Biceps tendinopathy/rupture

Question 1

What classical sign is seen on biceps rupture?

Answer 1

“Popeye” sign

Question 2

What are the uses of the Yergason’s test?

Answer 2

The Yergason’s Test = biceps tendon pathology, such as bicipital tendonitis and an unstable superior labral anterior posterior (SLAP) lesion.

Question 3

How is Yergason’s test carried out?

Answer 3

Patient’s elbow in 90 degrees of flexion in a pronated position.

The patient is asked to externally rotate and supinate their arm against the manual resistance of the therapist produced by wrapping the hand around the distal forearm (just above the wrist joint).

Examiner presses on the insertion of the biceps

Question 4

Where do the two biceps tendons attach proximally?

Answer 4

The biceps muscle has 2 tendons at its origin; the long tendon which attaches to the glenoid and the short tendon which attaches to the coracoid process

It inserts distally via another tendon onto the radial tuberosity.

Question 5

Which tendon is usually affected in biceps rupture?

Answer 5

Most frequently occurs at the long tendon (90%), but rarely can occur in the distal tendon (10%).

• Proximal biceps tendon ruptures generally occur in older patients, over the age of 60 and account for 90% of biceps tendon ruptures. This occurs at the long tendon.
• Distal biceps tendon ruptures are much less common and only account for 10% of cases. The mean age of presentation is 40, it almost always occurs in men and at a rate of 2.55 per 100,000 patient-years.

Question 6

Who is most affected by biceps rupture?

Answer 6

men than women at a 3:1 ratio

Question 7

What are the risk factors for biceps rupture?

Answer 7

• Heavy overhead activities
• Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon
• Smoking
• Corticosteroids; these weaken tendons

Question 8

What is the mechanism of injury in biceps rupture?

Answer 8

Proximal biceps long tendon ruptures: typically occurs when the biceps are lengthened and contracted and a load is applied. e.g. the descent phase of a pull-up

Distal biceps tendon ruptures: Usually when a flexed elbow is suddenly and forcefully extended whilst the biceps muscle is contracted

Question 9

What are the clinical features of biceps rupture?

Answer 9

• A sudden ‘pop’ or tear either at the shoulder (long tendon), or at the antecubital fossa (distal tendon) which is followed by pain, bruising and swelling
• ‘Popeye’ deformity = proximal tendon; this is when the muscle bulk results in a bulge (less obvious in cachectic/obese)
• ‘Reverse Popeye’ deformity = distal tendon; not a reliable sign.
• Weakness in the shoulder and elbow typically follows including difficulty with supination
• Some patients who may have had chronic shoulder pain prior to tendon rupture might notice an improvement in their pain.

Question 10

What investigations are used to diagnose biceps tendon rupture?

Answer 10

Biceps squeeze test (Ruland’s) - if it is intact then a squeeze will cause forearm supination

Ultrasound - first line by skilled clinician

MRI - first line for distal rupture or if uncertain diagnosis/other pathology coexists. Distal rupture usually requires surgery.

NB: for suscpected long head biceps rupture imaging is not needed as management is conservative