Biceps Tendon Injuries in Athletes
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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Cited by (17)
Return to sports following distal biceps tendon repair: A current concepts review
2023, Journal of ISAKOSDistal biceps tendon rupture during softball swing: case report of a previously unreported mechanism of injury
2023, JSES Reviews, Reports, and TechniquesDistal biceps ruptures in National Football League players: return to play and performance analysis
2021, Journal of Shoulder and Elbow SurgeryBiceps and Triceps Ruptures in Athletes
2017, Hand ClinicsCitation Excerpt :Residual pain and weakness may persist despite appropriate rest, warranting continued rest or surgical consideration. There have been documented cases of progression to complete rupture and chronic triceps dysfunction in athletes who return to participation immediately.25,26,36,37 The literature regarding return to sport after operative repair is not robust.
Cadaveric Study of Insertional Anatomy of Distal Biceps Tendon and its Relationship to the Dynamic Proximal Radioulnar Space
2017, Journal of Hand SurgeryCitation Excerpt :The surgical reattachment level (SL) was defined as a point 2 cm proximal to the bicipital tuberosity attachment. The surgical level of 2 cm was based on 2 factors as described in the literature: (1) most surgical techniques recommend debridement and resection of a ruptured tendon for approximately 10 mm; and (2) the debrided tendon is further pulled into a bone tunnel of approximately 10 mm.20,21,27 This debridement and tendon sliding approximates the 2-cm mark (SL) at the bone–tendon interface.
MR Imaging of the Elbow in the Injured Athlete
2013, Radiologic Clinics of North AmericaCitation Excerpt :Newer therapies have shown encouraging results and include injections of autologous blood or platelet-rich plasma.50 Although relatively rare in the young athlete population, distal biceps tendon rupture is a serious injury.51 In football players, this may occur with forced extension of a flexed elbow while making a tackle.
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.