Biceps tendon (rupture of long head)

The long head of the biceps may rupture near to it's scapular origin in older patients, over the age of 50 years, following quite minimal trauma.

Typically, the patient reports that they heard something "snap" in the shoulder whilst lifting. Often, the shoulder aches and the upper arm is bruised. Characteristically, flexion of the arm at the elbow produces a firm lump in the lower part of the arm - this is the unopposed contracted muscle belly of the biceps

• long head of biceps may rupture due to sudden loading (which may be painful and associated with an audible pop) or may occur asymptomatically and painlessly
  • examination may reveal bruising over the proximal anterior arm
    • there may be an obvious swelling in the arm caused by the contracted biceps muscle ('Popeye sign') which does not move with supination
      • click here for image of Popeye sign
        
        
    • Ludington's test (hands clasped behind the head and the biceps muscles flexed) is useful to look for asymmetry in muscle bulk between both biceps
      • click here for video of Luddington's test
        
    • may be tenderness on palpation along the course of the biceps tendon and muscle belly, including the bicipital groove, with the arm placed in 5-10º of internal rotation
      
      
    • assess power of the upper limb and range of movement (ROM) of the shoulder and elbow
      
      
    • proximal biceps rupture results in approximately 20% forearm flexion loss but more significant loss of forearm supination
      
      
    • distal biceps rupture (at the tendon insertion) is rare, occurring in sports such as weightlifting, and always requires urgent surgical referral for repair.

Investigation

• most cases, proximal and distal ruptures can be detected on the basis of history and physical examination alone
• plain x-rays may reveal hypertrophic spurring or bony irregularities that increase the risk of rupture and so support a clinical diagnosis
• ultrasonography and MRI of the anterior shoulder may also be useful in confirming the diagnosis, as they will show an absence of the tendon in the bicipital groove.

Management

• management of proximal biceps rupture is dependent upon the individual clinical case.
  • if painful, the initial management should be the standard RICE (rest, ice, compression and elevation) approach combined with physiotherapy when the acute swelling has settled
    • often an isolated injury does not need to be treated. The function of the biceps is generally good as the short head continues to function and in time, hypertrophies, and the soft tissue swelling will gradually subside
      • in elderly patients with a proximal biceps rupture a conservative approach can be adopted as most will become asymptomatic after 4-6 weeks
    • however, ruptures which occur as part of a rotator cuff lesion and those in young, active patients, may be candidates for surgical repair e.g. anterior acromioplasty. At the same time, the distal stump of the tendon can be sutured to the bicipital groove

Reference:

1. Arthritis Research UK (2011). Hands On (9) - gout: presentation and management in primary care.