Biceps tendon rupture of the elbow

What is a biceps tendon disruption?

When the biceps tendon ruptures at the elbow, it is torn from where the elbow meets the radius. The radius juts out slightly at the point where the biceps tendon joints, known as the radial tuberosity. Although the tendon usually pulls completely away from the bone insertion, some tendon tears are incomplete.

Biceps tendon rupture usually causes some degree of impairment because the biceps muscle is important for both bending the elbow (called elbow flexion) and turning the palm face up (called forearm supination).· Studies have shown that distal tendon rupture of this structure may result in about a 30 percent loss of elbow bending strength and about a 40 percent loss of strength in turning the palm up.

How does biceps tendon disruption occur?

•  The elbow is subjected to a sudden force while lifting or holding something, exceeding the inherent tensile strength of the muscle-tendon unit.

•  It typically occurs in middle-aged athletes lifting something very heavy.

What increases the risk of developing biceps tendon disruption?

•  Weightlifting and bodybuilding

•  Heavy labor

•  Poor physical conditioning (inadequate strength, poor flexibility)

•  Inadequate warm-up before practice or play

What are the symptoms of biceps tendon rupture?

•  Acute pain in the front of the elbow, accompanied by a pop or tearing sensation at the time of injury

•  Visible deformity or bulge is often noted above the elbow crease

•  Pain exacerbated by elbow flexion against resistance

•  Pain and weakness on attempting forearm supination against resistance

•  Evolution of ecchymosis (bruising) in the elbow or forearm

How is biceps tendon rupture diagnosed?

Physical exam is reliable in the vast majority of cases with a visible deformity above the elbow crease, tenderness along the course of the tendons’ attachment to its radial insertion and weakness with forearm supination against resistance.

Are there any special tests?

•  X-rays

•  MRI is the definitive test to confirm suspected distal biceps tendon rupture.

How is biceps tendon rupture treated?

Initial treatment consists of medication and ice to relieve the pain, and a sling may be recommended for comfort.

Historically, surgical treatment was unusual because it was believed that long-term function of the tendon was not compromised when it was left alone. But more recent studies have revealed that some patients continue to suffer from significant deficits in strength, particularly in movements requiring forearm supination (e.g., opening doors, opening jars, using screwdrivers, etc.)· Non-operative treatment may be preferable for those patients whose affected arm is their non-dominant one, who want to avoid surgery or who are less active.

Most patients are candidates for surgical reattachment of the biceps tendon. Surgery is usually recommended as soon as is reasonable after the injury, ideally within 3 weeks, to minimize retraction of the torn tendon and to take advantage of the healing environment. Delay in surgery may result in inability to re-attach the tendon due to muscle retraction. Operative treatment requires re-attachment of the tendon to its normal insertion on the radial tuberosity.

•  The surgery for a ruptured biceps tendon cannot be done laparoscopically. Current techniques require open exploration to identify the torn tendon end, which is then debrided (surgically excising the unhealthy degenerative tendon tissue through which the tear occurred). Suture material is weaved throughout the tendon remnant so that it can be used to pull it into a tunnel created at its original attachment site. Several techniques are used to secure the tendon.

•  The historic practice for repairing the tendon has been a “two incision” technique, making one incision in the front of the elbow (within the elbow crease) to retrieve the torn tendon, and another on the dorsum (back part) of the forearm near the elbow to help secure reattachment to bone.

•  The advent of newer surgical fixation devices have led to the development of a “single incision” approach, in which the only incision necessary is that anteriorly in the antecubital fossa (skin crease in the front of the elbow). Surgical retrieval, debridement, suturing, and insertion of sutured tendon into the radial tuberosity bone tunnel are all achievable.

•  Once the tendon has been introduced into the tunnel, fixation can be achieved using a “button” (known as a Retro or Endo button), in which a small metal button is flipped against the opposite side of the tunnel, securing like a molly bolt the tendon within the tunnel. An alternative technique, used by itself or in conjunction with the button, is an “interference screw,” in which a bioabsorbable screw is seated within the tunnel against the tendon, thereby securing it against the tunnel wall, much like a cork fit into a champagne bottle. Regardless of which fixation technique is used, tendon to bone healing appears to occur within about 6 weeks.

•  Post-operative treatment requires immobilization in a sling, followed by exercises to restore motion and, eventually, strength. The pace of return to activity and rehabilitation depends upon a number of factors and is individually determined at the time of surgery. These factors include the tendon quality and quantity (amount of quality tissue remaining after debridement of the torn end), security of fixation, and patient considerations (their “handedness,” demands, reliability).

What are the potential complications from treatment?

Possible complications of non-operative treatment include:

•  Weakness, especially with activities involving supination (turning forearm/palm “up”)

•  Mild elbow flexion weakness (typically not significant with daily activities because the brachialis, the muscle beneath the biceps, is a strong flexor of the elbow)

Possible complications of operative treatment include:

•  Surgical complications not specifically associated with the distal biceps tendon repair, such as pain, bleeding (uncommon), infection (<1 percent), nerve injury (uncommon), stiffness, problems with anesthesia, and inability to return to previous level of pre-injury activity.

•  Complications specific to surgical treatment of this condition include repair failure, persistent pain and restriction in motion. Repair failure is attributed to the security of fixation and compliance with post-operative requirements. Pain is an uncommon problem. Restriction in motion can occur if there is insufficient tendon length or if there is protracted immobilization post-operatively.

When can you return to your sport/activity?

•  With current fixation techniques, most patients will be able to resume daily activities within a few weeks of surgery. This means dressing, hygiene, typing and returning to non-physically demanding jobs. Lifting anything heavier than a cup of coffee requires minimum of 6 weeks, until the tendon has had a preliminary chance to begin healing. At 3 months, the tendon is secure enough to tolerate beginning resistance exercises, including resistance tubing and lifting weights. These should advance progressively and be modified as necessary. These serve as guidelines rather than an obligatory timetable.

•  Return to sports depends on the type of sport and position.

•  Full elbow and wrist motion and strength are necessary before returning to sports.

•  Four to eight months are necessary for complete healing before a return to sports or heavy lifting.

How can a biceps tendon disruption be prevented?

•  Appropriately warm up and stretch before practice or competition

•  Avoid overloading with excessive weights, which is typically how this tear occurs

•  Allow time for rest and recovery between practices and/or competition

•  Use proper technique