Rupture Long Head Biceps

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Definition/Description

Rupture of the biceps tendon often occurs after a sudden contraction of the biceps with resistance to flexion and supination of the forearm. Also intrinsic degeneration of the tendon release and frictional wear of the tendon belly may have an impact.This intrinsic degeneration is caused by improper training or fatigue, inordinate stresses can be placed on the biceps as it attempts to compensate for other muscles. This can lead to attrition and failure, either within the tendon substance or at its origin. [1]

The long head of the biceps has several functions like dynamic stabilizer of the glenohumeral joint and a depressor of the humeral head[2]

A00031F01.jpg

Clinically Relevant Anatomy

The M. biceps brachii has 2 parts: The long head and the short head. The long head originates at the tuberculum supraglenoidale scapulae and is attached to the dorsal aspect of the tuberositas radii.[3]

The long head biceps 
starts from the tuberculum subraglenoidale with an intra-articular part. The part passes over the humeral head and then follows the bicipital groove distal to the glenohumeral joint. [4]


There is a strong evidence that the short head is used as more powerful elbow flexor, while the long head is more used as a powerful supinator.[5]

Both parts of the tendon are different in shape. The intra-articular part is wide and flat. The extra-articular part is rounder and smaller. [4]
The articular portion of the Long head Biceps is irrigated by the anterior circumflex artery. [4]
The distal part of LHB is fibrocartilaginous and avascular. The part most vascularized is the proximal tendon. [4]
A soft-tissue stabilizes the extra-articular LHB when it enters the bicipital groove en this is built by fibers of the coracohumeral ligament, superior glenohumeral ligament and parts of the subscapularis tendon.[4]

Epidemiology /Etiology

Biceps rupture mainly occurs in individuals between 40 and 60 years who already have a history of shoulder problems. This often happens due overuse: many tears are the result of a wearing down and fraying of the tendon that occurs slowly over time. It can be worsened by repeating the same shoulder motions again and again. Overuse can cause a range of shoulder problems, including tendonitis, shoulder impingement, and rotator cuff injuries. Having any of these conditions puts more stress on the biceps tendon, making it more likely to weaken or tear. [6] Also younger individuals can have this injury but usually after a traumatic fall on an outstretched arm, heavy weightlifting or consistently sport activities such as snowboarding, soccer, ... [5] [7]
Tendon rupture usually results from sudden contraction of the biceps associated with resisted flexion and supination of the forearm, and a predisposing role is possibly played by intrinsic degeneration of the tendon tissue or frictional wear of the tendon belly. [1]
The dominant arm is involved more commonly, probably because it is used more often than is the nondominant arm. [2]
Long head of biceps tendon rupture occurs in 31%-56% of isolated subscapular tears. [2]
No correlation exists between race and the incidence of biceps rupture. [2]
The chance on a tendon tear of the biceps increases with:
- Age. Older people have put more years of wear and tear on their tendons than younger people. [1]
- Heavy overhead activities. [1]
- Shoulder overuse. [1]
- Smoking. Nicotine use can affect nutrition in the tendon. [1]
- Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness. [1]
- Gender. Men suffer of biceps rupture more commonly than women, but this difference may result primarily from vocational or avocational    factors. [2]

Characteristics/Clinical Presentation

Patients with a long head biceps rupture report a wide variety of symptoms. [7]

Some patients hear a pop at the time of the trauma, others feel a sharp pain in the anterior shoulder. [5] 
This acute pain can be accompanied by snapping sensation [7]
Some patients have a nondescriptive pain while performing overhead activities. [7]
Other patients have a nondescriptive anterior shoulder pain that may get worse at night.[7]
Most LHB pathologies were associated with Rotator Cuff tears of a duration longer then 3 months and an area of 5 cm2. [8]Also shoulder problems like tendonitis or schoulder impingement can cause a rupture of the Long head biceps. [7]

The subscapularis tendon is mostly involved with LHB pathologies.[8]

If there is a rupture of the distal biceps tendon, a Popeye deformity can be seen. [7]

Differential Diagnosis

Acromioclavicular Joint Separations[7]
Gout[7]
Rotator Cuff Disease[7]
Septic Arthritis[7]

Diagnostic Procedures

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Outcome Measures

  • Magnetic resonance imaging (MRI) and ultrasound.

