Biceps tendinopathy and tendon rupture
- Stephen M Simons, MD, FACSM
Stephen M Simons, MD, FACSM
- South Bend-Notre Dame Sports Medicine Fellowship
- J Bryan Dixon, MD
J Bryan Dixon, MD
- Clinical Assistant Professor of Family Medicine
- Michigan State University College of Human Medicine
- Medical Director
- United States Olympic Education Center
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Shoulder pain is a common presenting complaint to primary care offices and sports medicine clinics. The basic workup for shoulder pain should include assessment of the biceps tendon, which has been considered a common cause of shoulder pain since the 1930s [1,2].
Biceps tendon injuries include a spectrum of disorders ranging from mild tendinopathy to complete tendon rupture. Rupture occurs most frequently at the long head of the proximal tendon, but may occur in the distal tendon. Coexistent injuries at the biceps tendon origin and superior glenoid labrum constitute a variety of disorder known as SLAP (superior labrum, anterior to posterior) lesions . SLAP lesions are reviewed separately. (See "Superior labrum anterior posterior (SLAP) tears".)
This topic review will discuss the presentation and management of biceps tendinopathy (primarily of the proximal long head of the biceps tendon) and biceps tendon rupture, both proximal and distal. The general evaluation of shoulder complaints in adults and other discrete causes of shoulder pain and dysfunction are reviewed separately. (See "Evaluation of the patient with shoulder complaints" and "Physical examination of the shoulder" and "Rotator cuff tendinopathy" and "Presentation and diagnosis of rotator cuff tears" and "Glenohumeral osteoarthritis" and "Overview of upper extremity peripheral nerve syndromes", section on 'Proximal neuropathies'.)
EPIDEMIOLOGY AND RISK FACTORS
Data describing the incidence of biceps tendon injury by sport or occupation is scant and should be interpreted cautiously. Such injuries appear to occur more often among those who engage in frequent pulling, lifting, reaching, or throwing for work or recreation. Two clinical series describe biceps tendon ruptures in rock climbers and weight lifters [4,5].
Degenerative tendinosis and biceps tendon rupture are usually seen in older patients, while isolated tendonitis usually presents in the young or middle aged . According to a single-center study from the United Kingdom, among older patients (seventh decade of life) biceps tendon ruptures occurred at a rate of 0.53/100,000 over five years, with a male to female ratio of 3:1 . This study did not distinguish among proximal and distal biceps tendon injuries. Based on clinical experience, proximal biceps tendon injuries are far more common.
- Harwood MI, Smith CT. Superior labrum, anterior-posterior lesions and biceps injuries: diagnostic and treatment considerations. Prim Care 2004; 31:831.
- Gill HS, El Rassi G, Bahk MS, et al. Physical examination for partial tears of the biceps tendon. Am J Sports Med 2007; 35:1334.
- Snyder SJ, Karzel RP, Del Pizzo W, et al. SLAP lesions of the shoulder. Arthroscopy 1990; 6:274.
- Schöffl VR, Harrer J, Küpper T. Biceps tendon ruptures in rock climbers. Clin J Sport Med 2006; 16:426.
- Cope MR, Ali A, Bayliss NC. Biceps rupture in body builders: three case reports of rupture of the long head of the biceps at the tendon-labrum junction. J Shoulder Elbow Surg 2004; 13:580.
- Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury 2008; 39:1338.
- Kelly MP, Perkinson SG, Ablove RH, Tueting JL. Distal Biceps Tendon Ruptures: An Epidemiological Analysis Using a Large Population Database. Am J Sports Med 2015; 43:2012.
- Taylor SA, O'Brien SJ. Clinically Relevant Anatomy and Biomechanics of the Proximal Biceps. Clin Sports Med 2016; 35:1.
- Patton WC, McCluskey GM 3rd. Biceps tendinitis and subluxation. Clin Sports Med 2001; 20:505.
- Ding DY, Garofolo G, Lowe D, et al. The biceps tendon: from proximal to distal: AAOS exhibit selection. J Bone Joint Surg Am 2014; 96:e176.
- Wilk KE, Hooks TR. The Painful Long Head of the Biceps Brachii: Nonoperative Treatment Approaches. Clin Sports Med 2016; 35:75.
- McDonald LS, Dewing CB, Shupe PG, Provencher MT. Disorders of the proximal and distal aspects of the biceps muscle. J Bone Joint Surg Am 2013; 95:1235.
- Cone RO, Danzig L, Resnick D, Goldman AB. The bicipital groove: radiographic, anatomic, and pathologic study. AJR Am J Roentgenol 1983; 141:781.
- Catonné Y, Delattre O, Pascal-Mousselard H, et al. [Rupture of the distal tendon of the biceps brachialis: apropos of 43 cases]. Rev Chir Orthop Reparatrice Appar Mot 1995; 81:163.
- Virk MS, Cole BJ. Proximal Biceps Tendon and Rotator Cuff Tears. Clin Sports Med 2016; 35:153.
- McFarland EG, Borade A. Examination of the Biceps Tendon. Clin Sports Med 2016; 35:29.
- Gazzillo GP, Finnoff JT, Hall MM, et al. Accuracy of palpating the long head of the biceps tendon: an ultrasonographic study. PM R 2011; 3:1035.
- Holtby R, Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: comparison with arthroscopic findings. Arthroscopy 2004; 20:231.
- Bennett WF. Specificity of the Speed's test: arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy 1998; 14:789.
- Caliş M, Akgün K, Birtane M, et al. Diagnostic values of clinical diagnostic tests in subacromial impingement syndrome. Ann Rheum Dis 2000; 59:44.
- Chen HS, Lin SH, Hsu YH, et al. A comparison of physical examinations with musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis. Ultrasound Med Biol 2011; 37:1392.
