Diagnosis and Management of Biceps Tendon Rupture
Initial Diagnostic Approach
Begin with plain radiographs (minimum 3 views: AP in internal and external rotation, plus axillary or scapular-Y view) to exclude associated fractures, glenohumeral dislocation, and bony Bankart lesions, followed by MRI without contrast as the definitive imaging study. 1, 2
Clinical Presentation
Distal biceps ruptures typically occur in middle-aged males after an eccentric extension load is applied to the elbow, presenting with sudden, sharp, painful tearing sensation in the antecubital region with a palpable defect and proximal migration of the biceps muscle belly 3, 4, 5
Proximal tears (long head of biceps) are more common than distal tears, with partial rupture of the long head with intact short head representing the most common injury pattern 1
Perform the biceps squeeze test and hook test as specific diagnostic maneuvers for distal biceps ruptures 3
Imaging Strategy
MRI without contrast is the gold standard imaging modality with 86.4% accuracy compared to ultrasound's 45.5% accuracy for complete distal biceps tears. 1, 2, 6
Use the FABS (flexion-abduction-supination) view for optimal visualization of the distal biceps tendon on MRI 1, 2, 6, 4, 5
MRI demonstrates superior sensitivity (76%) and specificity (50%) compared to ultrasound and can reliably distinguish partial from complete tears 2
Reserve ultrasound only when MRI is contraindicated, recognizing its significant limitations in detecting partial tears and tendinopathy 1, 2, 6
Consider MR arthrography when distinction between full-thickness and partial-thickness tears remains unclear or for assessing associated pathologies including rotator cuff tears, pulley lesions, and SLAP lesions 2
Management Strategy
Acute Complete Ruptures
Surgical anatomic reinsertion is the treatment of choice for acute complete biceps tendon ruptures in patients who cannot tolerate functional deficits, as nonoperative treatment results in 40% loss of supination strength, 47% loss of supination endurance, and 21-30% loss of flexion strength. 3, 7, 8, 5
Perform early anatomic re-attachment as the primary goal to restore strength and endurance 3, 7
Both single-incision and two-incision techniques with various fixation methods (suture anchors, bone tunnels, endobutton, or biotenodesis screws) demonstrate similarly good clinical outcomes 3, 5
Endobuttons show higher load-to-failure strengths in biomechanical studies, though clinical outcomes remain excellent regardless of fixation method 3
Surgical reinsertion provides consistently good results with high subjective satisfaction, though slight weakness in flexion and supination may persist 7, 5
Partial Ruptures
Initiate conservative treatment initially for partial ruptures, which are significantly less common than complete tears 3
Use MRI (particularly FABS view) to confirm the diagnosis of partial rupture, as this distinction is crucial for management decisions 1, 2, 6, 4
Chronic Ruptures
Chronic tears require reconstructive techniques using tendon grafts (semitendinosus, fascia lata, hamstring, Achilles, or flexor carpi radialis) due to tendon retraction and poor tissue quality. 3, 8
Delayed reconstruction (even up to 4 years post-injury) using autograft or allograft constructs with EndoButton fixation can successfully restore function 8
Primary repair is preferred when possible; augmentation with tendon graft is reserved for cases where native tendon quality precludes anatomical repair 4, 8
Conservative Management
- Reserve nonoperative treatment for older patients or those who can tolerate functional deficits, understanding this results in significant loss of flexion and supination strength and endurance 3, 5
Critical Pitfalls to Avoid
Do not rely solely on ultrasound for diagnosis, as its 45.5% accuracy is inadequate compared to MRI's 86.4% accuracy 1, 2, 6
Do not fail to distinguish between partial and complete tears, as this fundamentally changes management from conservative to surgical 1, 2, 6
Do not delay surgical intervention in acute complete ruptures in active patients, as chronic tears are significantly more difficult to treat and may require complex reconstruction 3, 4, 8
Surgical Complications
Posterior interosseous nerve palsy and symptomatic heterotopic ossification represent the major complications, though meticulous surgical technique can minimize these risks 4, 5
Minor complications are common, but reruptures are rare 4, 5
Heterotopic bone formation around the radial tuberosity occurs in approximately 40% of surgical cases 7
Temporary deep branch radial nerve dysfunction may occur but typically resolves 7