Biceps Strain or Rupture

Biceps Strain vs. Rupture: Key Differences

Biceps Strain (Partial Tear)

• Definition: A partial rupture of the distal biceps tendon signifies microscopic damage to muscle or tendon fibers without full detachment. Unlike a complete rupture, the biceps tendon can still be palpated in the antecubital fossa. Partial tendon failure can occur at the tendon's insertion point on the bone or within the substance of the tendon itself, which might become elongated. It is believed that pre-existing pathological changes or initial tendon degeneration can lead to incomplete or partial tears.
• Symptoms: The symptoms of a partial rupture are similar to those of a complete rupture but are described as more subtle. These include a sudden, sharp, painful tearing sensation in the antecubital region of the elbow, which may be replaced by a dull ache. Patients may experience pain and tenderness in the antecubital fossa, swelling, and weakness in elbow flexion and forearm supination. While the hook test can identify an intact tendinous insertion, it will often be painful to palpation in cases of partial tears.
• Treatment: The approach to treating partial tears depends on their severity. Partial tears involving less than 50% of the tendon thickness can often be managed nonoperatively. However, if nonoperative treatment fails to alleviate symptoms, surgical intervention is recommended. Patients with high-grade partial tears, involving 50% or more of the thickness, have a significantly higher failure rate with nonoperative treatment (76% in one review) and are therefore more likely to benefit from surgical management. Surgical treatment typically involves releasing the remaining portion of the biceps tendon, debriding the frayed end, and then anatomically reattaching the tendon as if it were a complete rupture. Successful surgical management often allows patients to return to their normal work activities.

Biceps Rupture (Complete Tear)

• Definition: A complete rupture of the distal biceps tendon involves the total separation of the tendon from its insertion, most commonly from the radial tuberosity. On physical examination, the biceps tendon will appear absent or cannot be palpated in the antecubital fossa.
• Symptoms: Patients with complete distal biceps tendon ruptures typically report a sudden, sharp, painful tearing sensation in the antecubital region of the elbow, often accompanied by an audible "pop". This intense pain usually subsides after a few hours, being replaced by a dull ache. Physical examination reveals a palpable and visible deformity of the distal biceps muscle belly, which retracts proximally and accentuates the defect in the antecubital fossa (sometimes referred to as a "reverse Popeye" sign depending on retraction). Ecchymosis and swelling are common in the antecubital fossa and along the medial aspect of the arm and proximal forearm. Patients experience significant weakness in elbow flexion and, more profoundly, in forearm supination. On average, this injury can lead to a 30% loss in flexion peak torque and a 40% to 50% loss in supination peak torque. The hook test is a highly sensitive and specific diagnostic tool: the inability to hook a distinct cord-like structure in the antecubital fossa with an actively supinated and flexed elbow indicates a positive test and a complete rupture.
• Treatment: For most patients, particularly those who require upper extremity strength for vocational and recreational activities, early surgical repair of the ruptured biceps tendon to the radial tuberosity is advocated for optimal results. Surgical repair consistently demonstrates better outcomes in restoring strength and endurance compared to nonoperative management. While nonoperative management might be considered for elderly, sedentary patients or those with high surgical risk, it can lead to persistent activity-related pain and significant functional deficits, including losses of strength and endurance in supination and flexion. Immediate surgical repair allows for a predictable recovery of elbow supination and flexion strength.

Proximal (Shoulder) vs. Distal (Elbow) Tears

• Distal Biceps Tendon (DBT) Tears (Elbow): These injuries account for about 3% of all biceps injuries, indicating they are less common than proximal tears. They typically occur in the dominant extremity of men between 40 and 60 years of age. The most common mechanism is a sudden, unexpected extension force applied to an arm flexed to 90 degrees. The rupture almost always occurs at the tendon's insertion point into the radial tuberosity, often in an area of pre-existing tendon degeneration or mechanical impingement. The distal biceps is the strongest supinator of the forearm and assists in elbow flexion. Therefore, rupture of the distal biceps tendon results in profound functional implications concerning activities that rely on power during elbow flexion and forearm supination. For optimal functional recovery, surgical repair is typically recommended.
• Proximal Biceps Tears (Shoulder): The sources mention that proximal biceps tendon injuries, particularly involving the long head, are common in overhead-throwing athletes. These injuries can manifest as tendinitis, partial- or full-thickness tears, biceps tendon instability (subluxation or dislocation), and Superior Labrum Anterior-Posterior (SLAP) lesions. The underlying causes can be a traumatic event or chronic overuse, such as repetitive overhead throwing. For athletes, especially overhead athletes, initial treatment is often nonoperative, focusing on strengthening the entire kinetic chain and addressing muscle imbalances. Operative treatment is indicated when nonoperative measures fail or when there are structural deficits that require repair. This aligns with the common clinical practice of managing many proximal biceps issues non-surgically, except in specific high-demand or persistent cases.

