Orthopaedic Surgery - Biceps Tendon Rupture

Basics

The biceps tendon may rupture either proximally near the shoulder or distally near the elbow.

Most biceps tendon ruptures occur proximally.

At the shoulder, the long head of the biceps contributes to stabilization and depression of the humeral head. Distally, the biceps is the principal supinator of the forearm and also contributes significantly to elbow flexion.

Epidemiology

Biceps tendon rupture occurs most commonly in men between 40 and 60 years of age.

The dominant upper extremity is affected more frequently.

Although the condition is classically seen in middle-aged adults, rupture can also occur in younger athletes. In younger individuals, a history of anabolic steroid use should be considered because steroid exposure may weaken tendon structure.

Risk Factors

Important risk factors include male sex, age between 40 and 60 years, tendon degeneration, and anabolic steroid use.

For proximal ruptures, associated rotator cuff impingement or rotator cuff disease increases the risk of tendon failure.

For distal ruptures, chronic degenerative changes within the tendon predispose it to avulsion during a sudden high-load eccentric contraction.

Pathophysiology

Most biceps tendon ruptures occur through a background of degenerative tendon change.

This degeneration may be symptomatic or may remain clinically silent until rupture occurs.

In the proximal tendon, degeneration may result from reduced vascularity or chronic mechanical impingement beneath the coracoacromial arch.

Distal Tendon Pathophysiology

The distal biceps tendon commonly fails near its attachment to the radial tuberosity.

A degenerated tendon may avulse when subjected to a sudden and powerful eccentric force, particularly when the elbow is flexed and the muscle is attempting to contract against resistance.

This mechanism is often seen when a person suddenly tries to hold or lower a heavy object.

Associated Conditions

Biceps tendon rupture is commonly associated with rotator cuff disease, particularly when the rupture is proximal.

The presence of associated shoulder pathology should therefore be assessed during evaluation.

Diagnosis

Signs and Symptoms

Symptoms depend on whether the rupture is proximal or distal.

A sudden tearing sensation may be followed by pain, bruising, swelling, weakness, and visible change in the contour of the biceps muscle.

History in Proximal Rupture

Patients with a proximal biceps tendon rupture may complain of pain in the anterior shoulder, upper arm, or antecubital region.

Pain may be acute initially but can improve relatively quickly.

Some patients primarily notice a change in arm appearance rather than major functional loss.

History in Distal Rupture

Patients with a distal rupture commonly report antecubital pain together with weakness during forearm supination or elbow flexion.

The injury often follows a clear history of a sudden heavy eccentric load applied to a contracting biceps muscle.

Patients may describe a pop or tearing sensation at the time of injury.

Physical Examination

Proximal Rupture

Proximal tears may produce bruising and swelling around the shoulder, arm, or antecubital fossa.

The biceps muscle belly may retract distally, creating an abnormal contour of the arm.

This can produce the characteristic “Popeye” deformity.

Distal Rupture

With a distal tendon rupture, the biceps muscle belly retracts proximally toward the shoulder.

The normal tendon may no longer be palpable in the antecubital fossa.

A clearly absent distal tendon strongly suggests a complete distal rupture.

Strength Testing

Weakness may be present with both elbow flexion and forearm supination.

The loss of strength is usually more clinically significant after a distal rupture because the distal biceps plays a major role in supination.

Pain during resisted flexion or supination may occur in partial tears.

Popeye Sign

The Popeye sign describes visible bunching or distortion of the biceps muscle belly after tendon rupture.

It is more classically associated with proximal long-head biceps rupture, although changes in muscle contour may also occur with distal injury.

The location of muscle retraction helps distinguish proximal from distal rupture.

Imaging

MRI

MRI is the most useful imaging study when the diagnosis is uncertain or when the extent of injury must be defined.

It can identify complete or partial tendon disruption, tendon retraction, associated rotator cuff pathology, and surrounding soft-tissue injury.

MRI is particularly useful for planning surgery in distal ruptures or symptomatic partial tears.

Differential Diagnosis

Important differential diagnoses include rotator cuff impingement and rotator cuff tear.

Other causes of shoulder or antecubital pain should also be considered when the examination does not clearly demonstrate tendon rupture.

Treatment

General Principles

Management depends primarily on whether the rupture is proximal or distal, as well as the patient’s age, activity level, functional demands, cosmetic concerns, and associated pathology.

