Monday, May 5, 2014

Biceps Tendon Tear at the Shoulder - Patient education

The biceps muscle is in the front of your arm and its main function is to bend the elbow but most importantly to rotate your forearm externally (like turing a key with your hand). The muscle that lies underneath the biceps is called brachialis and is responsible for your strength in bending your elbow. The muscle originates from the shoulder as shown in the picture below and inserts in your forearm. If you tear the biceps tendon at the shoulder, you may lose some strength in your arm and be unable to forcefully turn your arm from palm down to palm up.
Many people can still function with a biceps tendon tear, and only need simple treatments to relieve symptoms. Some people require surgery to repair the torn tendon.
Anatomy of the biceps

The upper end of the biceps muscle has two tendons that attach it to bones in the shoulder. The long head attaches to the top of the shoulder socket (glenoid). The short head attaches to a bump on the shoulder blade called the coracoid process.The shoulder has 3 joints. The ball and the socket which is the humerus and shoulder blade (scapula or glenoid). The collarbone to the scapula which is called the acromioclavicular joint. The shoulder blade to your chest which is called the scapulothoracic joint. When you move your shoulder all of these 3 joints work in coordination for a smooth move of the shoulder. A number of muscles and tendons keep the ball into the socket while the motion of the ball is initiated by the rotator cuff muscles. These muscles are shown below . They cover the head of your upper arm bone and attach it to your shoulder blade.
The two heads of the biceps muscle) 

Depending on the force of the injury the tendon may rupture completely or partially. If the tendon is not completely torn then there is no deformity seen on the arm. When the tendon is fully torn then the arm may have a cosmetic deformity or otherwise called the Poppye sign. 

A complete tear of the long head at its attachment point in the glenoid. Click on the image for larger size view.
On several occasions the tendon may rupture with minimal
effort especially in older patients. That happens because there may be some fraying of the tendon which was pre-existing. Weakening of the tendon results in easier rupture
Most of the time the long head of the biceps tendon is torn. 
Even if the long head of the tendon is torn the muscle will still function because most of the time the short head remains intact. 

What causes a tear?
The tendon can be torn because of severe trauma even if there is no denegeration of the fibers of the tendon. The frayed tendon as the rope depicted below can be torn with less force (degenerative tear or overuse) while the intact tendon requires significant force and is usually seen in younger patients. A lot of times a degenerative tear of the long head of the biceps will be associated with prior degenerative tears of the rotator cuff as well. This is seen in old patients with irreperable tears of the rotator cuff.

Arthroscopic (through a telescope) picture of a "frayed" biceps tendon


The mechanism is a fall on a outstretched arm or lifting something very heavy.


Having degenerative tear of the rotator cuff tendons puts higher stresses on the long head of the biceps. With overuse  the biceps tendon gets weak, gets frayed, making it more likely to tear.

What factors are associated with a ruptured tendon of the biceps?

The risk for a tendon tear increases with:
Age. Older people have put more years of wear and tear on their tendons than younger people.
Heavy overhead activities. Too much load during weightlifting is a prime example of this risk, but many jobs require heavy overhead lifting and put excess wear and tear on the tendons.
Shoulder overuse. Repetitive overhead sports - such as swimming or tennis - can cause more tendon wear and tear.
Smoking. Nicotine use can affect nutrition in the tendon.
Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.

  • Sudden, sharp pain in the upper arm
  • Sometimes an audible pop or snap
  • Cramping of the biceps muscle with strenuous use of the arm
  • Bruising from the middle of the upper arm down toward the elbow
  • Pain or tenderness at the shoulder and the elbow
  • Weakness in the shoulder and the elbow
  • Difficulty turning the arm palm up or palm down
  • Because a torn tendon can no longer keep the biceps muscle tight, a bulge in the upper arm above the elbow ("Popeye Muscle") may appear, with a dent closer to the shoulder.


Medical History and Physical Examination

Your doctor will ask questions about the mechanism of injury and examine your arm. The diagnosis is often obvious for complete ruptures because of the deformity of the arm muscle ("Popeye Muscle").

A biceps tendon tear is made more obvious by contracting the muscle ("Popeye Muscle").
Partial ruptures are less obvious. To diagnose a

partial tear, your doctor may ask you to bend your arm and tighten the biceps muscle. Pain when you use your biceps muscle may mean there is a partial tear.
It is also very important that your doctor identify any other shoulder problems when planning your treatment. The biceps can also tear near the elbow, although this is less common. A tear near the elbow will cause a "gap" in the front of the elbow. Your doctor will check your arm for damage to this area.
In addition, rotator cuff injuries, and tendonitis are some conditions that may accompany a biceps tendon tear. Your doctor may order additional tests to help identify other problems in your shoulder.

Diagnosis with Xrays or MRI

X-rays. Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause shoulder and elbow pain.
Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears. The indication to order these tests is based on the judgement of the doctor. Sometimes its not necessary to be ordered for the diagnosis. Sometimes are necessary to be ordered to rule out other pathology.

How is this problem treated?

Without surgery

Most patient will get better overtime after a complete rupture of the tendon. The echymosis of the arm will resolve. Mild arm weakness or arm deformity may not bother some patients, such as older and less active people.
If there is no injury to crucial muscles and tendons like the rotator cuff, nonsurgical treatment is a reasonable option for the old and minimal demand patient. This can include:
Ice. Several times a day apply ice to keep down swelling. Make sure that the ice does not come in contact with the skin. Wrap the ice in a towel to decrease the chances of a skin burn. Do not apply ice directly to the skin.
Nonsteroidal anti-inflammatory medications. Drugs like ibuprofen, diclofenac, or naproxen reduce pain and swelling. Consult with your primary care physician prior to taking those medications. They can affect your blood pressure and kidney function if you take them one or two weeks scheduled every day.
Rest. Avoid activities that may cause stress to the tendon or muscle. Heavy lifting and overhead activities may increase pain and swelling. Use of a sling is optional and for comfort only.
Physical therapy. Flexibility and strengthening exercises and strengthen your shoulder after your pain has come to a minimal level. Exercises can be found by clicking here.

With surgery

Surgical treatment for a long head of the biceps tendon tear performed in some patients who need complete recovery of strength, such as athletes or manual laborers. Sometimes partial tears can be quite painful due to the stress in the remaining intact fibers. For those cases surgery may also be required. 
Procedure. Several new procedures have been developed that repair the tendon with minimal incisions or open incisions. The goal of the surgery is to re-anchor the torn tendon back to the bone. Your doctor will discuss with you the options that are best for your specific case. For a partial tear in older patients your doctor may suggest completion of the tear without repair (biceps tenotomy).
Complications. Complications with this surgery are rare. Re-rupture of the repaired tendon is uncommon but it may happen.
Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling. Once the patient subsides then you will soon start therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.
Surgical Outcome. Successful surgery can correct muscle deformity and return your arm's strength and function to nearly normal.