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Background and Etiology

A tendon is part of the muscle that attaches muscle to bone. It is a strong, fibrous tissue that is responsible for transferring the forces generated by the muscle to the bone, thus producing movement at the joint. When stressed or damaged tendons can tear, or in extreme cases even rupture.

Biceps Tendon

The head of the humerus (upper arm bone) fits into the socket of the shoulder joint. Several muscles and tendons keep the arm anchored in the shoulder joint, including the long head of the biceps tendon, which attaches on the glenoid aspect of the scapula. A biceps tendon rupture is a partial or complete tear of the long head of the biceps tendon.

This tendon is responsible for bending the elbow (flexion), turning the forearm (supination) and assists in raising the arm over head. It is commonly irritated with repetitive overhead activities, like routine lifting and chores, which causes pain and weakness in the front of the shoulder. The tendon can weaken with age and rupture.

The biceps tendon can tear at the shoulder or distally at the elbow causing the “Popeye Arm” effect.

  • Participating in athletic activities that can strain the biceps, like weight training or wrestling when the arm is forced straight against resistance.
  • Repetitive strain injuries (RSI) that occur in people who consistently use the biceps muscle for sport or work with heavy lifting
  • Strain caused by an underlying condition like impingement syndrome or shoulder instability.
  • The tendon can weaken with age
  • An injury to the elbow or shoulder, or a direct blow to the tendon.
  • Laceration of the tendon
  • Steroid use has been linked to tendon weakness
  • Certain systemic diseases have been associated with biceps tendon weakness.
  • Shoulder and/or elbow pain,
  • Feeling of weakness in the elbow with difficulty actively bending the elbow but especially turning the hand up or supination.
  • Possible audible pop when the elbow is injured.
  • Patient may have a history of prior elbow pain or tendinitis
  • Swelling, tenderness and possible discoloration above the elbow.
  • Individual has difficulty or is unable to straighten their arm all the way.
  • MRI can confirm disruption or tear in the tendon.
  • Immediate pain at time of injury.
  • There is a gap where the tendon has ruptured

Early diagnosis and treatment is the key to a successful outcome for biceps tendon ruptures. If diagnosis or treatment is delayed the integrity of the healing tissue can be compromised as a result of scarring and decreased blood flow. Surgical repair followed by structured and physical therapy may be a treatment of choice for complete ruptures. This decision depends on the loss of function that is present following the injury. In some cases the surrounding muscles will compensate for the loss of the biceps and those individuals function well. Nonsurgical treatment should be considered for the elderly, inactive or those who are at risk with surgery. There will however always be a residual weakness. In the case of a small partial biceps tendon tear conservative treatment without surgery is an option. The surgical choice needs to be made in the first two to three weeks of injury.

Partial (small) Biceps Tendon Tear

  • A period of immobilization of the elbow is indicated to rest and promote healing.
  • Physical Therapy: following the period of immobilization your physician will decide when you are ready for physical therapy. Treatment will emphasize gradual weaning off the immobilizing device, and restoration of elbow’s range of motion. It is important that the physician and therapist communicate during the early stages and progress your recovery program based on the principles of healing so as not to compromise the biceps tendon.
  • Patient will be progressed to more functional activities as normal elbow range of motion and strength is restored.

Treatment of Complete Biceps Tendon Rupture

  • Immediate surgical repair of the tendon may be indicated in complete tears. Delaying surgery can lead to shortening of the tendon, formation of scar tissue and decreased blood flow, which can lead to a poor outcome.
  • Following surgery your elbow will be put in an immobilizing device to protect the joint.
  • Over the next 2-4 weeks use of the elbow will be increased and physical therapy will be initiated.
  • The surgeon will determine the physical therapy timeline and program.
  • Physical Therapy: treatment will emphasize gradual weaning off the immobilizing device, restoration of elbow’s range of motion and strengthening of the biceps muscles. It is important that the physician and therapist communicate during the early stages and progress your program based on the principles of healing so as not to compromise the biceps tendon.
  • Patient will be progressed to more functional activities as normal elbow range of motion and strength are restored.

Physical therapy for a tendon rupture must remain conservative at the onset in order to protect the repair. Emphasis will be on rest, tendon protection, reducing the inflammation and increasing the blood circulation for healing. Following the surgeon’s timeline and protocol, a program of stretching and strengthening will be initiated.

Common Physical Therapy interventions in the treatment of Biceps Tendon Rupture include:

  • Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization of the elbow by a physical therapist to improve joint mobility and range of motion of the elbow. Use of mobilization techniques also helps to modulate pain.
  • Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the biceps and muscles of the elbow and upper extremity.
  • Neuromuscular Reeducation (NMR) to restore stability, retrain the upper extremity and improve movement techniques and mechanics the involved upper extremity to reduce stress on the tendons in daily activities. Taping, strapping or bracing may be indicated to rest tendon and promote healing.
  • Modalities including the use of ultrasound, electrical stimulation, ice, cold, laser and others to decrease pain and inflammation of the involved tendon and bursa.

Prognosis

If repair and treatment are initiated immediately, individuals with biceps tendon ruptures generally do well. Delay can result from the formation of scar tissue and retraction of the tendons. Other factors that can affect recovery are:

  • Age: Older individuals are generally weaker and take longer to heal affecting the functional outcome.
  • Strength: Individuals who are strong and in good condition prior to the injury generally do better following surgical repair.
  • Tissue: Tissue quality prior to the surgical repair will effect healing and recovery following surgery. Poor circulation and presence of scar tissue will interfere with the healing process.

The healing time for a tendon repair will take up to 8-12 weeks but restoration of function and ability to accept full activity, load and stress can take up to one year.


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