Biceps Anatomy: Why Injuries Occur

The biceps muscle, a superficial muscle in the anterior compartment of the arm, is composed of two heads: the long head and the short head. Understanding its anatomy and biomechanics is crucial to comprehend why injuries occur and their functional consequences.

Biceps Anatomy: Why Injuries Occur

High-Risk Tendons and Injury Mechanisms:

• Long Head Tendon (Proximal): The long head of the biceps tendon originates from the supraglenoid tubercle on the scapula. Proximal biceps tendon injuries, often affecting the long head, are common in overhead-throwing athletes. These injuries can manifest as tendinitis, partial- or full-thickness tears, biceps tendon instability (subluxation or dislocation), and Superior Labrum Anterior-Posterior (SLAP) lesions. Causes can be traumatic events or chronic overuse, such as repetitive overhead throwing, where high loads are placed on the shoulder joint. For overhead athletes, initial treatment is often nonoperative, focusing on strengthening the entire kinetic chain and addressing muscle imbalances.
• Distal Tendon (Elbow): The distal tendon of the biceps muscle passes deep in the antecubital fossa to insert at the radial tuberosity. This insertion is typically on the posterior ulnar aspect of the radial tuberosity, which lies on the ulnar side of the proximal aspect of the radius. The distal tendon rotates 90 degrees externally as it crosses the elbow joint before inserting. Distal biceps tendon ruptures are increasingly reported and most commonly occur in the dominant extremity of men between 40 and 60 years of age. The most common mechanism of injury is a sudden, unexpected extension force applied to an arm flexed to 90 degrees. This involves an eccentric contraction (forceful extension against a contracting biceps) exceeding the tendon's load to failure. The rupture typically occurs at the tendon's insertion into the radial tuberosity, often in an area of pre-existing tendon degeneration. In some cases, the bicipital aponeurosis (lacertus fibrosus), which arises from the medial aspect of the muscle belly and blends with the forearm fascia, may also rupture.

Underlying Factors Contributing to Injury:

• Degeneration: It is generally accepted that normal tendons do not rupture. Degenerative processes and pre-existing pathological changes in the tendon are implicated as causes of rupture, leading to incomplete or partial tears that predispose to complete rupture with sudden contraction. Microscopic characterization of ruptured tendons shows various degenerative changes.
• Hypovascularity: A hypovascular zone has been identified in the distal biceps tendon, which could play a role in tendon rupture.
• Mechanical Impingement: The space available for the biceps tendon between the radius and ulna decreases significantly (by 48% or even 50%) when the forearm is pronated. Hypertrophic bone formation on the anterior margin of the radial tuberosity can contribute to tendon failure due to repetitive impingement with forearm rotation.

Risk Factors for Distal Biceps Tendon Tears:Beyond the demographic (middle-aged men), key risk factors include:

• Smoking: Associated with a 2.2 to 7.5 times greater risk of rupture. Smoking may exacerbate the tendon's hypovascularity.
• Elevated Body Mass Index (BMI): A significant association exists with a BMI of ≥30 kg/m², possibly due to increased load on the tendon and diminished response to microinjury.
• Anabolic Steroid Use: Although robust epidemiological studies are limited, case reports and general associations with other tendon injuries suggest a likely correlation.
• Corticosteroid Injection and Chronic Prednisone Use: Complete rupture has been reported after periarticular corticosteroid injection and chronic prednisone use.

Functions Affected:

The biceps muscle is the strongest supinator of the forearm and assists the brachialis in elbow flexion.

