Background

The biceps muscle is a collection of two muscular bodies (one termed ‘short’ and another ‘long’) which join at the elbow to form a single tendon. This tendon crosses the elbow and attaches to the radius bone in a region termed the radial tuberosity. Collectively, the biceps muscle works mainly as an elbow supinator (the motion involved in turning a screw driver or a door knob) and also an elbow flexor.

One of two components of a biceps tendon may rupture. The long head of the biceps tendon can rupture at the shoulder. This most commonly occurs in older individuals and requires no further treatment to achieve a good functional result. Conversely, the tendon may rupture at the elbow. This injury more commonly occurs in younger individuals and commonly requires surgical repair for optimal results. Rarely, the middle of the biceps tendon may rupture. This can occur in any age, and is commonly due to a direct blow to the arm or an object like a rope forcibly rubbing across the arm. No surgery is possible with this injury, and it is managed with splinting followed by gradual range of motion.

 

General Information

At the elbow, the biceps is responsible for 40% of elbow supination strength (i.e. turning a door knob or screw driver) and 20-30% of elbow flexion strength. Once injured, an individual frequently feels that they lose both strength and endurance when performing the above exercises. With time and therapy, we believe the arm can be strengthened to help compensate for the loss of the tendon. It nonetheless remains unclear how much strength deficit will remain if the tendon remains unattached by surgery.

 

Work-Up

Patients are often seen first in either the emergency room or their family physician’s office. For any patient with elbow pain where a fracture has been ruled out, clinical exam will dictate how quickly additional imaging should be considered. If a clinical exam is very highly suggestive of an distal biceps injury, an ultrasound can be quickly arranged to assess for the possibility of a tendon tear. Depending on the results of ultrasound and clinical exam, an MRI may be obtained to confirm the diagnosis. The diagnosis of a distal biceps tendon rupture should prompt an immediate referral to an Orthopaedic surgeon, as any surgery undertaken is best performed within 3-4 weeks of injury.

 

Treatment

Surgery

Your surgeon will present you with the treatment options they feel are relevant to your situation. Many people sustaining distal biceps tendon ruptures are active males that require strength to perform their job or sport. If seen before 3 weeks, surgery remains an option in most individuals. Unfortunately, those presenting after 4 weeks are not eligible for surgical repair, as the biceps has retracted and scarred in too much to allow for it to be repaired.

The purpose of surgery is to reattach the torn tendon back to its insertion on the radial tuberosity. Although there are several techniques, our surgeons utilize a one incision technique with a metallic button. For those interested, the product we use can be found here.

The benefit of surgery is the reattachment of the tendon, and thus the greatest chance at strength recovery. The drawback of surgery relates to the risks of the operation. Your surgeon should detail these risks to you, although a few ones are unique to this surgery.

  1. Several nerves are very close in the surgical site. Many people are left with a patch of numbness over the back of the wrist on the thumb side. Rarely, patients may have a significant motor nerve injury that compromises hand function.
  2. Operations around the elbow may cause heterotopic ossification. In this condition, abnormal bone forms around the elbow leading to stiffness. We prescribe an anti-inflammatory medication to decrease the risk of this complication.
  3. Stiffness: any operation around the elbow has the potential to lead to stiffness and motion loss.
  4. Weakness: re-attachment of the tendon does not guarantee perfect use and strength of the arm. Post-operative physical therapy is key in maximizing function following surgery.

Surgery also requires a brief period of immobilization (2 weeks) and avoiding strengthening exercises for 6 weeks following surgery. This period of time allows the tendon to heal. Following this, gradual strengthening may occur.

Return to work is variable and depends largely on the type of job a person performs.

Non-Surgical Treatment

Therapy alone may be recommended to some patients, while others may chose this treatment over surgery. The benefit of non-surgical treatment is that a person can begin to move and use the arm immediately, with no true restrictions. Pain and arm cramping associated with the tendon tear will gradually improve. With time and therapy, strength will continue to improve. It remains unlikely, however, that someone will regain full strength with therapy alone. This may not be an issue in some circumstances (such as an injury to a non-dominant hand) but should be factored into the decision making.

Patients for whom surgery is not an option, or for those who decide surgery is not for them, can return to work within 1-4 weeks of injury with progressive hours and duties.

 

General Therapy Instructions

Please note: this alone does not constitute as a formal referral to a physical therapy. The following guidelines are for non-operatively treated shoulders. Therapy should be initiated, conducted and monitored by trained professionals.

  • Stage 1 – Motion: The first goal is to achieve and maintain the maximal amount of range of motion possible, ideally back to pre-injury state. Active and active assisted range of motion of the elbow, shoulder, wrist and fingers is started.
  • Stage 2 – Light Strengthening: To start when 80% of expected range of motion is achieved. Recommend starting with light bands and progress to cables and finally free weights. Focus is on low weight with higher repetition.
  • Stage 3 – Strengthening and Conditioning: This stage involves increasing weight to regain pre-injury strength. Exercises are tailored towards job-specific or sport-specific tasks. Care should be taken to maintain proper form and avoid re-injury.
  • Stage 4 – Maintenance: An often forgotten or neglected component of the rehabilitation program. Exercises from Stage 3 should be incorporated into a weekly fitness regimen with the goal of avoiding re-injury.

 

Notable Challenges

  • Post-Operative Pain: Shoulder surgery is painful, especially in the first two weeks following an operation. We utilize a multi-modal pain management strategy to keep a patient comfortable while also decreasing narcotic medication consumption.
  • Shoulder Stiffness and Weakness: Stiffness around the shoulder is to be expected, especially in operatively managed shoulders requiring post-operative immobilization in a sling. It can take upwards of a year to maximize gains in shoulder range of motion and strength. Physical therapy and ongoing exercises are critical for recovery during this time.
  • Complex Regional Pain Syndrome: a challenging adverse pain response associated with some fractures. Requires time, physical therapy and occasionally medications to treat.

 

Summary of Common Treatment/Rehabilitation Pathway