Elsevier

Hand Clinics

Volume 25, Issue 3, August 2009, Pages 347-357
Hand Clinics

Biceps Tendon Injuries in Athletes

https://doi.org/10.1016/j.hcl.2009.05.007Get rights and content

Although rare, athletes involved in competitive strength training and contact sports may sustain distal tendon biceps injuries. Treatment of complete distal biceps tendon ruptures in athletes is primarily surgical. Early repair, through either one-incision or two-incision techniques with anatomic reinsertion of the ruptured tendon to the bicipital tuberosity, is highly recommended. In this article the etiology and pathophysiology of distal biceps tendon ruptures, current diagnostic modalities, and surgical indications are discussed. Also, treatment options, surgical techniques, outcomes, and potential complications are reviewed.

Section snippets

Surgical anatomy

Thorough knowledge of the anatomy of the distal biceps tendon may assist surgeons in correctly orientating the distal biceps tendon during anatomic repair, thus restoring more normal muscle kinematics.1 The biceps brachii is a long spindle-shaped muscle, placed in the anterior compartment of the arm. It arises by the short and long heads, which merge at the level of the deltoid tuberosity to form a single muscle belly. This muscle belly ends in a flattened tendon, which passes deep in the

Biomechanics

The biceps brachii is the most powerful supinator of the forearm, and serves elbow flexion in conjunction with the brachialis muscle. Eames and colleagues,7 in a cadaveric study, showed that the short head, inserted distal to the radial tuberosity, is a more powerful flexor of the elbow, whereas the tendon of the long head, inserted on the tuberosity further from the axis of rotation of the forearm, is a stronger supinator. These functions of the biceps are influenced by the position of the

Pathophysiology

Distal biceps tendon rupture was encountered rarely as an injury; only 65 cases were reported before 1941.4, 20 However, Safran and Graham21 recently reported an increased frequency in incidences of 1.2 ruptures per 100,000 persons per year. In the average population, the rupture typically occurs in the dominant extremity of active males between the fourth and sixth decades of life, although recent literature has shown that individuals of any age and of either gender can be affected.9, 11, 17,

Classification

Distal biceps tendon ruptures can be categorized as partial or complete. Partial ruptures are rare and often triggered by minor trauma without even being associated with a traumatic incident. Preexisting degeneration in the tendon is accounted by the latter situation.8 A subdivision of partial ruptures into insertional (to bone) and intrasubstance (tendon elongation), as seen on the MRI, was described by Ramsey.9

Complete ruptures are arbitrarily classified as acute and chronic, based on the

Clinical Examination

Diagnosis of the distal biceps rupture is mainly established on the basis of history, mechanism of injury, and clinical examination. Patients with complete distal biceps rupture usually report a traumatic event where an unexpected extension force was applied to the flexed arm, although others report that they attempted to avoid a sudden fall.46 This is usually associated with an audible pop or a snapping sensation followed by pain and weakness in the upper extremity. The intense pain often

Surgical indications

Treatment of complete distal biceps tendon ruptures in athletes is primarily surgical. Nonoperative management was the mainstay of treatment for distal biceps ruptures in the past.53, 54 Nevertheless, conservative treatment of distal biceps tears led to an appreciable decrease in strength and endurance in flexion and supination.24, 33, 55 Nonoperative treatment showed a 40% loss of supination strength and an average 30% loss of flexion strength.33 Pearl and colleagues56 reported on a weight

Complete Ruptures

The goal of any surgical procedure to repair the distal biceps tendon rupture should be restoration of the pre-injury anatomy and function as closely as possible. Single-incision and two-incision techniques, with various modifications, have been extensively described, each having its advantages and limitations. Controversy still exists over which approach is superior.

In 1961, Boyd and Anderson63 were the first to introduce the two-incision technique in an effort to limit surgical dissection and

Results

It is well documented in recent literature that early anatomic reattachment of the tendon to the biceps tuberosity in acute and subacute injuries will result in return to elbow flexion and supination strength and endurance.9, 10, 11, 23, 24, 25, 26, 27, 28, 33, 34, 35, 46, 55, 56, 57, 58, 59, 67, 68, 69, 70, 71, 72, 73 The ideal distal biceps tendon repair should have high fixation strength, allow early rehabilitation, and have extremely low complication rate. As mentioned, single-incision and

Complications

The main complication of the original single-incision technique has been neurologic sequelae. Lateral antebrachial cutaneous nerve paresthesia and subsequent posterior interosseous nerve palsy were the most common nerve injuries.14, 15, 17, 20, 57 With the introduction of newer fixation devices, the anterior one-incision technique was made feasible by limiting extensive soft-tissue dissection, resulting in minimal morbidity and a low complication rate. McKee and colleagues,17 in a series of 53

Summary

Distal biceps injuries are rare in overhead athletes, but they are more common in weight lifters and bodybuilders. The etiology and pathophysiology of tendon ruptures is controversial and multifactorial. Treatment of complete distal biceps tendon tears in athletes is primarily surgical, as this is the best method to restore both flexion and supination strength and endurance. Surgical repair, through either one-incision or two-incision technique, with anatomic reinsertion of the ruptured tendon

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    No declared financial interests for both authors in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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