Biceps Lesions

The biceps is a muscle that lies over the front of the arm and bends the elbow. It causes the elbow to flex or bend and the forearm to rotate ( supination) so the palm faces upwards. It also has a probable role in ‘ fine tuning’ the movement of the shoulder joint, especially during rapid, overhead activity, es, a tennis serve or pitching in baseball throw.Bi means it has 2 attachments at the shoulder end. One to the coracoid process which is a bony prominence of the scapula (shoulder blade) just beneath the outer edge of the clavicle; the other tendon (the ‘long head of biceps’) is unusual in that it enters the shoulder joint cavity and crosses over the top of the head of humerus to attach to the top of the glenoid, still inside the shoulder joint.

Tendonitis of the long head of biceps

The tendon weakens with age and overuse. Overuse can be a result of activity or secondary to injury.

The biceps is also a stabilizer of the shoulder joint, especially when the arm is out to the side. It has to work even harder if there is a loss of other stabilizing structures in the shoulder, for example, a rotator cuff or labral tear. In these cases the biceps becomes inflamed from overuse and from the extra friction caused by a poorly controlled humeral head.

Rupture of the Long Head of Biceps Tendon

The biceps can become detached from any of its 3 tendon attachments, or rupture through the muscle to the tendon attachment. More commonly it is the long head of biceps that ruptures. Common examples of mechanisms of injury are :-
a) Falling onto an outstretched hand.b)
b) Repetitive motions of throwing, taking the arm out and above the head.
c) Pushing hard to get out of a chair (if already weakened)
d) Overuse of weights/lifting eg a weight-lifter doing bicep curls.
e) Sudden overloading, eg catching a falling weight.
f) Tendon disease such as Rheumatoid Arthritis

Signs and symptoms

• Sudden sharp pain in the upper arm.
• Sometimes snapping/tearing feeling.
• A bulge in the upper arm above the elbow and/or a dent close to the shoulder.
• Bruising.
• Pain to touch the front of the shoulder.
• Weakness.

Diagnosis

Your surgeon may be able to tell from a physical examination that the biceps muscle is ruptured. He may request an ultrasound scan or MRI scan to see if any other muscle has been affected, this is especially true for tendonitis when other structures are usually involved.

Conservative Management

• Ice applications to keep the swelling down.
• Non steroidal anti-inflammatory drugs eg: Ibuprofen to keep the swelling down.
• Rest the muscle and avoid heavy lifting/exercise.
• Strengthening the rotator cuff and scapulothoracic muscles.

Surgery

A complete rupture of the long head of biceps tendon cannot be repaired.

Biceps Tenotomy

This surgery is performed to relieve the pain of biceps tendonitis. It is also performed during other forms of corrective shoulder surgery when the biceps tendon has become inflamed as a result of abnormal movement in the shoulder eg: after a rotator cuff tear.

The long head of biceps is released from its attachment in the shoulder allowing it to fall down into the upper arm. It is a quick and easy procedure. It can result in some weakness in the arm but will not inconvenience a sedentary person. If performed alone the procedure is done arthroscopically (key hole surgery) as a day case.

Biceps Tenodesis

In this procedure the long head of biceps is detached from its origin at the top of the shoulder joint and reattached to the humerus just below the joint.

It is more complex than a tenotomy and is used for people with an active lifestyle as it avoids the weakness that can occur after a tenotomy.

It can be used in cases of tendonitis or rupture.

Rupture of the Distal Biceps Tendon

The next most common biceps tendon to rupture is that which is attached to the ulna bone at the elbow. Occasionally it is pulled off with a small avulsed piece of bone.
Common mechanisms of injury are :

a) Lifting excessive weights in a gym environment, especially if weights are ‘built up’too quickly or after inappropriate use of ‘anabolic’corticosteroids.
b) Sudden overloading eg catching a falling weight or throwing a weight upwards.
c) Tendon disease such as Rheumatoid Arthritis.

Signs and symptoms

• Sudden, sharp pain in the arm above the elbow
• Sometimes a snapping feeling
• An abnormal contour to the front of the arm
• Bruising around the elbow
• Tenderness around the elbow and front of the arm above the elbow
• Weakness

DiagnosisYour surgeon will be able to tell by examining the arm. An Ultrasound scan or an MRI scan as well as plain x rays are useful in confirming the diagnosis and ensuring no other damage has occoured.

 

Conservative Management

• Ice applications to keep the swelling down.
• Non steroidal anti- inflammatory drugs e.g ibuprofen to keep the swelling down.
• Rest the muscle and avoid heavy lifting/exercise
• Later the other muscles which flex the elbow can be strengthened-Brachioradialis and Brachialis- to regain elbow and lifting strength. This compensates for the loss of biceps function.

 

Surgery

The distal biceps tendon can be repaired by reattaching it to the Ulna bone where it came from .This can be achieved with tunnels within the bone and with special ‘anchors’ or ‘screws’ placed within the bone.

PICTURE NEEDED HERE

The timing of this surgical repair is however critical; it is not usually possible to repair this tendon after approximately 3 weeks from injury if completely ruptured. It is sometimes possible even later if the tendon is only partially ruptured.

LINK TO VIDEO OR PICTURE SEQUENCE.

 

MUSCULOTENDINOUS BICEPS RUPTURE

Rupture of the muscle itself, or, more commonly the junction between the muscle and the tendon is the third most common event. The causes are similar to that of a distal avulsion described previously.

 

Signs and symptoms

• Sudden sharp pain in the arm above the elbow
• Sometimes a snapping feeling
• An abnormal contour to the front of the arm
• Bruising around the upper third of the arm
• Tenderness around the upper third of the arm
• Weakness
Diagnosis

This will bw by physical examination by your surgeon, often combined with an ultrasound or MRI , to determine the exact site and extent of the rupture.
Conservative Management
• Ice applications to keep the swelling down.
• Non steroidal anti- inflammatory drugs e.g ibuprofen to keep the swelling down.
• Rest the muscle and avoid heavy lifting/exercise
• Later the other muscles which flex the elbow can be strengthened-Brachioradialis and Brachialis- to regain elbow and lifting strength. This compensates for the loss of biceps function.

Surgery

This is rarely indicated. Occasionally a repair can be undertaken, in selected cases, particularly in very high demand patients , requiring peak performance of weight lifting ability, or requiring maximum strength in rotating the forearm into supination ( turning the palm upwards). It is possible in some cases to repair the rupture using a collagen scaffold patch or borrowing tissue from another part of the body.

Again, however, timing is critical and usually little can be achieved by attempting a repair after approximately 3 weeks from injury.