• Elbow Flexion: The biceps muscle is more active in flexion of the supinated forearm. Its contribution to forearm supination increases with elbow flexion, reaching a maximum at about 90 degrees of flexion. After a complete distal biceps rupture, patients experience significant weakness in elbow flexion. On average, this injury can lead to a 30% loss in flexion peak torque.
• Forearm Supination: This function is typically more profoundly affected than flexion. Rupture can lead to a 40% to 50% loss in supination peak torque. The biceps is the primary supinator of the forearm.
• Shoulder Stabilization: The long head of the biceps tendon contributes to shoulder stabilization. While the provided sources focus more on its role in shoulder injuries (e.g., SLAP lesions, tendinitis), the implication is that its integrity contributes to overall shoulder function and stability.

Causes & Risk Factors

Biceps tendon injuries, including tears, arise from a combination of acute traumatic events and chronic degenerative processes, affecting specific high-risk groups.

Causes of Biceps Tears:

Acute Injuries:

• Sudden, unexpected extension force: Distal biceps tendon (DBT) ruptures most commonly occur when an unexpected extension force is applied to an arm that is flexed, often at 90 degrees. This involves a sudden, forced eccentric contraction of the biceps muscle, where the muscle attempts to contract while being forcibly lengthened, exceeding the tendon's load to failure.
• Heavy lifting or sudden forces: Common scenarios include moving or lifting heavy objects, catching a falling object, or an arm being held onto a fixed object during a fall from height. A direct blow to the forearm can also cause DBT tears.

Chronic Degeneration:It is generally accepted that normal tendons do not rupture; instead, tears often occur in areas of preexisting tendon degeneration. This degenerative process can compromise the tendon's structural integrity over time.

• Hypovascularity: A "watershed area" or hypovascular zone in the distal biceps tendon, which has a thinner blood supply, has been identified between its proximal and distal vascular zones. This zone is susceptible to degeneration and shortening, predisposing the tendon to rupture.
• Mechanical Impingement: The space available for the biceps tendon between the radius and ulna significantly decreases when the forearm is pronated (by 48% or 50% in full pronation). This can lead to repetitive mechanical impingement of the tendon, especially if there is hypertrophic bone formation on the anterior margin of the radial tuberosity. Such chronic repetitive injury can weaken the tendon and lead to degeneration and eventual failure.
• Repetitive Overhead Motions: While more commonly associated with proximal (long head) biceps tendon injuries, chronic overuse from repetitive overhead throwing can cause biceps-related shoulder injuries.

Who is at Risk for Biceps Rupture?

High-Risk Demographics and Activities:

• Middle-aged men: Distal biceps tendon ruptures occur most commonly in the dominant extremity of men between 40 and 60 years of age. The average age at rupture is approximately 50 years. While complete ruptures are almost exclusively reported in men, partial ruptures have been reported in women, often with a more gradual onset of symptoms and at an older age (mean age 63).
• Heavy laborers and athletes: Individuals who require significant upper extremity strength for vocational or recreational activities are at higher risk. This includes manual laborers, weightlifters, and athletes involved in heavy lifting.

Underlying Risk Factors and Conditions:

• Smoking: Epidemiological studies have identified smoking as a substantial risk factor, associated with a 2.2 to 7.5 times greater risk of rupture. Smoking may exacerbate the tendon's hypovascularity.
• Elevated Body Mass Index (BMI): A significant association has been noted with a BMI of ≥30 kg/m². This may be due to increased load on the tendon and a diminished response to microinjury.
• Anabolic Steroid Use: Although robust epidemiological studies are limited, case reports and associations with other tendon injuries suggest a likely correlation between anabolic steroid use and DBT tears.
• Corticosteroid Injection and Chronic Prednisone Use: Complete rupture has been reported after periarticular corticosteroid injection and chronic prednisone use.
• Tendinosis/Tendonitis: Underlying tendinosis (tendon degeneration) or tendonitis can predispose the tendon to rupture.
• Shoulder Impingement and Biceps Degeneration: Factors contributing to the development of biceps tendon degeneration, such as internal impingement (often related to overhead activities), can lead to proximal biceps injuries like SLAP lesions. Weakness or imbalances in scapulothoracic and rotator cuff muscles are often present in patients with biceps-related disorders.
• Gymnasts: Gymnasts experience high mechanical loads and stresses on the shoulder joint, which can lead to involvement of the long head of the biceps tendon and labral irregularities, including SLAP lesions.

