What is the management of biceps tendon rupture, from presentation in a low-resource setting to follow-up at a tertiary care center and complete resolution?

From the Guidelines

Management of biceps tendon rupture begins with prompt recognition of the injury, which typically presents as sudden pain in the anterior shoulder or elbow, often accompanied by an audible "pop," weakness, and visible deformity such as the "Popeye sign" for proximal ruptures. In a low-resource setting, initial management includes rest, ice, compression, and elevation (RICE), along with pain control using NSAIDs like ibuprofen 400-600mg three times daily or naproxen 500mg twice daily 1. Immobilization with a sling for proximal ruptures or a posterior splint at 90 degrees for distal ruptures is recommended for 1-2 weeks. For most proximal biceps tendon ruptures, especially in older or less active patients, non-operative management is appropriate and yields good functional outcomes. However, distal biceps ruptures generally require surgical repair to restore strength, particularly in younger, active patients. At a tertiary care center, surgical options include anatomic reattachment using techniques like suture anchors or bone tunnels, ideally performed within 2-3 weeks of injury for optimal outcomes 1. Post-operative rehabilitation involves protected range of motion for 6 weeks, followed by progressive strengthening for 3-4 months. Complete resolution typically occurs within 4-6 months, with return to full activities including sports. The management approach balances the patient's age, activity level, and functional demands with available resources, recognizing that even with non-operative management, patients typically retain about 80% of supination strength and 90% of elbow flexion strength. Some key points to consider in the management of biceps tendon rupture include:

• The use of MRI in the assessment of biceps tears, which has an improved sensitivity for the detection of partial tears of the biceps and triceps tendons 1.
• The use of US to evaluate the distal biceps tendon, which can be an alternative to MRI in the evaluation of distal biceps tendon ruptures 1.
• The importance of relative rest and eccentric strengthening exercises in the treatment of overuse tendinopathies 1. The most recent and highest quality study 1 supports the use of MRI in the assessment of biceps tears and highlights the importance of prompt recognition and management of biceps tendon rupture to optimize outcomes.

From the Research

Management of Biceps Tendon Rupture

• The management of biceps tendon rupture involves both operative and nonoperative treatment options, with surgical repair resulting in excellent outcomes, particularly in terms of elbow and forearm strength and endurance 2.
• A systematic review and meta-analysis found that operative management was associated with significantly higher flexion strength, supination strength, flexion endurance, and supination endurance, as well as superior patient-reported outcomes, including Disabilities of the Arm, Shoulder and Hand (DASH) and Mayo Elbow Performance Score (MEPS) 2.

Presentation and Diagnosis

• Distal biceps tendon ruptures typically occur in the dominant arm of men in their fourth decade of life, resulting in weakness and deformity 3, 4.
• Diagnosis is often based on clinical presentation, with imaging studies such as MRI or ultrasound used to confirm the diagnosis.

Treatment Options

• Surgical repair is a common treatment option for distal biceps tendon ruptures, with various techniques and fixation methods available, including limited anterior incision, extensile anterior incision, and double incision, as well as different fixation methods such as suture anchors and cortical buttons 3, 5.
• Nonoperative management is also an option, although it may result in persistent weakness and deformity.

Complications and Outcomes

• Complications after distal biceps tendon repair can occur, including major complications such as posterior interosseous nerve injury, median nerve injury, and rerupture, as well as minor complications such as lateral cutaneous nerve injury and superficial radial nerve injury 3.
• Patient-reported outcomes, including DASH and MEPS, are generally superior after surgical repair, with most patients achieving good or excellent results 2, 6.

Rehabilitation and Return to Sport

• Rehabilitation after distal biceps tendon repair typically involves a period of immobilization followed by strengthening and range of motion exercises 5.
• Athletes who undergo surgical repair for distal biceps tendon rupture can expect a high return to sport rate, with earlier return to sport associated with nondominant-side injuries, acute injuries, and certain surgical techniques such as double-incision approach and cortical button fixation 5.

Low Resource Setting and Tertiary Care Center

• In a low resource setting, treatment options may be limited, and nonoperative management may be more common due to lack of access to surgical facilities and expertise.
• In a tertiary care center, surgical repair is often available, and patients can expect to receive high-quality care and rehabilitation, with a focus on achieving optimal outcomes and return to function.