PT Tip of the Month
Bicep Tendon Ruptures at the Elbow
The biceps is a "Y" shaped muscle, which has two attachments in the shoulder and one attachment at the elbow. At the shoulder, the long head of the biceps attaches to the bottom of the glenoid fossa (shoulder socket), while the short head attaches to the coracoid process, a bony protrusion on the front of the shoulder blade. With these attachments, the biceps can assist other muscles with reaching the arm overhead. Its lower (distal) attachment, below the elbow, attaches with one tendon to the radius of the forearm. This attachment allows for the elbow to bend and for the forearm to turn palm up.
Injury to the Biceps
Biceps tears can occur at either end of the attachment - the shoulder or the elbow. As there are two attachments in the shoulder, the long head, which attaches to the glenoid, is more vulnerable to injury as it travels through the shoulder joint. The short head rarely tears. Because of this second attachment, many people can still use the biceps muscle, even after a complete tear of the long head. Distally (at the lower attachment at the elbow), the story changes. When a full tear at the elbow occurs, the muscle is no longer functional as it only has one lower attachment. In most cases, tears to the distal biceps tendon are complete tears. Fortunately, due to the large number of muscles that assist in elbow motion, when this tendon ruptures other muscles can substitute. This generally allows for full motion and reasonable function. If not repaired, the arm can be left with a 30%-40% decrease in strength, particularly with turning the palm upward (supination).
In many cases, distal biceps tendon rupture is a sudden injury, as opposed to an overuse or chronic injury, which is common for the long head of the biceps in the shoulder. Injuries to the biceps tendon at the elbow occur when the elbow is forced to straighten against resistance. For example, if you were to lift a heavy box and struggled to keep your arms bent due to the heavy weight, the stress on your biceps would increase and the tendon can tear away from the bone.
Ruptures of the biceps tendon at the elbow are relatively uncommon, with one or two people per 100,000 sustaining this injury per year. This injury is rare in women and more commonly affects men over the age of 30 years old. Rupture is equally likely in the dominant and non-dominant arm. Additional risk factors include smoking, as nicotine can affect tendon health, and corticosteroids, as the use of steroids has been linked to increased muscle tissue and tendon weakness.
As the injury is often a sudden occurrence, a "pop" can be felt or heard at the front of the elbow. The tendon then recoils into the upper arm causing a bulge, which is known as a "Popeye's deformity." A gap in the front of the elbow can be seen, due to the absence of the tendon. Initially pain can be severe, but frequently subsides after one to two weeks. Other acute symptoms include swelling in the front of the forearm with visible bruising. Weakness with bending the elbow or turning the palm upward is often noted.
Because the tendon recoils into the upper arm, surgery is the only option to repair the tendon. In some cases, surgery may not be considered for patients who are elderly, inactive, or have medical problems that put them at high risk of complications for surgery. For those who do not receive surgery, full motion and function is obtainable, however the elbow may be 30%-40% weaker than the other side.
For those interested in surgery, the tendon should be repaired within the first few weeks after the injury. If left for a prolonged period, the muscle will begin to scar and shorten, making it unable for the surgeon to stretch it back down to the elbow and secure the tendon to the bone.
After surgery the arm is immobilized in a cast or splint to allow the tendon to heal back to the bone. Eventually, your surgeon will refer you to physical therapy and allow for gradual and gentle movement of the arm to help restore full range of motion. After a number of weeks, resistance exercises can gradually be added to your routine to regain strength. Exercises frequently include the shoulder, elbow, and forearm as the biceps muscle effects movement at all three of these locations. Heavy lifting and vigorous activity should be avoided for several months as it takes two to three months for the biceps tendon to fully heal. Although it may feel like a slow progress, most patients regain full motion and strength and return to heavy activities or manual labor is a reasonable expectation.
If you have sustained a bicep tendon rupture and you would like to schedule an evaluation, call 617-232-PAIN for our Brookline office, and 617-325-PAIN for our West Roxbury office.
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