Biceps tendon rupture

Background

• Vast majority are proximal
• Occurs with sudden or prolonged contraction in patient with chronic bicipital tenosynovitis

Clinical Features

• Snap or pop is described
• Flexion of elbow elicits pain
• May produce mid-arm "ball" but difficult in obese patients
• Proximal
  • Swelling and tenderness over bicipital groove
  • Loss of strength is minimal due to intact short head inserting at corocoid process
• Distal
  • Swelling and tenderness over antecubital fossa
  • Inability to palpate distal biceps tendon in antecubital fossa
  • Hook test (~100% sensitive and specific, as compared to MRI which is 92% and 85%, respectively)
    • Patient actively supinates and flexes elbow to 90 degrees
    • Hook the distal biceps tendon insertion at radial head to evaluate whether intact

Hook test

Differential Diagnosis

Elbow Diagnoses

Radiograph-Positive

• Radial head fracture
  • Essex-Lopresti fracture
• Capitellum fracture
• Olecranon fracture
• Elbow dislocation

Radiograph-Negative

• Lateral epicondylitis
• Medial epicondylitis
• Olecranon bursitis (nonseptic)
• Septic bursitis
• Biceps tendon rupture/dislocation

Pediatric

• Nursemaid's elbow
• Supracondylar fracture
• Lateral epicondyle fracture
• Medial epicondyle fracture
• Olecranon fracture
• Radial head fracture
• Salter-Harris fractures

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

• Shoulder Dislocation
  • Anterior shoulder dislocation
  • Posterior shoulder dislocation
  • Inferior shoulder dislocation
• Clavicle fracture
• Humerus fracture
• Scapula fracture
• Acromioclavicular injury
• Glenohumeral instability
• Rotator cuff tear
• Biceps tendon rupture
• Triceps tendon rupture
• Septic joint

Nontraumatic/Chronic:

• Rotator cuff tear
• Impingement syndrome
• Calcific tendinitis
• Adhesive capsulitis
• Biceps tendinitis
• Subacromial bursitis

Refered pain & non-orthopedic causes:

• Referred pain from
  • Neck
  • Diaphragm (e.g. gallbladder disease)
• Brachial plexus injury
• Axillary artery thrombosis
• Thoracic outlet syndrome
• Subclavian steal syndrome
• Pancoast tumor
• Myocardial infarction
• Pneumonia
• Pulmonary embolism

Evaluation

• Obtain radiographs to rule-out avulsion fracture
• Ultrasound can help with diagnosis

Management

• Proximal rupture
  • Sling, ice, NSAIDS, physical therapy, referral to ortho
  • Surgical tenodesis is usual for young, active patients
  • Mostly nonoperative for elderly, with most patients asymptomatic after 4-6 weeks
• Distal rupture requires tenodesis, sutures to anchor tendon into radius

See Also

• Elbow diagnoses
• Shoulder diagnoses

Sources

Authors

Kevin Lu, Ross Donaldson, Neil Young, Jonathan Osgood, Daniel Ostermayer