Biceps Rupture - Symptoms, Diagnosis, and Treatment

What Is Biceps Rupture?

Biceps rupture is a loss in continuity or breaks or tears in the tendon that connects the muscle called the biceps to the shoulder or elbow. Tendons are connective tissue structures that connect muscle to the bone that is flexible and prevent muscle injury. Bicep rupture is considered a major shoulder problem, and it can lead to swelling in the shoulder, like the cartoon character ‘Popeye’ in a cartoon show. So, it is called Popeye deformity or Popeye’s muscle.

How Does It Occur?

The biceps muscle is a muscle present in the upper arm between the elbow and shoulder. It has two heads which are short and long. The long head attaches to the shoulder socket, and the short head attaches to the bump in the shoulder blade. Bicep tendons help in supination (a movement in which the wrist faces upwards) of the forearm and flexion (bending) of the elbow.

The long head of the tendon is most commonly injured, and it often occurs in the dominant arm. The short head of the biceps rarely ruptures. Long head rupture occurs in old-aged people but can occur in younger individuals, too, if there is a traumatic fall. The biceps' short and long head tears have different etiology and mechanisms. So even if the long head of the biceps is completely torn, the other attachment helps people use the biceps.

When the shoulder is overused for a prolonged time and if there is a frequent lifting of shoulders over the head, biceps rupture occurs. Jobs that require more of these kinds of activities include weightlifting, tennis, swimming, and wrestling. Injury to the biceps muscle can also lead to rupture. The use of steroids and smoking has also been found to be causing bicep rupture.

What Are the Symptoms?

• Sharp pain that is sudden in onset.

• A popping sound or snapping sensation when trying to move the shoulder.

• A bulge in the bicep is known as Popeye’s deformity, which occurs in the long head of the biceps tendon.

• Inability to perform activities that include lifting shoulder overhead.

• Weakness of the affected arm.

• Bruising may be present in cases of injury to the biceps muscle.

• Swelling and inflammation of the affected site.

• Activities such as using a manual screwdriver and opening a jar become difficult for the affected individuals.

How Is It Diagnosed?

MRI (magnetic resonance imaging) and ultrasound are taken to picture the tendon tears clearly. X-ray is also taken to rule out other abnormalities. Finally, some diagnostic tests are taken to confirm the diagnosis.

1. Popeye’s Sign: It is a classic sign to confirm the presence of rupture. There is a pronounced swelling in the distal aspect of the arm in the bicep region.

2. Speed’s Test: In this test, the patient’s arm is flexed and externally rotated, the forearm is supinated, and the elbow is fully extended by the examiner. Then a downward force is applied by the examiner on the affected arm, and the presence of pain in the bicipital tendon confirms the diagnosis.

3. Hook Test: The patient is asked to abduct the shoulder to 90 degrees with the elbows bent perpendicularly, and the forearm is supinated with the thumb facing the ceiling. Resistance is applied by the examiner when the patient actively supinates. Then the examiner uses the index finger to hook from the lateral to the medial side of the biceps tendon, which is intact. On the affected hand, the tendon cannot be hooked due to a rupture. This indicates a positive test.

How Can It Be Treated?

1. Operative Treatment: It is important that surgery is done immediately after a rupture is diagnosed. An acute complete tear is an indication of an operative procedure in the biceps. It is done by fixing the tendon internally back to the radial tuberosity (bump on the medial side of the radius bone) after debriding the torn tendon. Patients can resume normal activities after three to four months of surgery.

2. Non-operative Treatment: In patients with an incomplete tear or those who are non-compliant with surgery, non-operative treatments are done. After conservative treatments, there can be mild and permanent deformity of the bicep, but the range of motion and elbow strength can be fully restored in some patients.

• Rest: Resting the affected arm is the first step to healing. Adequate rest and restraining from activities that can induce pain should be avoided.

• Ice Packs: The application of ice to the affected area greatly helps in reducing pain.

• Medications: Non-steroidal anti-inflammatory drugs (NSAIDs) like Aspirin, Ibuprofen, and Naproxen can be used to control pain and swelling.

• Physical Therapy: Stretching and strengthening exercises are done to rehabilitate the affected arm. This rehabilitation program can take around four to six weeks to complete.

A) Week One (Acute Phase): In this phase, the glenohumeral (shoulder joint) range of motion is restored. Joint mobilization is done to restrict the capsular tissue in the shoulder joint. Stretching activities like cross-arm stretching and sleeper stretching are advised.

1. Cross-Arm Stretching: This will help reduce pain and stiffness. The patient is asked to stand straight and asked to lift the affected arm, and reach shoulder level touching the shoulder bone of the other hand. If the patient finds it difficult, the support of the unaffected hand to lift the arm is advised. Now slowly pull the elbow to the affected side such that the hand of the affected arm is behind the back. Hold this stretch for 20 seconds and repeat it 20 times daily.

2. Sleeper Stretching: This exercise is done by lying on a bed on the affected side and the neck bent. Now the affected arm is lifted from the bed and internally rotated using the unaffected hand until a stretch is felt. Hold this position for 20 seconds and repeat it 20 times a day.

B) Week Two (Subacute Phase): Continue with the same exercises to improve the range of motion. Rotator cuff strengthening exercises with TheraBand are introduced this week.

• TheraBand Exercises: Stand with the TheraBand under the feet, hold the free ends with both hands, and slowly lift the ends up until shoulder level by bending the elbow and then bring them back to relax for five seconds. Repeat this exercise 20 times.

C) Week Three (Advanced Phase): Continue the strengthening exercises along with TheraBand exercises that include a bear hug, reverse fly, and push-ups. Weight training is also done to improve strength.

1. Bear Hug: It is done using a resistance band tied to a firm object such as door handles or windows. Place the resistance band behind the shoulder blades, with a slight bend in the elbow. Hold the band by making a fist and try to move the arms around and forward like hugging a bear and then return to the normal position. Repeat this two to three times for up to 15 times.

2. Reverse Fly: This exercise is also done by using a resistance band. Stand straight by holding the resistance band up near the shoulder level with both hands by making a fist. Slowly expand the band as long as the hands are horizontally straight and parallel to the floor. Relax back to the original position and repeat this.

D) Week Four (Return to Activities): The patient is usually recovered at this stage and can resume their normal chores. Exercises at home and return to sport are advised. Re-evaluation at specific intervals is also advised.

How to Prevent Biceps Rupture?

• Strengthening the shoulder, elbow, and forearm.

• A warm-up and stretching session should be performed before any sporting activities.

• Avoid overuse of the shoulder and lifting heavy weights.

• Repetitive actions like forceful pushing or pulling and weightlifting should be reduced.

• Caution must be taken while lifting and dropping things that are heavy.

• Steroid use should be avoided or reduced as it can lead to weakness and rupture.

• Smoking is also a risk factor that has to be avoided.

Conclusion:

Biceps rupture rarely occurs but is a debilitating condition and has to be treated immediately. Non-operative treatments are advised for patients who cannot undergo surgery and those with incomplete ruptures. Tendon debridement and internal fixation of the biceps are mandatory for symptomatic patients with a complete tear of the biceps and those who did not benefit from non-operative treatments. However, non-operative treatments have significantly replaced the form and function of the affected joints significantly in patients who have had partial biceps tears.