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Non-Surgical vs. Surgical Treatment

The treatment approach for distal biceps tendon (DBT) tears, whether non-surgical or surgical, depends on the extent of the injury (partial vs. complete) and the individual patient's needs and activity levels.

Partial Tears (Strain)

• Can a biceps tear heal without surgery?
  • Non-operative management is often considered for partial tears involving less than 50% of the tendon thickness, with reports of high success rates. This approach typically involves rest and physiotherapy.
  • However, if symptomatic partial DBT ruptures fail to respond to non-operative treatment, or for high-grade partial tears (50% or more of the thickness), surgical management is often recommended.
• When is biceps surgery needed for partial tears?
  • Surgery is needed for partial tears that fail conservative treatment or for high-grade partial tears (involving 50% or more of the tendon thickness). Surgical intervention often involves releasing the remaining tendon portion from the radial tuberosity, debriding the frayed end, and reattaching the tendon as if it were a complete rupture.
  • An unusual form of partial tearing, elongation of the biceps tendon without failure at the tuberosity, has also been successfully treated surgically with Z-plasty shortening and suture reinforcement to reestablish the length-tension relationship.

Factor

Strain (Partial Tear)

Treatment

Rest, physiotherapy.

Surgical management if nonoperative fails or for high-grade tears (≥50% thickness).

‍Recovery Time

‍The sources do not provide a specific recovery time for non-surgical partial tears. For surgically managed partial ruptures, patients have been able to return to normal work activities without difficulty.

‍Strength Return

‍Non-operative management for partial tears involving less than 50% thickness has high success rates. For surgically managed partial ruptures, one patient achieved normal values, and another showed a 33% decrease in supination strength with normal flexion strength. Elongation of the biceps tendon treated with Z-plasty shortening restored power, with postoperative flexion and supination strength equivalent to the non-injured arm.

Rupture (Complete Tear)

• Can a biceps tear heal without surgery?
  • While some patients may choose non-operative management for complete ruptures, they should be informed of the possibility of activity-related pain, as well as decreased strength and endurance in both flexion and supination.
  • Non-operative management is generally reserved for elderly, low-demand, or high-surgical-risk patients who do not require significant strength and endurance in flexion and supination. This approach involves reducing swelling and inflammation, initiating early range of motion, and progressive strengthening.
  • However, non-operative management of complete ruptures can result in significant functional deficits, including a reported loss of 30% in flexion peak torque and 40% to 50% in supination peak torque. Patients may also experience persistent activity-related pain.
• When is biceps surgery needed for complete tears?
  • Early anatomic surgical repair to the radial tuberosity is widely considered necessary for optimal results and to restore strength and endurance in both supination and flexion. Surgical repair is the more recently accepted approach and is recommended in the majority of cases, particularly for high-demand patients (e.g., heavy laborers, athletes).
  • Early surgical intervention (within 2-3 weeks) of acute tears is associated with a lower complication rate and better outcome measures compared with surgical repair of chronic tears. Delays in treatment beyond 6 weeks can compromise the ability to obtain primary anatomic repair and increase subsequent complications due to tendon retraction, atrophy, and scarring.
  • For chronic ruptures (often defined as >4 weeks), surgical reattachment may still be considered if there is considerable disability, even though results can be less predictable. These cases may require more extensive dissection and tendon augmentation using autograft or allograft due to inadequate tendon length and scarring.

Factor

Rupture (Complete Tear)

Treatment

Early anatomic surgical repair to the radial tuberosity + rehab.

Non-operative management is reserved for elderly, low-demand, or high-surgical-risk patients. Chronic tears may require tendon augmentation/reconstruction.

‍Recovery Time

‍Postoperative rehabilitation is crucial.

