Biceps Rupture in Climbers

What is the Anatomy and Physiology of the Biceps Brachii?

The biceps muscle, formally known as biceps brachii has two proximal attachment sites. It originates as two distinct muscle bellies and converges near the middle of the humerus (upper arm bone). The more medially located muscle belly is known as the short head of the biceps. The short head of the biceps muscle originates from an anatomical structure of the shoulder blade known as the coracoid process, a bony protrusion that can be felt at the front of the shoulder joint. The long head of the biceps brachii muscle lies more laterally and originates from the glenoid labrum which is a ring of cartilage that envelopes the rim of the shoulder joint - this makes the origin of the long head of the biceps muscle unique because it is continuous with the cartilage lining the shoulder joint rather than attaching directly to the bone as most other tendons do. Distal to the mid-shaft of the humerus, the two muscle bellies converge and insert as a single tendon into an anatomical structure on the lateral side of the forearm called the radial tuberosity.

The biceps brachii muscle is a multi-joint muscle that spans both the shoulder and the elbow, meaning it has a role in movement at both of these joints. Its main action is elbow flexion (bending the elbow), but it also has many secondary actions such as forearm supination (turning the palm up), and shoulder flexion (raising the arm overhead).

A biceps tendon rupture denotes an injury where the biceps muscle is subjected to excessive loads and detaches from one or more of its proximal attachment sites.

The most common locations for a biceps tendon rupture are at the proximal attachment of the long head (where it connects to the glenoid labrum), and distally where the tendon inserts into the radius.

What are the Signs and Symptoms of Biceps Tendon Rupture?

Signs and symptoms of a biceps rupture include:

• Pain and tenderness either at the shoulder or the elbow

• Swelling

• Marked weakness of the elbow and shoulder

• Limited elbow range of motion

• Upper arm deformity

If you are experiencing any of the signs or symptoms listed above after sustaining an acute injury to your arm, you should seek medical attention and assessment from a professional. Upon assessment, several tests and measures will be used in combination with a detailed subjective history and physical examination to confirm the diagnosis of a biceps tendon rupture.

What is the Assessment for Biceps Tendon Rupture?

Some subjective complaints that may hint towards a biceps tendon rupture are:

• Hearing a loud pop

• Immediate severe pain around elbow/shoulder region following trauma

• Severe pain subsiding to a dull ache after 20 minutes of rest

• Inability to bend elbow

Clues upon observation and palpation of the injured area:

• Tenderness over the anterior region of the elbow (distal injury)

• Inability to flex elbow through ROM

• Upper arm deformity due to a retracted bicep muscle belly (“popeye deformity”)

Your physiotherapist or doctor may also perform a cluster of special diagnostic tests when a biceps tendon rupture is suspected such as:

• Biceps squeeze test

• Bicipital aponeurosis flex test

• Hook test

• Passive forearm pronation test

• Biceps crease interval test

After the initial portions of the assessment are performed, if a qualified clinician requires further confirmation, diagnostic imaging may be required such as ultrasound (US) or magnetic resonance imaging (MRI).

Surgical Intervention - Is it possible I may need surgery?

In the case of biceps rupture, surgical intervention is almost always warranted. The type of surgery will depend on whether the rupture occurred proximally (at the shoulder), or distally (at the elbow).

Distal biceps rupture typically involves refixation of the tendon onto the radial tuberosity using a combination of absorbable anchors and/or sutures. This is a minimally invasive, low risk procedure and is usually associated with good clinical outcomes.

Repairing a proximal biceps ruptures is a little bit more complex, and there are several options for the surgical intervention. One common type of repair for distal biceps tendon rupture is called a biceps tenodesis in which the surgeon will attach the long head of the biceps muscle to the humerus bone (instead of back to original location on the glenoid labrum). Another technique called a biceps tendon transfer involves attaching the long head tendon to the coracoid process of the shoulder blade alongside the short head tendon.

What is the Rehabilitation Process like?

Your recovery after surgery will depend on the specific surgical methods and protocol used, but in general patients can expect to have the arm immobilized for a period of a few weeks during which your physiotherapist will instruct you on how to perform passive range of motion exercises to keep the arm mobile. The next phase of recovery will involve light exercise aimed at restoring full active range of the elbow and shoulder in a progressive, stepwise fashion. After approximately 6-8 weeks have passed since the surgery, you will begin performing more advanced resisted exercises to regain strength. The final phase of rehabilitation occurring after approximately 2-3 months will involve gradual return to normal activities and sport specific training.

The information above outlines a very general timeline. As always, your recovery and return to sport will be unique and progressions and adaptations to your rehabilitation protocol will be made based on your individual progress. Your physiotherapist and surgeon will collaborate with eachother to ensure you receive the best possible care during your post-operative recovery.

For more information, contact our Vancouver physiotherapists at our Main Street clinic.

Original Article by Rachel Rubin-Sarganis

Photo by Jesper Aggergaard