Distal Biceps Tendon Ruptures
A) Rest, NSAIDs and return to lifting as tolerated
B) Referral to orthopedic surgery
C) Hinged elbow sleeve, early ROM and therapy
D) Platelet rich plasma and then physical therapy
Figure 1. Distal Biceps Tendon Anatomy (Adopted from )
On examination, there may be a bulge proximal to the insertion, which is sometimes called a “Reverse Popeye” deformity. There will be asymmetric weakness in supination and elbow flexion when compared to the opposite side. The provider can also isolate the biceps from the supinator by flexing the elbow to 90 degrees with the arm in maximal supination and testing supination strength. The most common special test is the hook test, which has been shown to have a high specificity and sensitivity . The examiner uses their finger to capture the lateral edge of the distal biceps tendon. If the tendon is intact, the examiner should be able to insert the finger roughly one centimeter underneath the tendon .
The biceps crease interval (BCI) is used to assess for biceps rupture by measuring the distance between palpable anatomic landmarks. First, the patient’s elbow is brought from flexion into full extension while supinating the forearm. The main flexion line of the antecubital fossa is marked (Fig. 2). The contour of the distal biceps is lightly palpated back and forth along a line parallel to its long axis to identify the point at which the curve of the distal biceps begins to turn most sharply toward the antecubital fossa (cusp). The cusp is marked with a transverse line.
Figure 2. Demonstration of biceps crease interval (adopted from )
Standard radiographs of the elbow are sometimes done and may show soft tissue swelling and occasionally show a bony avulsion injury, although this is rare. Magnetic resonance imaging (MRI) is sometimes done to characterize the amount of tendon remaining in the setting of a partial biceps tendon tear or to elucidate the amount of retraction present in the setting of a full tear. The FABS (flexed elbow, abducted shoulder and forearm supinated) view is ideal for MRI studies and should be ordered when evaluating this injury . MRI has been reported to be reliable in identifying distal bicep tears with a 100% sensitivity and 82.8% specificity for diagnosis of complete tears and partial tears, respectively .
Figure 4. A shows biceps tendon partial tear on long axis oblique view. B shows the same on short axis anterior view. C shows the an image of the partial tear with radial tuberosity (RT) labeled. D shows the axial MRI image of the same partial tear.
Treatments options depend on severity of injury and nonoperative management may be indicated for partial tears. Nonsurgical management is an option for tendon tears that encompass less than 50 percent of the tendon insertion or in individuals that are not fit for surgical management. Nonoperative management initially focuses on decreasing swelling, inflammation and performing early range of motion exercises. With nonoperative management, a 40% to 50% reduction in supination strength, 30% reduction in flexion strength, and 15% reduction in grip strength can be expected. A discussion with a full understanding of the patient’s activities, comorbidities, activity level, hand dominance, and surgical risk-to-benefit ratio should be performed when making a decision between operative and nonoperative management.
Surgical management is typically recommended for complete ruptures or partial tears encompassing more than 50 percent of the tendon insertion. Surgical reinsertion to the radial tuberosity may be achieved through one or two incisions and with different devices. Timing must be carefully considered, since in case of delayed surgery, the tendon is generally retracted proximally and sometimes it is impossible to bring it back to the radius. Ideally, surgery is performed within three weeks of injury. Moreover, the healing process starts early after injury, and scar tissue may obliterate the original location of the tendon making surgery challenging .
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