The biceps brachii tendon process consists of 2 heads arising from the coracoid process (short head) and from the supraglottic germ of the scapular (long head). The bicephalic head takes refuge in the bicephalic tumour of the radius. The biceps brachii serves to flex and hyperextend the elbow. Rupture of the biceps extensor tendon can be treated conservatively, whereas rupture of the distal biceps tendon usually requires surgery.
Rupture of the biceps extensor tendon is due to excessive eccentric force as the arm is brought from flexion to extension. Rupture of the biceps extensor tendon is generally not due to a single mechanism of injury, but is highly correlated with the rupture of the rotator cuff. Risk factors include age, smoking, obesity, corticosteroid use and repetitive movements. Rare causes include quinolone use, diabetes, systemic lupus erythematosus and chronic kidney disease.
Most patients with biceps rupture are male, with an average age of 35 years to 54 years. Peripheral ruptures mainly involve the dominant limb. Age, overuse, smoking and corticosteroid use contribute to tendon degeneration and, later, tendinopathy.
Patients suffering from a ruptured biceps tendon complain of sudden acute pain in the elbow or shoulder, depending on the location of the rupture. Usually, there is a history of sudden eccentricity with the elbow in flexion. The pain may persist for weeks to months. In complete rupture, the pain may decrease. Patients usually complain of swelling in the upper arm due to excessive contraction of the biceps muscle, known as “Popeye’s deformity”.
In patients with rupture of the biceps collateral tendon, there is effusion, swelling and tenderness inside the elbow. Patients with rupture of the extensor heads of the biceps may have effusion of the proximal humerus, which sometimes extends to the elbow. Rupture of the proximal biceps does not result in a long-term change in elbow or shoulder strength.
The treatment of a biceps tear depends on the location of the tear. For rupture of the distal head of the biceps, conservative treatment is often sufficient, as it is more common in older patients. However, residual sensory deformity and some intermittent cramping may remain. Younger patients who do not want the aesthetic deformity and athletes may opt for surgery in the form of biceps tendonis. For rupture of the flexor biceps tendon, conservative treatment can be applied to patients with low physical demands and multiple comorbidities. Conservative treatment for rupture of the biceps cataplegic tendon results in 40% to 50% loss of supination strength, 30% loss of flexion strength, and approximately 15% loss of grip strength. Surgical treatment is applied to younger active patients who do not wish to sacrifice the functionality of their hand, with the benefits of faster recovery and return to sport. Surgery should be performed as early as possible as over time the tear scarring scars and a more extensive approach may be required. Surgical repair of the distal biceps tendon can be roughly divided into 2 methods. The nonanatomic approach involves end-to-end suturing of the tear, which is a simple and effective method for regaining flexion strength. The anatomic approach involves reattachment of the rhytoid tendon to the biceps radius tumor, which has better results in restoring flexion and forearm subtalar flexion.
