What are the clinical presentation, diagnosis, and treatment options for biceps tendon ruptures?

Biceps Tendon Ruptures: Clinical Presentation, Diagnosis, and Treatment

Early surgical reattachment is strongly recommended for complete distal biceps tendon ruptures to achieve optimal functional outcomes, while partial tears may be managed conservatively with close monitoring. 1, 2

Clinical Presentation

Demographics and Mechanism

• Most common in middle-aged men (40-60 years)
• Typically occurs in the dominant arm
• Usually results from an unexpected extension force applied to a flexed arm
• Often presents with a history of a painful "tearing" or "popping" sensation in the antecubital region 2

Physical Examination Findings

• Visible and palpable deformity of the distal biceps muscle belly ("Popeye" deformity)
• Weakness in elbow flexion and forearm supination
• Ecchymosis in the antecubital fossa
• Tenderness at the anterior elbow

Special Tests

• Hook test: Inability to hook the examiner's finger under the biceps tendon
• Biceps squeeze test: Lack of forearm supination when squeezing the biceps muscle
• Strength testing should compare elbow flexion and forearm supination to the unaffected side 1

Diagnosis

Imaging

1. Plain Radiographs

   • Standard three-view series (AP, lateral, and oblique) should be obtained first
   • May show hypertrophic bone formation at the radial tuberosity
   • Can identify avulsion fractures at tendon attachment sites 1, 2

2. Ultrasound

   • First-line imaging for suspected tendon rupture
   • Non-invasive, readily available, and cost-effective
   • High sensitivity (95%) for distinguishing complete vs. partial tears 1

3. MRI

   • Superior for definitive assessment and identification of tear type
   • Indicated when ultrasound is inconclusive or surgery is being considered
   • The FABS (flexion-abduction-supination) view is particularly helpful for partial or chronic ruptures 1, 3

Treatment Options

Complete Ruptures

• Early surgical reattachment is recommended for optimal functional outcomes
• Surgery should ideally be performed within 2-3 weeks of injury
• Surgical approaches:
  1. Modified two-incision technique (most widely used)
  2. Anterior single-incision technique (equally effective if radial nerve is protected)
  3. Fixation methods include suspensory cortical button, suture anchors, or interosseous screws 2, 4

Partial Ruptures

• Conservative management for tears <50%:
  • Rest, brief immobilization, elevation
  • NSAIDs and acetaminophen for pain management (limited opioid use only if necessary)
  • Regular follow-up to monitor progress
• Surgical treatment for tears >50% (similar to complete tears) 1

Chronic Ruptures

• Surgical reattachment may still be beneficial
• Challenges include:
  • Proximal retraction and scarring of muscle belly
  • Inadequate tendon length may require augmentation
  • Reconstruction using allograft or autograft when primary repair isn't possible 2, 5

Postoperative Rehabilitation

Early Phase (0-8 weeks)

• Protected range of motion exercises should begin early to prevent stiffness
• Avoid prolonged immobilization
• Gradual progressive strengthening exercises should start after 1-2 weeks 1

Late Phase (8+ weeks)

• Formal strengthening may begin at 8 weeks
• Return to unrestricted activities, including lifting, by 5 months
• Supervised physical therapy is recommended for optimal functional outcomes 2

Potential Complications

Surgical Complications

• Sensory and motor neurapraxia (particularly posterior interosseous nerve palsy)
• Infection
• Heterotopic ossification
• Radioulnar synostosis (can be minimized with meticulous surgical technique) 4, 3

Non-Surgical Complications

• Permanent weakness in elbow flexion and forearm supination
• Cosmetic deformity
• Chronic pain
• Delayed diagnosis may lead to suboptimal outcomes 1

Important Considerations

• Conservative treatment results in significant loss of supination strength (up to 40%) and flexion strength (up to 30%)
• Surgical repair is superior to conservative management for active individuals
• Delaying diagnosis and appropriate treatment may lead to suboptimal outcomes 1, 4
• Watch for signs of compartment syndrome (pain out of proportion to injury, pain with passive stretching, paresthesia, pallor, pulselessness) 1