Distal Biceps Tendon Tear: Causes, Symptoms, and Treatment
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 .
– Read More: https://wikism.org/Distal_Biceps_Tendon_Injury
- Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002 Nov;404:275-83.
- Kelly MP, Perkinson SG, Ablove RH, Tyeking JL. Distal biceps tendon ruptures: an epidemiological analysis using a large population database. Am J Sports Med. 2015;43(8):2012e2017.
- van den Bekerom MPJ, Kodde IF, Aster A, Bleys RLAW, Eygendaal D. Clinical relevance of distal biceps insertional and footprint anatomy. Knee Surg Sports Traumatol Arthrosc. 2016 Jul;24(7):2300-7. Epub 2014 Sep 18.
- Seiler JG 3rd, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA. The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg. 1995 May-Jun;4 (3):149-56.
- O’Driscoll SW, Goncalves LBJ, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007 Nov;35(11):1865-9. Epub 2007 Aug 8.
- Devereaux MW, ElMaraghy AW. Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: a nuanced approach to the clinical examination. Am J Sports Med. 2013 Sep;41(9):1998-2004. doi: 10.1177/0363546513493383. Epub 2013 Jun 26. PMID: 23804587.
- Smith, Matthew V., et al. “Comprehensive review of the elbow physical examination.” JAAOS-Journal of the American Academy of Orthopaedic Surgeons 26.19 (2018): 678-687.
- Devereaux MW, ElMaraghy AW: Improving the rapid and reliable diagnosis of complete distal biceps tendon rupture: A nuanced approach to the clinical examination. Am J Sports Med 2013;41:1998-2004.
- Tagliafico A, Michaud J, Capaccio E, Derchi L, Martinoli C. Ultrasound demonstration of distal biceps tendon bifurcation: normal and abnormal findings. Eur Radiol. 2010;20:202–8.
- Festa, Anthony, et al. “Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture.” The Journal of hand surgery 35.1 (2010): 77-83.
- Lobo, Lucas Da Gama, et al. “The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings.” American Journal of Roentgenology 200.1 (2013): 158-162.
- Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. 1985 Mar;67 (3):418-21.
- Freeman CR, McCormick KR, Mahoney D, Baratz M, Lubahn JD. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Joint Surg Am. 2009 Oct;91(10):2329-34.
- Barker SL, Bell SN, Connell D, Coghlan JA. Ultrasound-guided platelet-rich plasma injection for distal biceps tendinopathy. Should Elb. 2015;7(2):110–4.
- Sanli I, Morgan B, van Tilborg F, Funk L, Gosens T. Single injection of platelet-rich plasma (PRP) for the treatment of refractory distal biceps tendonitis: long-term results of a prospective multicenter cohort study. Knee Surg Sports Traumatol Arthrosc. 2016;24(7):2308–12
- Cerciello S, Visonà E, Corona K, Ribeiro Filho PR, Carbone S. The Treatment of Distal Biceps Ruptures: An Overview. Joints. 2019;6(4):228-231. Published 2019 Oct 11. doi:10.1055/s-0039-1697615
- Srinivasan, Ramesh C., William C. Pederson, and Bernard F. Morrey. “Distal biceps tendon repair and reconstruction.” The Journal of hand surgery 45.1 (2020): 48-56