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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. A biceps tendon rupture is when one of these tendons separates from its attachment site or is torn across it's full width. This most frequently occurs at the long tendon (90%), but rarely can occur in the distal tendon (10%).
Incidence: 1.00 cases per 100,000 person-years
Peak incidence: 40-50 years
Sex ratio: more common in males 8:1
Patients typically report the following symptoms/signs:
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
Rupture of the proximal tendon causes 'Popeye' deformity; this is when the muscle bulk results in a bulge in the middle of the upper arm. Seen more easily in muscular individuals and less obvious in overweight or cachectic patients
Rupture of the distal tendon can cause 'reverse Popeye' deformity but this is 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.
Start with a basic examination, palpate the long head and distal biceps tendon and assess neurovascular function the upper extremities
The biceps squeeze test: If it is intact then a squeeze will cause forearm supination
Musculoskeletal ultrasound by a skilled clinician and should always be the first investigation for suspected biceps tendon rupture
For suspected long head biceps tendon rupture there is little role for further imaging given the conservative management. However MRI can be considered if there is a limited examination or likely concomitant pathology.
For suspected distal biceps tendon rupture, an urgent MRI should be performed as a diagnosis on clinical signs alone is challenging, and this usually requires surgical intervention.