       These studies can create a good image of soft tissues like the biceps tendon. [1]

  • Disabilities of the Arm, Shoulder, and Hand (DASH), Quick DASH [8]
  • Yergasons test : Yergason's Test is considered positive if pain is reproduced in the bicipital groove during the test [2]

Examination

Diagnosis can be based on clinical examination (grades of recommendation:B) , based on:

  • Inspection of the shoulder and arm contour and compare with the contralateral side [2]

   -  the presence of the classic Popeye sign or a less striking descent of the biceps muscle in the middle part of the arm. (more obvious by contracting the muscle ) [3]

  • MRI findings in two planes, axial and parasagittal, is required to diagnose accurate a rupture of the biceps tendon.[9]
  • Constant score: [3]

     - assesses pain, function, ROM, and strength.[5]

     -  Pain is allotted a maximum of 15 points, activities of daily living (function) 20 points, ROM 40 points, and strength 25 points. The           component scores are summated to achieve a maximum possible total score of 100. A maximum score indicates greater shoulder function.[5]

  • Shoulder strength [3] (measured with a MicroFET dynamometer)
  • Flexion strength of the forearm[3](measured with a MicroFET dynamometer)

     -  with the forearm flexed at 90° and the arm adducted to the body, with the hand in full supination

Medical Management

There is no consensus about surgical repair.


  • Generally they do surgery for young, athletic patients or patients who needs maximum supination strength.
-> Patients lose up to 20% of supination strength but there is rarely impact on ADL.
  • Non-operative management is considered appropriate for older patients or patients who do not require a high level of supination strength. [7]

There are anti-inflammatory medications that can be used to reduce the underlying inflammatory process that may predispose tendons to rupture. When tendons may be stressed or partially disrupted, anti-inflammatory medications can provide an analgesic effect.(Grades of recommendation = F) [9]


Physical Therapy Management

  • without surgery:
- we can do mobilizations
- control swelling by cold modalities such as cold packs, ice massage
- against inflammation: NSAIDs except for contraindications
- Preserving ROM:

         - Codman pendulum exercises

         - Functional exercises

  • 
After surgery:
- 10 - 14d: soft sling + light exercises for ROM
- 14d - 6 to 8w: functional exercises using pulleys or therapy bands
- after 6 à 8w: moderate loading may be tolerated but heavy loading is prohibited for the first months.[8] (LoE: 3B)



  1. surgery

Before the doctor decides to operate, he considered about the advantages and disadvantages. In this situation, the activities of the patiënts , the way of living and the age are important. The operation is often carried out by young people or people who have a hard work, like a carpenter, port worker,… etc. These people need a maximal supination strenght. There will also be operated when some people can’t accept the Popeye malformation. The operation trial ( tenotomy) includes the attaching torn tendon to the bone. The results of the other studies shows us that the function of the muscle fully recovers and that the strength can go back like it was before the rupture. They also see a good cosmetic result. [10] (LoE: 3B)

postoperative (tenotomy) rehabilitation [11] (LoE: 5)

phase 1: passive

  • pendulums to warm-up
  • passive ROM

week 1

  • full passive elbow flexion/ extension
  • full passive forearm supination/pronation
  • full passive shoulder ROM
  • seated scapular retractions
  • phase 2: active
  • pendulums to warm-up
  • active ROM, with terminal stretch to prescribed limits


Phase 2: active
week 2

  • full active shoulder ROM, lawn chair progression
  • active elbow flexion/ extension
  • full ROM allowed
  • active forearm supination/pronation
  • full ROM allowed


phase 3: resisted

  • pendulums to warm-up and continue the program

week 3

  • sport cord internal/ external rotation at 30° abduction
  • Prone I,T,Y,W
  • Sport cord standing forward punch
  • Sport cord low rows
  • Sport cord bear hugs
  • Biceps curls
  • Resisted supination/pronation


Phase 4 : weight training
Week 4

  • Keep hands within eyesight, keep elbows bent, minimize overhead activities
  • Return to activities

       -  Computer after 1-2 weeks
       -  Golf after 4 weeks
       -  Tennis after 8 weeks [7] [11] (LoE: 5)



     2.   conservative treatment

Is more used in older patients and who do not need maximal supination strength in their daily life and work. There are some advantages in comparison with the first treatment. Therefore, this treatment is better tolerated and presents fewer complications. The costs are also lower and because there was no operation, the people can get back to work quicker. But with this choice of treatment the strength is 20% lower then before. But it hasn’t have influence at the ADL activities and that maybe is the reason why people hold off an operation. Also doctors recommend this treatment faster when people are afraid or when the injury is too old.
The treatment takes 4-6 weeks 2-3 times in a week. It consists of mobilization and flexibility exercises to improve the shoulder ROM. After that, there are also strength and stretching exercises. The muscle will also be static trained. At home there will be home exercises. The exercises are extension and flexion and supination en pronation exercises. After a period the pain needs to be lower and the strength have to be better. Most people go back to work after 2-3 weeks but the work is adapted. After 8 weeks the ROM and the strength is back to normal. Normally there aren’t anymore restrictions more but the popeye malformation remains. [10] (LoE: 3B)


Nonoperative rehalitation
Phase1: acute phase
Week 1

  • Clinical modalities as needed
  • Glenohumeral ROM

       - apply appropriate joint mobilization to restrictive capsular tissues
       - implement wand stretching as indicated
       - supplement with home program
                 - cross-arm stretch
                 - sleeper stretch
                 -  Early scapular strengthening

        -  begin scapular stabilization with instruction in lower trapezius facilitation


phase 2: subacute phase, early strengthening
Week 2

  • Continue with modalities and ROM.
  • Begin rotator cuff strengthening

        -  sport cord internal/external rotation in 30° abductee
        -  sport cord low rows ( prone, scapular plane abduction (<90°), celling punch, biceps en triceps)


phase 3: advanced strengthening
Week 3

  • continue with strengthening

       - resisted PNF patterns
       - sport cord bear hug
       - sport cord reverse fly
       - sport cord IR/ ER at 90° abduction for neuromuscular re- education
       - push-up progression
       - begin 2- arm plyometric exercises advancing to 1-arm exercises
       - weight training

phase 4: return to activities
week 4

  • continue with program
  • re-evaluation with physician and therapist
  • advance to return-to-sport program, as motion and strength allow [7] (LoE: 5)



Key Research

These are the articles we found most relevant :

  • Elser F, Braun S, 2011, Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon, Arthroscopy (level of evidence = 1A)
  • Chien-Hao Chen, MD; Chih-Hwa Chen, 2012, Classification and analysis of pathology of the long head of the biceps tendon in complete rotator cuff tears, Chang Gung Med J. (level of evidence = 3B)

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References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 GURMINA STEFANO, CARBONE STEFANO, PERUGIA DARIO et al, ‘Rupture of the long head biceps tendon treated with tenodesis to the coracoids process. Results at more than 30 years.’, International orthopaedics, 2011, 35:713-716
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 WARNER JJ, McMAHON PJ, ‘The role of the long head of the biceps brachii in superior stability of the glenohumeral joint.’, J bone joint surg Am, 1995, 77:366-372
  3. 3.0 3.1 3.2 3.3 3.4 SHUNKE M., SCHULTE E., SCHUMACHER, ‘Anatomische atlas Prometheus: Algemene anatomie en bewegingsapparaat., Nederland, Bohn Stafleu Van Loghum, 2005
  4. 4.0 4.1 4.2 4.3 4.4 Elser F, Braun S, 2011, Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon, Arthroscopy (level of evidence = 1A)
  5. 5.0 5.1 5.2 5.3 5.4 QUACH TONY, JAZAYERI REZA, SHERMAN ORRIN H., et al;, ‘Distal biceps tendon injuries. Current treatment options.’, Bulletin of the NYU hospital for joint diseases, 2010, 68 (2):103-111 (level of evidence = 1A)
  6. BICEPS TENDON TEAR AT THE SHOULDER, 2009 may, American academy of Orthopaedic surgeons ( level of evidence = 5)
  7. 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 Biceps rupture: medscape, Gary L Branch, DO Mid-Michigan Orthopedics, Staff Physician, Memorial Healthcare Center. (level of evidence = 5)
  8. 8.0 8.1 8.2 8.3 Chien-Hao Chen, MD; Chih-Hwa Chen, 2012, Classification and analysis of pathology of the long head of the biceps tendon in complete rotator cuff tears, Chang Gung Med J. (level of evidence = 3B)
  9. 9.0 9.1 ZANETTI MARCO, WEISHAUPT DOMINIK, GERBER CHRISTIAN, HODLER JUERG, ‘tendinopathy and rupture of the tendon of the long head of the biceps brachii muscle: evaluation with MR arthrography, AJR, 1998, 170:1557-1561 (level of evidence = 2B)
  10. 10.0 10.1 When is a conservative approach best for proximal biceps tendon rupture?, Sofya Pugach, the journal of family practice, vol 62 nr 3, (level of evidence = 3B)
  11. 11.0 11.1 Krupp, Ryan J., et al. "Long head of the biceps tendon pain: differential diagnosis and treatment." Journal of orthopaedic & sports physical therapy 39.2 (2009): 55-70. (level of evidence: 5)


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