Biceps Tear or Injury | Mathew Mazoch, MD

Bone & Joint Clinic of Baton Rouge | Sports Medicine


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Biceps Tear or Injury

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Introduction to Biceps Tears or Injuries

The biceps muscle goes from the shoulder to the elbow on the front of the arm. Two separate tendons connect the upper part of the biceps muscle to the shoulder, the long head tendon and the short head tendon.  The long head of the biceps connects the biceps muscle to the top of the shoulder socket, the glenoid.  The long head of the biceps tendon runs within the bicipital groove.   The short head of the biceps connects on the corocoid process of the scapula.  The lower biceps tendon is called the distal biceps tendon and it attaches to the radial tuberosity in the forearm.  The biceps is most commonly injured at the long head and more rarely it can be injured at the distal biceps tendon.  Depending on where it is injured and the finding depends on how the injury needs to be treated.

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This diagram shows the basic anatomy of the biceps tendon in the arm.

Causes of Biceps Tears

A biceps tear or rupture usually involves a complete tear of the main tendon that attaches the top of the biceps muscle to the shoulder. It happens most often in middle-aged people and is usually due to years of wear and tear on the shoulder. A torn biceps in younger athletes sometimes occurs during weightlifting or from actions that cause a sudden load on the arm, such as hard fall with the arm outstretched.

The distal biceps tendon can also be torn at the elbow, this is usually caused by an eccentric contraction of the biceps.  A tear of the distal biceps is rarer but often requires more aggressive treatment.

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This diagram shows a ruptured distal biceps tendon at the elbow.

Why did my biceps tear?

Biceps tears/ruptures generally occur in people who are between 40 and 60 years old and have had shoulder problems for a long time. Often the biceps ruptures after a long history of shoulder pain from tendonitis (inflammation of the tendon) or problems with shoulder impingement. Shoulder impingement is a condition where the soft tissues between the ball of the upper arm and the top of the shoulder blade (acromion) get squeezed with arm motion and become irritated.

Years of shoulder wear and tear begin to fray the biceps tendon. Eventually, the long head of the biceps weakens and becomes prone to tears or ruptures. Examination of the tissues within most torn or ruptured biceps tendons commonly shows signs of degeneration. Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon. Some of the individual strands of the tendon become jumbled due to the degeneration, other fibers break, and the tendon loses strength.

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This diagram shows a tear of the long head of the biceps tendon with retraction.

A rupture of the proximal biceps tendon can happen from a seemingly minor injury if the tendon already has advanced degeneration.   Aging adults with rotator cuff tears also commonly have a biceps tendon tears. When the rotator cuff is torn, the ball of the humerus is free to move too far up and forward in the shoulder socket and can impact the biceps tendon. The damage may begin to weaken the biceps tendon and cause it to eventually rupture.

Related Page: Rotator Cuff Repair Surgery

What does a biceps tendon tear feel like?

 

Patients often recall hearing and feeling a snap in the top of the shoulder for proximal biceps tears. Immediate and sharp pain follow. The pain often subsides quickly with a complete rupture because tension is immediately taken off the pain sensors in the tendon. Soon afterward, bruising may develop in the middle of the upper arm and spread down to the elbow. The biceps may appear to have balled up, especially in younger patients who’ve had a traumatic biceps rupture. The arm may feel weak at first with attempts to bend the elbow or lift the shoulder.

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Some people with proximal biceps ruptures will get a ‘popeye’ muscle. This is wear the muscle belly of the long head retracts and created a ball of muscle in the arm.

When the distal biceps tendon is torn, people often feel or hear a pop around the elbow.  It is not uncommon to see a lot of bruising around the elbow.  Occasionally, the muscle belly of the biceps will appear retracted back towards the shoulder.  Often people have difficulty with elbow flexion and twisting activities of the forearm.

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This diagram shows the muscle belly of the biceps retracted towards the shoulder. This can be seen in distal biceps ruptures.

Diagnosing Biceps tendon tears

Proper diagnosis of biceps tears requires a good history and physical exam. Your doctor may position your arm to see which movements are painful or weak. By feeling the area of the muscle and tendon, the doctor can often tell if the tendon has ruptured. The muscle may look and feel balled up in the middle of the arm as above or the tendon may not be able to be felt where it should.

X-rays are commonly taken to identify if the ruptured tendon pulled off a piece of bone with it.  They also help identify other bone abnormalities that may have contributed to the tear including bone spurs that can be present in impingement.  Plain X-rays do not show soft tissues like tendons and will not show a biceps rupture.

Magnetic resonance imaging (MRI) scans are often used in proximal and distal biceps ruptures. This is the most reliable way to check whether the biceps tendon is only partially torn or if the tendon actually ruptured.  The MRI can also show if there are other problems in the shoulder like a rotator cuff tears or other soft tissue abnormalities around the shoulder or the elbow.

Treatment of Biceps tendon tears

Nonsurgical Treatment of proximal biceps tendon tears

Doctors often treat a ruptured long head of biceps tendon without surgery. This is especially true for older individuals who can tolerate loss of arm strength or if the injury occurs in the nondominant arm.

Not having surgery usually only results in a moderate loss of strength. The short head of the biceps is still attached and continues to supply strength to raise the arm up. Flexion of the elbow may or may not be affected, but supination (the motion of twisting the forearm such as when you use a screwdriver) is usually affected more. Not repairing a ruptured biceps reduces some supination strength.

Nonsurgical measures could include a sling to rest the shoulder. Patients may be given anti-inflammatory medicine to help ease pain and swelling and to help return people to activity sooner after a biceps tendon rupture. Therapy is sometimes helpful in returning to function after proximal biceps tendon injuries.

Some NFL quarterbacks have ruptured their proximal biceps tendon of their throwing arm and not had surgery and done very well.

Non-surgical treatment of distal biceps tendon tears

Non-surgical management of distal biceps tendon ruptures is considered if the tear is very old, someone has limited need or use of the arm, or has other medical issues.  Sometimes distal biceps ruptures are more symptomatic and painful if treated non-operatively than proximal biceps ruptures.  As always an individualized approach is needed to decide whether non-operative treatment is the correct choice.

Surgery for proximal biceps tears

Surgery is reserved for patients who need arm strength, are concerned with cosmetics of the balled up biceps, or who have pain that won’t go away.

Biceps Tenodesis
Biceps tenodesis is a surgery to anchor the ruptured end of the biceps tendon. A common method,  involves anchoring the ruptured end to the upper end of the humerus.

Surgery for distal biceps tears

Surgery is more commonly indicated for distal biceps tears.  It usually involves securing the biceps tendon to the radial tuberosity through a variety of techniques.  Recovery time and limitations depend on the quality of the tissue, tension on the repair and the chronicity of the injury.  In general acute repairs can be more aggressive about advancing activities and chronic tears have a more protracted recovery.

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This is a stylized diagram showing a distal biceps repair.

Biceps tendon surgery of the shoulder or elbow is not to be undertaken lightly; however, if performed for the right reasons it can result in significant pain relief and an increased quality of life.  If you have any further questions please don’t hesitate to schedule an appointment with Dr. Mazoch.