Rupture Long Head Biceps

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Original Editors - Cynthia Meert

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- long head biceps rupture
- long head biceps tendon
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Definition/Description

Rupture of the biceps tendon often occurs after a sudden contraction of the biceps with resistance to flexion and supination of the forearm. Also intrinsic degeneration of the tendon release and frictional wear of the tendon belly may have an impact.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.

The long head of the biceps has several functions like dynamic stabilizer of the glenohumeral joint and a depressor of the humeral head

Clinically Relevant Anatomy

The M. biceps brachii has 2 parts: The long head and the short head. The long head originates at the tuberculum supraglenoidale scapulae and is attached to the dorsal aspect of the tuberositas radii.[3]

The long head biceps 
starts from the tuberculum subraglenoidale with an intra-articular part. The part passes over the humeral head and then follows the bicipital groove distal to the glenohumeral joint. [8]

There is a strong evidence that the short head is used as more powerful elbow flexor, while the long head is more used as a powerful supinator.[4]

Both parts of the tendon are different in shape. The intra-articular part is wide and flat. The extra-articular part is rounder and smaller. [8]
The articular portion of the Long head Biceps is irrigated by the anterior circumflex artery. [8]
The distal part of LHB is fibrocartilaginous and avascular. The part most vascularized is the proximal tendon. [8]
A soft-tissue stabilizes the extra-articular LHB 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.[8]

Epidemiology /Etiology

Biceps rupture mainly occurs in individuals between 40 and 60 years who already have a history of shoulder problems. This often happens due overuse: many tears are the result of a wearing down and fraying of the tendon that occurs slowly over time. It can be worsened by repeating the same shoulder motions again and again. Overuse can cause a range of shoulder problems, 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. [10] Also younger individuals can have this injury but usually after a traumatic fall on an outstretched arm, heavy weightlifting or consistently sport activities such as snowboarding, soccer, ... [4] [5]
Tendon rupture usually results from sudden contraction of the biceps associated with resisted flexion and supination of the forearm, and a predisposing role is possibly played by intrinsic degeneration of the tendon tissue or frictional wear of the tendon belly. [11]
The dominant arm is involved more commonly, probably because it is used more often than is the nondominant arm. [12]
Long head of biceps tendon rupture occurs in 31%-56% of isolated subscapular tears. [12]
No correlation exists between race and the incidence of biceps rupture. [12]
The chance on a tendon tear of the biceps increases with:
- Age. Older people have put more years of wear and tear on their tendons than younger people. [11]
- Heavy overhead activities. [11]
- Shoulder overuse. [11]
- Smoking. Nicotine use can affect nutrition in the tendon. [11]
- Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness. [11]
- Gender. Men suffer of biceps rupture more commonly than women, but this difference may result primarily from vocational or avocational    factors. [12]

Characteristics/Clinical Presentation

Patients with a long head biceps rupture report a wide variety of symptoms. [5]

Some patients hear a pop at the time of the trauma, others feel a sharp pain in the anterior shoulder. [4] 
This acute pain can be accompanied by snapping sensation [5]
Some patients have a nondescriptive pain while performing overhead activities. [5]
Other patients have a nondescriptive anterior shoulder pain that may get worse at night.[5]
Most LHB pathologies were associated with Rotator Cuff tears of a duration longer then 3 months and an area of 5 cm2. [7]Also shoulder problems like tendonitis or schoulder impingement can cause a rupture of the Long head biceps. [5]

The subscapularis tendon is mostly involved with LHB pathologies. [7]

If there is a rupture of the distal biceps tendon, a Popeye deformity can be seen. [5]

Differential Diagnosis

Acromioclavicular Joint Separations[5]
Gout[5]
Rotator Cuff Disease[5]
Septic Arthritis[5]

Diagnostic Procedures

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Outcome Measures

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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 [12]

   -  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 ) [13]

• MRI findings in two planes, axial and parasagittal, is required to diagnose accurate a rupture of the biceps tendon.[6]
• Constant score: [13]

     - assesses pain, function, ROM, and strength.[14]

     -  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.[14]

• Shoulder strength [13] (measured with a MicroFET dynamometer)
• Flexion strength of the forearm[13](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. [12]
• - yergason’s test 
• - speed test [12]

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.
  

Physical Therapy 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.

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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