What is the recommended treatment for a patient with an atraumatic biceps tendon rupture?

Atraumatic Biceps Tendon Rupture: Treatment Recommendations

Immediate Recommendation

For atraumatic biceps tendon ruptures, initial non-operative management with relative rest, NSAIDs, and physical therapy is the recommended first-line approach, as these injuries are primarily degenerative rather than inflammatory and respond well to conservative treatment. 1, 2

Understanding the Pathophysiology

Atraumatic biceps tendon ruptures differ fundamentally from traumatic injuries:

• These are degenerative conditions, not inflammatory, and should be labeled as "tendinopathy" or "tendinosus" rather than "tendonitis" 3
• Atraumatic ruptures involve the long head in 89% of cases, whereas traumatic ruptures more commonly involve the short head 1
• The underlying pathology involves hypoxic tendon degeneration in relatively hypovascular areas proximal to the tendon insertion 3

Initial Conservative Management Protocol

Begin with a structured non-operative approach for 3-6 months:

Relative Rest

• Continue activities that do not worsen pain, but avoid complete immobilization to prevent muscular atrophy 3
• No clear evidence-based duration exists, but most patients recover within 3-6 months 3

Cryotherapy

• Apply ice through a wet towel for 10-minute periods for acute pain relief 3
• Reduces tissue metabolism and may decrease swelling 3

Eccentric Strengthening Exercises

• This is critical: Eccentric exercises stimulate collagen production and guide normal alignment of newly formed collagen fibers 3
• Proven beneficial in tendinopathies and should be incorporated early 3

Pain Management

• NSAIDs are effective for acute pain relief but cannot be recommended over other analgesics for long-term use 3
• Topical NSAIDs eliminate gastrointestinal hemorrhage risk while providing pain relief 3

Role of Corticosteroid Injections

Use peritendinous corticosteroid injections with caution:

• May provide better acute pain relief than oral NSAIDs 3
• Do not alter long-term outcomes 3
• Potential deleterious effects when injected into tendon substance 3
• Optimal drugs, dosages, and intervals remain unknown 3

When to Consider Surgical Intervention

Surgery should be reserved for patients who fail conservative therapy after 3-6 months:

• Approximately 80% of patients fully recover with conservative treatment 3
• For proximal long head ruptures (most common in atraumatic cases): Non-operative management provides adequate results 2
• Delayed repair up to 4 months does not adversely affect outcomes, so immediate surgery is not required 2

Surgical Considerations for Specific Scenarios

Distal biceps ruptures (less common in atraumatic cases):

• Conservative management results in 30-40% reduction in flexion power and >50% reduction in supination power 4
• Anatomic reinsertion reduces supination power loss to 0-25% 4
• Early surgical reattachment provides consistently good results and restores strength and endurance 5

Proximal long head ruptures:

• Loss of flexion/supination power amounts to 8-21% with conservative treatment 4
• Refixation offers small but evident improvement in power and endurance 4
• Surgery reduces cases with remaining weakness by >50% 4

Diagnostic Confirmation

Before finalizing treatment, confirm diagnosis with imaging:

• Plain radiographs first to rule out fractures or bony abnormalities 1, 6
• MRI without contrast is superior (86.4% accuracy vs 45.5% for ultrasound) for distinguishing partial from complete tears 1, 6
• FABS view recommended for optimal biceps tendon visualization 1, 6

Common Pitfalls to Avoid

• Do not assume inflammation: These are degenerative conditions requiring different management than inflammatory tendonitis 3
• Do not rush to surgery: This is not an emergent condition, and 80% recover with conservative treatment 3, 2
• Do not rely solely on ultrasound: MRI is significantly more accurate for diagnosis 1, 6
• Do not inject corticosteroids into tendon substance: Use peritendinous approach only and with caution 3
• Do not completely immobilize: Tensile loading stimulates proper collagen healing 3

Treatment Algorithm

1. Confirm diagnosis with plain radiographs followed by MRI 1, 6
2. Initiate conservative management: relative rest, ice, eccentric exercises, NSAIDs for pain 3, 2
3. Continue for 3-6 months with progressive rehabilitation 3
4. Reserve surgery for failed conservative therapy after this period 3
5. Consider patient factors: Young, active patients may benefit more from surgical intervention if conservative treatment fails 7, 4