What is the appropriate management for a 38-year-old patient with a suspected biceps injury, presenting with a 'pop' sound while doing biceps curls, slight swelling above the acromioclavicular (AC) joint, and intermittent throbbing pain (4/10) radiating to the upper inner biceps?

Suspected Proximal Biceps Tendon Rupture

This 38-year-old patient with an audible "pop" during biceps curls, swelling above the AC joint, and pain radiating along the inner biceps most likely has a proximal biceps tendon injury (likely long head of biceps rupture or tendinopathy), and requires immediate clinical examination for a "Popeye sign" (biceps muscle bunching distally), followed by plain radiographs to exclude bony injury, and MRI if diagnosis remains unclear or surgical repair is being considered. 1

Immediate Clinical Assessment

Key Physical Examination Findings to Document

• Inspect for asymmetry: Look for the pathognomonic "Popeye sign" - visible bunching of the biceps muscle belly in the distal arm, indicating complete rupture of the long head of biceps tendon 1
• Palpate for tenderness: Specifically assess the bicipital groove (anterior shoulder), supraspinatus tendon, and AC joint to localize the injury 1
• Test range of motion: Document passive and active shoulder abduction, external rotation, and elbow flexion/supination strength 1
• Perform provocative maneuvers: Speed's test (resisted forward flexion with elbow extended and forearm supinated) and Yergason's test (resisted supination with elbow flexed at 90°) reproduce biceps tendon pain 1
• Neurovascular examination: Confirm intact sensation, motor function, and distal pulses - the absence of numbness/tingling is reassuring but must be formally documented 2

Critical Historical Details

The "pop" sound during loaded biceps activity is highly suggestive of tendon rupture rather than simple tendinopathy 1. The location "above the AC joint" with radiation down the "inner biceps" (medial aspect) suggests proximal biceps involvement rather than distal biceps rupture, which would present at the elbow 1.

Diagnostic Imaging Algorithm

First-Line: Plain Radiography

Standard shoulder radiographs (AP in internal/external rotation plus axillary or scapular Y view) are mandatory as the initial imaging study to exclude fracture, dislocation, or calcific tendinopathy, even though soft tissue injuries won't be visible 2. This is essential before proceeding to advanced imaging 2.

Advanced Imaging: MRI Without Contrast

If clinical examination suggests complete rupture or if pain persists despite conservative management, MRI without contrast is the preferred advanced imaging modality 2. MRI will:

• Confirm biceps tendon rupture versus partial tear versus severe tendinopathy 2
• Assess for associated rotator cuff pathology (present in >90% of proximal biceps ruptures) 1
• Evaluate for labral tears (SLAP lesions) in younger patients 1
• Identify subacromial bursitis or other shoulder pathology 1

Ultrasound is an acceptable alternative if local expertise is available, particularly for evaluating biceps tendon and rotator cuff pathology 2. However, MRI provides more comprehensive assessment 2.

Management Strategy

For Complete Proximal Biceps Rupture (Most Likely Diagnosis)

Most patients with proximal long head biceps ruptures can be managed conservatively with excellent functional outcomes 1. The treatment approach depends on patient age, activity level, and functional demands:

Conservative Management (Preferred for Most Patients)

• Relative rest: Avoid overhead activities and heavy lifting for 3-6 weeks 1
• Ice application: 15-20 minutes every 2-3 hours during acute phase 1
• Pain control: Acetaminophen up to 4 grams daily as first-line; NSAIDs can be used short-term (7-10 days) for acute pain relief but should not be continued long-term 1, 2
• Early range of motion: Begin gentle pendulum exercises and passive range of motion within first week to prevent stiffness 1
• Progressive strengthening: Start eccentric strengthening exercises at 3-6 weeks, which are the cornerstone of tendon rehabilitation 1

Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with this conservative approach 1.

Surgical Referral Indications

Refer to orthopedic surgery if:

• Young, high-demand athlete or laborer requiring maximal strength 1
• Cosmetic concerns are significant (the "Popeye deformity") 1
• Associated massive rotator cuff tear requiring repair 2
• Failed conservative management after 3-6 months 1

For Partial Tear or Severe Tendinopathy

If imaging shows partial tear or severe tendinopathy without complete rupture:

• Same conservative protocol as above 1
• Consider corticosteroid injection for refractory pain, though use with caution as it may increase rupture risk 1
• Physical therapy focusing on scapular stabilization and rotator cuff strengthening 1

Return to Activity Guidelines

Gradual return to weightlifting should follow a structured progression 1:

1. Weeks 0-3: Rest from biceps-loading exercises; maintain cardiovascular fitness with lower body activities 1
2. Weeks 3-6: Begin isometric biceps exercises and light resistance band work 1
3. Weeks 6-12: Progressive resistance training with eccentric emphasis, starting at 50% pre-injury weight 1
4. After 12 weeks: Return to full weightlifting if pain-free with full strength restoration 1

Critical Pitfalls to Avoid

• Do not assume this is simple muscle soreness: The audible "pop" indicates structural injury requiring formal evaluation 1
• Do not order MRI before plain radiographs: This violates standard imaging protocols and may miss important bony pathology 2
• Do not prescribe NSAIDs long-term: While effective for acute pain, they do not improve long-term outcomes in tendinopathy and carry significant risks 1, 2
• Do not inject corticosteroids into the biceps tendon itself: This increases rupture risk; peritendinous injection only if needed 1
• Do not rush surgical referral: Most proximal biceps ruptures have excellent functional outcomes with conservative management, even with visible deformity 1
• Do not ignore associated rotator cuff pathology: Proximal biceps pathology rarely occurs in isolation in patients over 35 years 2

Follow-Up Plan

• Reassess at 2 weeks: Evaluate pain improvement and range of motion 1
• Reassess at 6 weeks: Should demonstrate significant functional improvement; if not, obtain MRI and consider specialist referral 1
• Final assessment at 3-6 months: Most patients achieve full recovery by this timeframe 1