- Quach T, Jazayeri R, Sherman OH, Rosen JE. Distal biceps tendon injuries--current treatment options. Bull NYU Hosp Jt Dis 2010; 68:103.
- Haverstock J, Athwal GS, Grewal R. Distal Biceps Injuries. Hand Clin 2015; 31:631.
- Ruland RT, Dunbar RP, Bowen JD. The biceps squeeze test for diagnosis of distal biceps tendon ruptures. Clin Orthop Relat Res 2005; :128.
- O'Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med 2007; 35:1865.
- Brasseur JL. The biceps tendons: From the top and from the bottom. J Ultrasound 2012; 15:29.
- Lobo Lda G, Fessell DP, Miller BS, et al. The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings. AJR Am J Roentgenol 2013; 200:158.
- Read JW, Perko M. Shoulder ultrasound: diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg 1998; 7:264.
- Teefey SA, Hasan SA, Middleton WD, et al. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 2000; 82:498.
- Armstrong A, Teefey SA, Wu T, et al. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg 2006; 15:7.
- Skendzel JG, Jacobson JA, Carpenter JE, Miller BS. Long head of biceps brachii tendon evaluation: accuracy of preoperative ultrasound. AJR Am J Roentgenol 2011; 197:942.
- Rodeo SA, Nguyen JT, Cavanaugh JT, et al. Clinical and Ultrasonographic Evaluations of the Shoulders of Elite Swimmers. Am J Sports Med 2016; 44:3214.
- Hung CY, Chang KV, Özçakar L, et al. Can Quantification of Biceps Peritendinous Effusion Predict Rotator Cuff Pathologies?: A Retrospective Analysis of 1352 Shoulder Ultrasound. Am J Phys Med Rehabil 2016; 95:161.
- Malavolta EA, Assunção JH, Guglielmetti CL, et al. Accuracy of preoperative MRI in the diagnosis of disorders of the long head of the biceps tendon. Eur J Radiol 2015; 84:2250.
- Carr RM, Shishani Y, Gobezie R. How Accurate Are We in Detecting Biceps Tendinopathy? Clin Sports Med 2016; 35:47.
- Dubrow SA, Streit JJ, Shishani Y, et al. Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI. Open Access J Sports Med 2014; 5:81.
- Razmjou H, Fournier-Gosselin S, Christakis M, et al. Accuracy of magnetic resonance imaging in detecting biceps pathology in patients with rotator cuff disorders: comparison with arthroscopy. J Shoulder Elbow Surg 2016; 25:38.
- Tadros AS, Huang BK, Wymore L, et al. Long head of the biceps brachii tendon: unenhanced MRI versus direct MR arthrography. Skeletal Radiol 2015; 44:1263.
- Schickendantz M, King D. Nonoperative Management (Including Ultrasound-Guided Injections) of Proximal Biceps Disorders. Clin Sports Med 2016; 35:57.
- Espiga X, Alentorn-Geli E, Lozano C, Cebamanos J. Symptomatic bicipitoradial bursitis: a report of two cases and review of the literature. J Shoulder Elbow Surg 2011; 20:e5.
- Aldhilan AS. Preoperative diagnosis of bicipitoradial bursitis: a case report. Pan Afr Med J 2014; 17:41.
- Klonz A, Loitz D, Reilmann H. [Proximal and distal ruptures of the biceps brachii tendon]. Unfallchirurg 2003; 106:755.
- Deutch SR, Gelineck J, Johannsen HV, Sneppen O. Permanent disabilities in the displaced muscle from rupture of the long head tendon of the biceps. Scand J Med Sci Sports 2005; 15:159.
- Sturzenegger M, Béguin D, Grünig B, Jakob RP. Muscular strength after rupture of the long head of the biceps. Arch Orthop Trauma Surg 1986; 105:18.
- Mariani EM, Cofield RH, Askew LJ, et al. Rupture of the tendon of the long head of the biceps brachii. Surgical versus nonsurgical treatment. Clin Orthop Relat Res 1988; :233.
- Chillemi C, Marinelli M, De Cupis V. Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion--clinical and radiological evaluation after 2 years. Arch Orthop Trauma Surg 2007; 127:705.
- Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii. Operative versus non-operative treatment. J Bone Joint Surg Am 1985; 67:414.
- Freeman CR, McCormick KR, Mahoney D, et al. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Joint Surg Am 2009; 91:2329.
- Virk MS, Nicholson GP. Complications of Proximal Biceps Tenotomy and Tenodesis. Clin Sports Med 2016; 35:181.
- Hashiuchi T, Sakurai G, Morimoto M, et al. Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg 2011; 20:1069.
- EPIDEMIOLOGY AND RISK FACTORS
- CLINICAL ANATOMY
- MECHANISM OF INJURY
- CLINICAL PRESENTATION
- PHYSICAL EXAMINATION
- General approach and overview
- Long head (proximal) biceps tendon evaluation
- - Inspection and palpation
- - Special tests
- Distal biceps tendon evaluation
- - General examination
- - Special tests
- DIAGNOSTIC IMAGING
- Approach to imaging
- Additional ultrasound resources
- Plain radiographs
- Magnetic resonance imaging
- DIFFERENTIAL DIAGNOSIS
- Long head biceps tendon (anterior shoulder pain)
- Distal biceps tendon (anterior elbow pain)
- INDICATIONS FOR ORTHOPEDIC REFERRAL
- Proximal biceps tendon injury
- Distal biceps tendon injury
- INITIAL TREATMENT
- Glucocorticoid injection for tendinopathy
- FOLLOW-UP CARE
- Long head (proximal) biceps tendinopathy
- Proximal long biceps tendon tear initially managed nonsurgically
- Distal biceps tendon tear
- RETURN TO SPORT OR WORK
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS