Ortho Case: Bicep Tendon Rupture

Author: David Han, MD

Editor: Victor Huang, MD

 
 

Introduction:

Spectrum of Disorders Affecting the Biceps:

  • Tendinopathy

  • Complete Tendon Rupture

    • Most common: Proximal at long head

    • can occur distally (around 10%)

  • Pain can be localized to shoulder

  • Often associated with other shoulder pathology

    • Subacromial impingement

    • Stenosis of bicipital groove

    • Rotator cuff tears

  • Common in weightlifters, rock climbers

    • Pulling, lifting, reaching, throwing motions

Pathology and Anatomy:

  • Tendinosis: Chronic overuse —> Degeneration of collagen

  • Course of the tendon itself primarily extends from the glenoid rim as a rope-like structure coursing over the head of the humerus, and then into the intertubercular groove of the humerus, where it is reinforced by a covering of thick fascia.

  • Biceps - functions

    • Shoulder flexion, elbow flexion, forearm supination

The biceps brachii muscle has two heads, one from the coracoid process (short head) and the other from the supraglenoid tubercle of the scapula (long head biceps). The majority of biceps rupture involves the long head.

Long head biceps tendon (LHBT)

  • Three clinically relevant zones

    • Inside: superior labrum and biceps anchor

      • Anchor is proximal attachment site, usually supraglenoid tubercle

    • Junction: intra-articular portion of LHBT and pulley

    • Tunnel: includes extra-articular portion

  • Presents as the classic “Popeye deformity”

 Short head of biceps tendon

  • Originates at coracoid process, with coracobrachialis

    • Medial to long head

  • Typically less susceptible to injury or tendinosis

Anatomy of Biceps Brachii

Diagnosis:

Physical Exam:

Long Head Biceps Tendon Rupture

  • Proximal arm swelling/ecchymosis

  • “Popeye” sign

  • Point tenderness in palpation over biceps tendon or at bicipital groove (tendinopathy)

    • Identifying greater tubercle of humerus -> moving fingers medially into bicipital groove

    • External rotation ~30 degrees

    • Elbow flexed at 90 degrees

    • Flexion/extension to appreciate pain/crepitus

  • Speed’s and Yergason’s Tests

Ultrasound:

Musculoskeletal Ultrasound:

  • High Sensitivity and Specificity

  • LHBT can be assessed, tightly packed hyperechoic fibrillar pattern.

  • Pathology: hypoechoic, partial -> disruptions

  • Focal areas of tendon discontinuity or abnormal blood flow

“Popeye” Sign

Biceps tendon located in bicipital groove

Treatment:

Referral to Orthopedics

Proximal: Based on level of function at baseline and personal preferences

  • Sports

  • Occupational

  • Cosmetic

  • Secondary injuries (SLAP: superior labral tear)

Distal: referral ASAP

  • Can be treated conservatively with good results

  • Generally expedited surgical referral warranted

 
 

References

  • Harwood MI, Smith CT. Superior labrum, anterior-posterior lesions and biceps injuries: diagnostic and treatment considerations. Prim Care 2004; 31:831.

  • Gill HS, El Rassi G, Bahk MS, et al. Physical examination for partial tears of the biceps tendon. Am J Sports Med 2007; 35:1334.

  • Accuracy of preoperative MRI in the diagnosis of disorders of the long head of the biceps tendon. Malavolta EA, Assunção JH, Guglielmetti CL, de Souza FF, Gracitelli ME, Ferreira Neto Eur J Radiol. 2015;84(11):2250. Epub 2015 Jul 29.

  • https://www.orthobullets.com/shoulder-and-elbow/3045/biceps-tendonitis

  • https://www.uptodate.com/contents/biceps-tendinopathy-and-tendon-rupture?search=biceps%20tendon%20rupture&source=search_result&selectedTitle=1~20&usage_type=default&display_rank=1#H1

 
Booth EM