‍Strength Return

‍With surgical repair, excellent results are reported, with strength return often comparable to the uninvolved extremity. Studies show 97% flexion strength and 95% supination strength compared with the uninjured arm. Return to unrestricted activities, including strenuous lifting, is generally allowed by 5 months after repair. Some clinical outcomes show patients returning to activity at an average of 6.5 weeks from surgery and performing normal activities at 2 years postoperatively with a combined cortical button and interference screw fixation method. Criteria for returning to activities typically include full and painless range of motion, and strength within 10% of the contralateral, uninjured upper extremity.

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Exceptions:

• Non-surgical rupture rehab may be considered for sedentary individuals with proximal tears.
  • The sources indicate that non-surgical management of complete distal biceps tendon ruptures should be considered only for elderly, sedentary patients who do not require strength and endurance in flexion and supination, and for patients who are too ill to undergo surgery.
  • The provided sources do not discuss "proximal tears" as an exception for non-surgical treatment of distal biceps tendon ruptures. The information given pertains specifically to the management of distal biceps tendon injuries.
  • For complete ruptures managed non-surgically, patients can expect significant functional deficits, including loss of supination (40% to 50%) and flexion (30%) strength, which may be tolerated if the injury affects the non-dominant arm or for patients with low functional demands.

Physiotherapy Rehab Protocol

A comprehensive physiotherapy rehabilitation protocol for distal biceps tendon tears, whether managed non-surgically or surgically, progresses through distinct phases, emphasizing protection, gradual strengthening, and return to activity.

Phase 1: Early Healing (Weeks 1–4)

• Goals:
  • Reduce pain and swelling.
  • Prevent stiffness.
  • Protect the surgical repair (if applicable).
  • Optimize the tissue healing environment.
  • Ultimately, achieve full, pain-free range of motion by week 6.
• Immediate Biceps Tear Care / Post-Op Biceps Rehab:
  • For surgically repaired tears, the arm is typically immobilized. This can involve the elbow in 90 degrees of flexion with the forearm in supination for 7 to 10 days, or a cast for 10 to 14 days, or a soft dressing for 1 week.
  • Following initial immobilization, a hinged flexion-assist splint with a 30-degree extension block may be used until 8 weeks post-surgery to protect the repair. If the surgeon initially limited extension due to tendon tension (common in retracted tears), a hinged elbow brace may be used to maintain these parameters.
  • During this early phase, no active elbow flexion or supination is permitted.
  • Patients must refrain from any lifting with the operative extremity, and a less than 0.5 Kg weight lifting restriction is often in place.
  • Exercises:
    • Hand and wrist range of motion and gripping exercises (e.g., rubber ball squeezing) should begin immediately.
    • Shoulder girdle range of motion (passive and active glenohumeral and scapulothoracic movements) is encouraged to prevent stiffness and aid hygiene.
    • Gravity-assisted flexion and extension of the elbow may begin at two weeks post-operatively, with limits based on surgical parameters.
    • Active extension with gravity and active-assisted flexion, along with active and active-assisted pronation and supination, can be instructed as early as 1 week post-surgery.
  • Cardiovascular fitness training (e.g., treadmill walking, elliptical without arm use, bike) can be introduced as early as week one.
  • Computer work/typing is generally allowed.
  • For non-surgical management, especially for partial tears or complete tears in sedentary individuals, the focus is on reducing swelling and inflammation and initiating early range of motion of the elbow.
• Progression Criterion: Progression to the next phase is contraindicated if there is persistent or recurrent pain and/or swelling.

Phase 2: Strengthening (Weeks 4–12)

• Goals:
  • Maintain proper scapulothoracic mechanics.
  • Initiate upper extremity strengthening.
  • Restore full range of motion by 6 weeks.
• Resistance Band Biceps Rehab / Light Weights After Tear / Post-Op Biceps Rehab:
  • Resisted active range of motion is not performed until 6-8 weeks following repair. No excessive elbow flexion against resistance is allowed for the first 3 months.
  • Isometric triceps exercises may begin at six weeks post-operative.
  • Isotonic triceps exercises may begin at week 8.
  • Strengthening of wrist flexors and extensors may also commence at week 8.
  • Biceps isometrics begin at the start of Phase III (around week 12).
  • Light biceps isotonics (e.g., Traditional, Hammer, and Reverse grip curls) generally begin at week 16.
  • For non-operative management, a focus on progressive secondary strengthening is key, although patients should be aware of potential decreased strength and endurance in both flexion and supination.
  • Activities of daily living and active motion are allowed as tolerated at 4 weeks.
  • Exercises with moderate biceps loads (20%-50% maximal voluntary isometric contraction [MVIC]) are suitable for this intermediate phase. Examples from studies on biceps muscle activity include:
    • Pull-up in pronation with Redcord (24.06% MVIC)
    • Air punch (27.58% MVIC)
    • Forward flexion in external rotation and forearm supination with dumbbell (35.56% MVIC)
    • Pull-up in supination with Redcord (41.96% MVIC)
    • Inclined biceps curl with dumbbell (43.99% MVIC)
• Progression Criterion: To advance, the patient should have full, painless range of motion of the shoulder, elbow, wrist, and hand, proper scapulothoracic mechanics (no dyskinesia), and full biceps strength against gravity (5/5 manual muscle test).

