What is the plan of care for a patient with a bicep rupture?

Plan of Care for Bicep Rupture

The management of bicep rupture depends critically on the location (proximal vs. distal) and completeness of the tear, with early surgical repair strongly recommended for distal biceps ruptures in active patients to restore supination strength and elbow flexion, while proximal ruptures can often be managed conservatively.

Initial Diagnostic Approach

Clinical Evaluation

• History: Painful tearing sensation in either the antecubital region (distal) or anterior shoulder (proximal), typically occurring during eccentric contraction of the biceps when unexpected extension force is applied to a flexed arm 1
• Physical examination findings:
  • Distal rupture: Palpable and visible deformity of the distal biceps muscle belly with weakness in flexion and supination; inability to palpate the tendon in the antecubital fossa suggests complete tear 1
  • Proximal rupture: Anterior shoulder pain, tenderness in the bicipital groove, and unusual bulging ("Popeye sign") of the injured biceps 2
• Patient demographics: Most commonly affects dominant extremity of men aged 40-60 years for distal ruptures 1, 3

Imaging Protocol

• Plain radiographs first: Obtain standard views to rule out associated fractures, glenohumeral dislocation, and bony abnormalities; may show hypertrophic bone formation at radial tuberosity in distal ruptures 4, 5, 1
• MRI without contrast: Most accurate imaging modality with 86.4% accuracy for biceps tendon tears, superior to ultrasound (45.5% accuracy) 4, 5, 6
• FABS view for distal biceps: Use flexion-abduction-supination positioning (prone, elbow flexed 90°, shoulder abducted, forearm supinated) for optimal visualization of entire distal tendon 4, 5
• MR arthrography: Consider for post-surgical evaluation or when distinction between full-thickness and partial-thickness tears is unclear, particularly valuable for assessing associated rotator cuff tears, pulley lesions, and SLAP lesions 4

Treatment Algorithm

Distal Biceps Rupture

Complete Tears:

• Early surgical reattachment to radial tuberosity is the treatment of choice for healthy, active persons to restore supination strength (most significant) and elbow flexion strength 1, 3
• Surgical techniques include modified two-incision technique (most widely used) or anterior single-incision approach with radial nerve protection 1
• Suspensory cortical button technique exhibits maximum peak load to failure; suture anchor and interosseous screw techniques yield least displacement 3

Partial Tears:

• Conservative management may be attempted initially with relative rest and oral NSAIDs 5
• MRI is crucial to distinguish partial from complete tears, as ability to palpate tendon in antecubital fossa may indicate partial tearing 6, 1

Chronic Ruptures:

• Surgical reattachment may still benefit patients, though proximal retraction and scarring make mobilization difficult and may necessitate tendon augmentation 1

Proximal Biceps Rupture

• Conservative treatment enables most patients to regain normal strength and is the primary approach 2
• Complete shoulder examination is necessary as injury is often associated with rotator cuff tendinitis 2
• Surgical intervention (tenotomy or tenodesis) has insufficient evidence for routine recommendation 6

Postoperative Rehabilitation for Distal Biceps Repair

Phase 1: Protection Phase (0-6 weeks)

• Protected return of motion for first 8 weeks is mandatory to avoid re-rupture 1
• Gradual restoration of range of motion without placing undue stress on biceps brachii 7
• Focus on strengthening supporting muscles of upper extremity 7

Phase 2: Early Strengthening (6-8 weeks)

• If full active range of motion achieved before 6th week, slow transition into light strengthening may be possible 7
• Formal strengthening may begin as early as 8 weeks postoperatively 1

Phase 3: Return to Activity (3-5 months)

• Return to unrestricted activities, including lifting, by 5 months 1
• Criterion-based progressive rehabilitation with avoidance of premature stress to healing soft tissue 8

Common Pitfalls to Avoid

• Do not rely solely on ultrasound for diagnosis, as it has significant limitations in accuracy (45.5%) compared to MRI (86.4%) 4, 5, 6
• Do not fail to distinguish between partial and complete tears, which requires accurate MRI imaging 5, 6
• Do not delay surgical repair in active patients with complete distal biceps ruptures, as early repair yields optimal results 1, 3
• Do not initiate aggressive strengthening before 6-8 weeks postoperatively to prevent re-rupture 1, 7

Surgical Complications to Monitor

• Sensory and motor neurapraxia 3
• Infection 3
• Heterotopic ossification 3
• Re-rupture (minimized with appropriate rehabilitation timeline) 8