises
• Restoring full passive shoulder range of motion
• Passive shoulder external rotation with a foam roll
• Manual therapy and modalities as needed

1. Progressive phase (Weeks 2-6):

• Gradual increase in range of motion exercises
• Introduction of strengthening exercises
• Focus on scapular control and stability
• Progression from isometric to eccentric and concentric loading

1. Advanced phase:

• Continued strength training with a maximum 5% weight increase per week
• Exercises from previous phases with increased load
• Emphasis on proper form and scapular control

Throughout the rehabilitation process, the physiotherapist should:

• Monitor pain and swelling
• Adjust the program based on individual patient needs and responses
• Focus on restoring normal shoulder mechanics
• Gradually progress exercises and activities

The rehabilitation protocol is flexible and adaptable, allowing for modifications based on individual patient progress rather than following a rigid timeline. Return to activity criteria include full pain-free range of motion, adequate strength for occupational demands, normal scapular mechanics, and no pain with resistance training.

Surgical Management

Surgical management of long head biceps tendon rupture is typically considered for three main groups:

1. Younger, more active individuals
2. Those who find the "Popeye" deformity cosmetically unacceptable
3. People whose occupations require full supination strength

The two main surgical procedures for long head biceps tendon rupture are:

1. Tenotomy: Cutting the long head of biceps tendon prior to its intra-articular superior labral insertion.
2. Tenodesis: Cutting the long head of biceps tendon and securing it at a new attachment site along its anatomical path in a more distal position. This can be performed using various fixation methods:
   • Keyhole technique
   • Anchor fixation
   • Interference screw
   • Gilcreest technique (suturing the tendon to the bicipital aponeurosis)

Open Subpectoral Tenodesis is another approach that involves making a larger incision in the armpit area for better access to the tendon.

The best surgical outcomes are achieved when tenodesis is performed within 3-4 weeks of the rupture. Both open and arthroscopic techniques can be used for ruptures or instabilities.

It's important to note that while surgical intervention is an option, in most cases, conservative treatment yields good results, especially for older patients or those who don't require complete supination strength.

Post-operative rehabilitation: Physiotherapy management

Post-operative rehabilitation for long head biceps tendon rupture is highly individualized and typically divided into phases. Here's a summary of the physiotherapy management:

Phase 1 (Days 1-14):

• Use of a standard sling for comfort
• Elastic wrap over the upper arm for support
• TENS unit for pain management
• Gentle rhythmic stabilization exercises
• Scapular stabilization exercises
• Restoring full passive shoulder range of motion
• Passive shoulder external rotation with foam roll
• Manual therapy and modalities as needed

Phase 2 (Weeks 2-6 for tenotomy, Weeks 2-12 for tenodesis):

• Advancing to active range of motion exercises
• Preventing upper trapezius substitution
• Progressing rhythmic stabilization exercises
• Introducing light isotonic strengthening, starting eccentrically

Phase 3 (typically Week 3 for tenotomy, Week 7 for tenodesis):

• Endurance and strength training
• Biceps strengthening (supination and elbow flexion)
• Proprioception and neuromuscular re-education
• Rotator cuff and scapular stabilizer strengthening

Return to Sport phase (4-6 weeks for tenotomy, 8-12 weeks for tenodesis):

• Plyometric exercises for dynamic stability and proprioception
• Gradual progression of sport-specific training

Throughout rehabilitation:

• Progression is based on patient's healing capacity and clinical response
• Treatment is adjusted based on pain and swelling patterns
• Focus on protecting healing tissue while gradually introducing controlled loads
• Strength training guidelines include a maximum 5% weight increase per week

Return to activity criteria include full pain-free range of motion, adequate strength for occupational demands, normal scapular mechanics, and no pain with resistance training.

Clinical Bottom Line

Ruptures of the long head of biceps tendon typically affect individuals between 40 and 60 years old who have underlying shoulder conditions, though younger, active individuals can also experience this injury. The condition is notably characterised by a distinctive "Popeye" deformity in the biceps muscle. For older patients and those who don't require complete supination strength, non-surgical treatment involving pain management and physical therapy is generally recommended, despite the typical 20% loss in strength that accompanies these injuries. However, surgical intervention, which involves cutting and reattaching the tendon, is typically reserved for three groups: younger, more active individuals; those who find the cosmetic appearance of the "Popeye" deformity unacceptable; and people whose occupations (particularly manual labor) demand full supination strength. Regardless of whether the treatment approach is conservative or surgical, physical therapy plays a crucial role in the rehabilitation process and overall recovery of patients with long head of biceps ruptures.