Phase 3: Functional Training (3+ Months)

• Goals:
  • Increase functional strength of the upper extremity.
  • Return to preferred sport and/or activity.
• Weightlifting Post-Tear / Biceps Tear Exercises:
  • Unrestricted motion and progressive strengthening begin after the splint is removed, typically at 8 weeks post-operatively. Formal strengthening may begin as early as 8 weeks.
  • This phase involves advancing biceps strengthening with exercises such as biceps curls (Hammer, Traditional, Reverse, and Side Curls) and triceps extensions.
  • Rotator cuff and periscapular strengthening exercises are also continued.
  • For high-demand patients, early surgical repair is often recommended for optimal results.
  • Exercises with high biceps loads (>50% MVIC) are appropriate for advanced and final phases of rehabilitation. Examples from studies on biceps muscle activity include:
    • Throwing forward flexion in 90 degrees with a soft weight ball (56.96% MVIC)
    • Reverse punch with elastic tubing (67.37% MVIC)
  • Biceps muscle activity can be effectively targeted by:
    • Sagittal plane elevation.
    • Elbow flexion with supination, without upper arm support.
    • Biceps contraction from an elongated position.
    • High-velocity, explosive exercises.
• Return to Sports After Biceps Rupture:
  • Return to unrestricted activities, including strenuous lifting, is generally allowed by 5 months after repair.
  • Return to sports is allowed between 3 and 6 months.
  • Patients with surgical repair, particularly with advanced fixation techniques like a cortical button and interference screw, may experience accelerated rehabilitation and return to activity at an average of 6.5 weeks from surgery, performing normal activities at 2 years postoperatively.
  • Sport-specific exercises are incorporated to prepare for specific activities.
  • Criteria for return to activity include full and painless range of motion, strength within 10% of the contralateral, uninjured upper extremity, and pain-free participation in activity-specific movement patterns.
  • For chronic tears or those requiring graft reconstruction, a modified protocol with extended milestones is used.

Important Considerations: Rehabilitation protocols should be tailored to the individual patient's needs and restrictions and performed under the careful supervision of a rehabilitation team.

Preventing Re-Injury

Preventing re-injury of the biceps tendon, whether after a tear or to strengthen it and avoid future issues, involves a combination of careful activity modification, addressing risk factors, and a structured, progressive strengthening program.

How to Avoid Biceps Tears & Strengthen Biceps Tendon

Do’s:

