Biceps lesions – mid arm to elbow

Muscle belly lesion

Definition

• Pain which is felt at the mid-arm, in which the lesion itself may lie in the muscle belly, usually the lower half

 

Cause

• Often a result of a single excessive strain typically involved with lifting

 

Localization

• Posterior aspect of the muscle belly (most common)
  • May be difficult to palpate
• At lower arm, at the musculotendinous junction
• At tenoperiosteal insertion at the tuberositas radii

 

Development

• Spontaneous cure may take 2 year
• Pain may continue indefinitely
  • Especially with active patients who participate in sports or occupational manual labor

Indications

• Pain at the lower arm may indicate a musculotendinous junction lesion
• Pain at the anterior aspect of the elbow may indicate lesion to the tenoperiosteal insertion

Examination

• Resisted flexion is painful
• Resisted supination is painful
• When the lesion lies at tenoperiost at tuberositas radii
  • Full passive pronation is painful in addition
  • Palpation is negative

Distal biceps rupture

Definition

• Either a complete rupture or a partial rupture of the biceps tendon at the distal aspect of the muscle that usually occurs at the insertion of the tendon at the tuberositas radii

 

Occurrence

• Prevalence is around 2.55 per 100000 patient years  ¹
• More than 95% of patients are male
• Usually happens between 35-54 years of age²

 

Cause

• Occurs during excessive eccentric flexion force is applied to the arm towards a stretched position³
• Typically occurs during
  • Weightlifting
  • Wrestling
  • Labor intensive jobs

Localization

• Usually at the insertion on the tuberositas radii

Risk factors

• Age
• Smoking
• Obesity
• Use of corticosteroids
• Over-exertion
• Musculotendinous ruptures are common injuries among athletes⁴,⁵

 

Development

• Pain can persist for weeks to months after the injury, pain will usually diminish faster if the tendon is completely torn
• Proximal biceps rupture patients generally recover with non-operative treatment and experience no long-term deficits in shoulder or elbow strength
• Distal biceps rupture, on the other hand, can cause persistent pain and forearm supination weakness⁶
• In complete distal biceps rupture
  • Thetendon can retract significantly and later repair in chronic cases would be technically challenging. Therefore quick diagnosis of distal biceps rupture is critical, especially in a young active patient.

 

Indications

• Patient may complain of a sharp sudden pain in the elbow after an eccentric force is applied to the flexed elbow
  • The patient may notice an audible ‘pop’ in the arm as it occurs

 

Observation

• Bruising and swelling may be present in the antecubital fossa
• Popeye sign may be present (bulge of the biceps in the mid-arm visible when patient flexes the arm), as the muscle is retracted to the upper arm and the distal tendon can be palpated

 

Examination

• Hook test
  • Palpating and noticing an absence of the distal tendon of the biceps
  • Position the patients arm in 90 degree of flexion and supination
  • Hook the tendon underneath the skin
    • When intact the examiner will be able to hook the index finger under the biceps tendon
    • Test has high sensitivity and specificity⁷
  • Resisted flexion - weakness
    • Not necessarily good prediction as the brachialis will perform much of the force in flexion, and weakness can be hard to detect even though the biceps tendon is ruptured

 

Treatment

• Surgery is generally indicated for faster recovery and return to sports after complete distal biceps rupture⁸
• Surgery is also adviced to regain maximal strength of the forearm supination and to relieve pain in the antecubital fossa