Proximal ruptures are often successfully treated nonoperatively.

Distal ruptures are more commonly treated surgically because untreated injury can result in meaningful loss of strength.

Proximal Biceps Tendon Rupture

Initial treatment of an isolated proximal rupture is usually nonoperative.

Many affected patients are older than 40 years and experience only modest weakness or functional limitation.

Pain often settles with conservative care, and many patients adapt well to the cosmetic deformity.

Candidates for Surgery After Proximal Rupture

Surgical treatment may be considered in patients who are younger, highly active, athletic, concerned about the appearance of the arm, or seeking maximal restoration of function.

Persistent cramping or pain may also support operative treatment.

Distal Biceps Tendon Rupture

For complete distal ruptures, surgical repair generally provides the best functional outcome, particularly in active patients.

Because the distal biceps is an important supinator, nonoperative treatment can result in persistent weakness, especially during activities requiring forceful supination.

Partial Distal Rupture

Partial distal biceps tears may initially be treated nonoperatively when symptoms are mild.

However, persistent pain or weakness despite conservative management may require surgical treatment.

Operative management may involve completing the partial release and then repairing the tendon back to the radial tuberosity.

Nonoperative Management

Conservative treatment includes rest, activity modification, analgesia, and gradual rehabilitation.

During the acute phase, the arm should be rested until pain and swelling decrease.

Gentle range-of-motion exercises can then begin.

Activity is gradually advanced as tolerated.

Physical Therapy

Physical therapy focuses initially on maintaining comfortable shoulder, elbow, and forearm motion.

As pain improves, strengthening can be introduced progressively.

In nonoperatively treated patients, rehabilitation aims to maximize the function of remaining muscles and compensate for any persistent weakness.

Medication

NSAIDs and acetaminophen may be used during the acute phase for pain relief.

Medication should be combined with rest and gradual restoration of function.

Surgical Management of Proximal Rupture

For selected proximal ruptures, the biceps tendon may be treated with tenodesis.

In this procedure, the tendon is fixed to the humerus to restore a more normal muscle contour and reduce cramping or discomfort.

Tenodesis is often performed mainly for functional or cosmetic reasons.

Proximal Rupture With Rotator Cuff Disease

When a proximal biceps rupture occurs together with significant rotator cuff or impingement pathology, surgery may address both conditions.

Procedures may include biceps tenodesis together with treatment of rotator cuff disease, and in selected cases acromioplasty may also be performed.

Surgical Management of Distal Rupture

Distal biceps repair involves reattaching the tendon to the radial tuberosity.

This can be performed through a single anterior incision or through a two-incision muscle-splitting approach.

The objective is to restore the normal insertion and regain elbow flexion and forearm supination strength.

Surgery for Symptomatic Partial Tears

A symptomatic partial distal tear may be treated surgically when pain or weakness persists.

The damaged tendon may be released and then formally reattached to the radial tuberosity.

This can improve both pain and function in appropriately selected patients.

Follow-Up

Follow-up should assess pain, swelling, range of motion, strength, and restoration of functional use of the arm.

Patients treated surgically require progressive rehabilitation according to tendon healing and the repair technique used.

Strengthening should be advanced carefully to protect the repair.

Prognosis

Patients undergoing successful surgical repair of a distal biceps rupture can generally expect a near-complete return of flexion and supination strength.

Outcome is typically best when repair is performed before substantial chronic retraction or scarring develops.

Prognosis After Proximal Tenodesis

Patients undergoing tenodesis for a proximal rupture can generally expect good pain relief and improvement in arm contour.

The procedure also helps reduce the prominence of the Popeye deformity.

Complications of Nonoperative Treatment

Without surgery, some patients may continue to experience activity-related pain, cramping, or weakness.

This is usually more clinically important after distal rupture than proximal rupture.

Loss of Supination Strength

The most important functional deficit after an untreated distal biceps rupture is reduced forearm supination strength.

Patients may notice difficulty with activities such as turning a screwdriver, opening a jar, using tools, or performing repetitive lifting with the palm facing upward.

Elbow flexion strength may also decrease, but the loss is generally less pronounced because other muscles can assist with flexion.

Patient Monitoring

Patients should be monitored for recovery of pain-free motion, strength, and functional use of the extremity.

Persistent weakness, ongoing pain, or difficulty with supination should prompt reassessment, particularly in patients with suspected distal rupture or symptomatic partial tendon injury.