• Warm Up and Prepare the Body for Activity: While dynamic stretches are not explicitly detailed in the provided sources as a prevention method, restoration of full range of motion is a key goal in rehabilitation, which is crucial for optimal function and preparing the body for activity. Engaging in regular cardiovascular fitness is also recommended for overall health.
• Strengthen Rotator Cuff and Scapular Muscles: It is essential to restore muscle imbalances in scapulothoracic and rotator cuff muscles and to continue rotator cuff and periscapular strengthening exercises to maintain overall upper extremity and postural health, promoting proper mechanics. Exercises that involve a scapular retraction component (e.g., pull-up in pronation/supination with Redcord, reverse punch) can also be valuable for strengthening the trapezius muscles.
• Engage in Progressive Biceps Tendon Strengthening:
  • Begin with low-to-moderate biceps loads in the early and intermediate phases of rehabilitation.
  • Progress to moderate-to-high biceps loads in more advanced phases of rehabilitation for biceps disorders.
  • Biceps muscle activity can be effectively targeted by:
    • Sagittal plane elevation.
    • Elbow flexion with supination, without upper arm support. Examples include the Pull-up in supination with Redcord (41.96% MVIC).
    • Biceps contraction from an elongated position. The Inclined biceps curl with dumbbell is an example, performed with the shoulder in extension, yielding high biceps activity (43.99% MVIC).
    • High-velocity, explosive exercises. Examples include Throwing forward flexion in 90 degrees with a soft weight ball (56.96% MVIC) and Reverse punch with elastic tubing (67.37% MVIC), which are suitable for advanced rehabilitation phases.
  • Specific exercises to incorporate during rehabilitation include isometric biceps exercises, followed by light isotonic biceps exercises such as Hammer, Traditional, and Reverse grip curls. Later, Side Curls can be introduced.
• Achieve Functional Milestones: Before returning to preferred sports or strenuous activities, ensure full and painless range of motion, and strength within 10% of the contralateral, uninjured upper extremity.
• Consider Early Surgical Repair for Complete Tears: For optimal results, especially for individuals requiring upper extremity strength for vocational and recreational activities, immediate surgical repair of the ruptured biceps tendon is advocated. Surgical repair has consistently shown better outcomes compared to nonoperative management, resulting in a predictable recovery of elbow supination and flexion strength. Advanced fixation techniques allow for early active range of motion and accelerated rehabilitation.

Don’ts:

• Lift with Excessive, Unexpected Force or in Vulnerable Positions: Avoid single traumatic events where an unexpected extension force is applied to an arm flexed to 90 degrees, as this is the most common mechanism of injury. Distal biceps tears often occur after an acute eccentric force to the elbow, frequently from a flexed and supinated position.
• Ignore Early Pain or Delay Diagnosis/Treatment: An early and accurate diagnosis is essential, as delayed diagnosis may preclude primary repair and lead to chronic weakness. Delays in treatment for more than 4 to 6 weeks can compromise the ability to obtain primary anatomic repair and increase subsequent complications. Persistent or recurrent pain and/or swelling indicate inappropriate phase progression during rehabilitation.
• Neglect Known Risk Factors:
  • Smoking: This is a substantial risk factor, associated with a 2.2 to 7.5 times greater risk of rupture, possibly by exacerbating the tendon's zone of hypovascularity.
  • Anabolic Steroid Use: This has been linked to tendon injuries, including distal biceps tears.
  • Chronic Corticosteroid Injections: Complete rupture after periarticular corticosteroid injection has been reported.
  • Elevated Body Mass Index (BMI): A significant association has been noted with a BMI of 30 kg/m^2 or higher.
  • Mechanical Impingement: Degenerative changes or hypertrophic bone on the radial tuberosity can reduce the space for the biceps tendon during forearm pronation, leading to repetitive impingement.
• Perform Heavy Lifting or Active Biceps Motion Too Soon After Repair: After surgical repair, no active elbow flexion or supination is permitted in the early phase. Resisted active range of motion is not performed until 6-8 weeks following repair. Patients must refrain from any lifting with the operative extremity, often with a less than 0.5 kg weight lifting restriction initially. No excessive elbow flexion against resistance is allowed for the first 3 months. Unrestricted activities, including strenuous lifting, are generally not allowed until 5 months after repair.
• Ignore the Contralateral Limb: Patients with an injury to one limb are at a substantially higher risk for injuring the contralateral limb, suggesting that general conditioning and addressing underlying intrinsic causes across both sides may be beneficial.

Rehabilitation protocols should always be tailored to the individual patient's needs and restrictions and performed under the careful supervision of a rehabilitation team.

FAQs

Q: Is the Popeye deformity reversible?

A: The "Popeye sign" is a classic sign for proximal biceps tendon rupture, whereas the "reverse Popeye sign" is a visible deformity of the distal biceps muscle belly where it retracts proximally, accentuating a defect in the antecubital fossa. The sources do not explicitly state whether this deformity itself is reversible through nonoperative means. However, they indicate that surgical repair aims to restore the anatomy by reattaching the tendon to the radial tuberosity. If the bicipital aponeurosis remains intact, the muscle belly deformity may not be as pronounced.

Q: What are the long-term effects of a biceps tear?

A: The long-term effects of a biceps tear vary significantly depending on whether the injury is managed operatively or nonoperatively:

• Nonoperative Treatment:
  • Results in significant and profound long-term functional deficits. Patients can expect to lose an average of 30% of elbow flexion peak torque and 40% to 50% of supination peak torque. Some studies indicate an even greater loss of supination endurance, estimated at 86%. There can also be a 15% loss of grip strength.
  • Patients may experience activity-related pain and cramping in the arm and forearm during activities involving supination.
  • Despite these functional losses, some patients treated nonoperatively for full-thickness tears may not experience chronic pain. This option is typically considered for elderly, sedentary patients, or those with high surgical risks who do not heavily rely on strength and endurance in flexion and supination.
  • With immediate splinting and conservative treatment, some individuals may be left with a Popeye deformity, but can regain nearly 100% of their strength.
• Surgical Repair:
  • Early anatomic repair is strongly recommended for optimal results and consistently shows excellent outcomes. Patients can expect to regain near-normal strength, with reported returns of 97% in flexion strength and 95% in supination strength compared to the uninvolved extremity.
  • Surgical management aims to restore the patient's function and their ability to return to desired work and recreational activities. Patients have been able to return to activity as early as 6.5 weeks from surgery and were performing normal activities at 2 years postoperatively.
  • For chronic ruptures, while improved strength and diminished activity-related pain can be achieved compared to nonoperative treatment, the degree of improvement in strength may vary and be less predictable than acute repairs.

Q: Can you still lift weights after a biceps rupture?

A: Yes, you can typically return to lifting weights after a biceps rupture, provided you undergo surgical repair and follow a structured, progressive rehabilitation protocol.

• Post-Surgical Restrictions: Immediately following repair, the arm is immobilized, and no active elbow flexion or supination is permitted in the early recovery phase (typically 0-6 weeks). Patients are instructed to refrain from any lifting with the operative extremity.
• Rehabilitation Progression:
  • Isometric triceps exercises may begin around 6 weeks post-operation, with isotonic triceps exercises starting at 8 weeks.
  • Isometric biceps exercises generally begin around 12 weeks, followed by light isotonic biceps exercises (e.g., traditional curls, hammer curls, reverse curls) at 16 weeks.
  • More advanced biceps strengthening like side curls can be introduced after 16 weeks.
• Return to Activity: Unrestricted activities, including strenuous lifting, are typically allowed by 5 months after repair. The goal is to achieve full and painless range of motion, with strength within 10% of the contralateral upper extremity before returning to activity. Advanced fixation techniques allow for earlier active or active-assisted range of motion postoperatively.
• Nonoperative Management: If a complete rupture is treated nonoperatively, the significant and permanent weakness in flexion and supination (up to 30-50% loss of peak torque) would severely limit the ability to lift heavy weights.

Q: Does a ruptured biceps heal on its own?

A: The ability of a ruptured biceps to heal on its own depends on the extent of the tear (partial vs. complete):

• Partial Tears: Partial tears may heal on their own or be managed nonoperatively, especially if they involve less than 50% of the tendon's thickness. However, if symptomatic partial ruptures fail to respond to nonoperative treatment, surgical management is recommended. High-grade partial tears (involving ≥50% of the thickness) have a high failure rate with nonoperative treatment and are more likely to benefit from surgery.
• Complete Tears: It is widely accepted that normal tendons do not rupture. Complete tears typically occur in areas of preexisting tendon degeneration. Due to this underlying pathology and the nature of the tear—often a complete avulsion from its insertion at the radial tuberosity—complete distal biceps tendon ruptures generally do not heal on their own to restore full strength and function. While some historical reports suggested satisfactory results with nonoperative management, modern biomechanical and clinical studies demonstrate that without surgical repair, complete ruptures lead to significant and disabling losses in elbow flexion and supination strength and endurance. Therefore, for most patients, particularly those who require upper extremity strength for vocational or recreational activities, early surgical reattachment is recommended for optimal return of function. Nonoperative management is an option for individuals willing to accept a modest reduction in elbow supination strength and potential cramping.

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Written by Grace Gong PT Student