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Bicep Tendon Rupture
Zach Wreath
Therapeutic Rehabilitation
Dr. Hankins
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Table of Contents
I.
Title Page
II.
Table of Contents
III.
Abstract
IV.
Introduction
V.
Injury Scenario
VI.
Anatomy
VII.
Predisposing Factors
VIII.
Mechanism of Injury
IX.
Signs and Symptoms
X.
Surgery Options
XI.
Outline of Rehab
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Abstract
The bicep tendon is a tendon that is located in the front of the arm. The bicep helps in
bending the elbow and rotating the forearm. The tendon is also helpful in keeping the shoulder
stable. The bicep has three locations that is attaches. It attaches in two spots near the shoulder
and once distally at the medial side of the elbow. If these tendons are torn it is recommended
that the patient have surgery to repair the bicep tendon. There are two different types of surgery
that the surgeons can perform. When performing a distal bicep tendon repair the surgeon can use
a one incision or the two incision method to repair the injury to the tendon. After the patient has
went through surgery to repair the tendon the surgeon will place the patient in a sling and brace
to keep the arm and shoulder stable. The rehab will take a couple months to fully heal from the
surgery and also a couple extra weeks depending on the speed of the recovery of the patient. In
order for the athlete to be able to return to play they must complete the return to play activities.
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Introduction
Discus throwing has been around for many centuries now. It originated in ancient Greece
around 708 B.C. The discus throw is a combination of the athlete’s strength plus their
coordination and precision. Discus throwing is one of the oldest Olympiad sports as it was
introduced back in the 18th Olympiad (Terry 2011). When discus was first introduced the discus
throwers stood on a pedestal that was 24 inches by 27 ½ inches. As the sport became more
popular around the world they started to make changes to the disc which was changes from 4 ½13 pounds to 4 ½ pound disc with a 22 cm diameter. They also took the athletes off the pedestal
and gave them a throwing circle that was 8 feet across. These changes were made in the early
1900s, and still are the common dimensions they use for discus throwing today. Discus throwing
is still a huge competition for athletes all around in world. There are competitors of many
different ages and genders (Terry 2011).
Discus throwing takes a lot of strength and power to throw the disc into the air. If the
athlete is not properly trained from the beginning injuries can occur. Discus throwing can cause
many injuries to the shoulder, elbow and knees. Some injuries that can happen to the shoulder
are possible bicep tendon ruptures, rotator cuff, labrum tear, or possible cartilage damage to the
shoulder. The elbow could have bicep tendon tears and other strains can occur. The knee could
be at risk of injury when throwing the discus because of the hard twisting and stops they
perform. This leading too many ligament and cartilage tears and ruptures. In this paper I will
discuss injury scenario, anatomy of the injury, predisposing factors, mechanism of the injury,
sign and symptoms, type of surgeries, post operation and pre rehab, the first ten weeks of rehab,
rehab progression after the tenth week, the return to play guideline and activities, and criteria to
return to play.
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Injury Scenario
The injury scenario involves a twenty year old male discus thrower named Nick. Nick
has been performing at the top of his game during this track season. He is the team’s best discus
thrower and has been placing in mostly every meet he participates in. Nick has been doing his
job and gaining points for the team in the discus throw. He was competing at a meet recently
and was on his third throw. As he loaded up and moving into the swinging motion he felt a pop
at the elbow. He then felt a sharp pain radiate up his arm into the shoulder. After the pain
calmed down, Nick’s main complaint was that he didn’t have full strength in his right arm. He
was then examined by the athletic trainer. The athletic trainer then went through and performed
tests on him. Nick was sent to the hospital for further examination and x-rays. The x-rays and
tests showed that Nick has a distal bicep tendon rupture. Nick then is schedule to have surgery
in the next week so that the bicep will now start to shrink in size and cause further problems.
Anatomy
The elbow has many different structures that make up the elbow. There are three joints
that make up the elbow. These joint are needed to make sure that the shoulder and wrist work
properly. The three bones that make up these joints are the humerous bone (upper part of the
arm), the radius (the larger bone in the forearm), and the ulna (Elbow 2011). In appendix A it
shows the three bones that make up the arm. The first one is the humeroulnar joint, which is
between the humerous and the ulna. The humerous bone widens at the joint and make up two
bony processes (lateral and medial epicondyles). This joint allows us to be able to flex and
extend our arms. The next joint is the humeroradial joint which is between the radius and
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humerous. This also helps us flex and extend our arm and also is more complex because it
allows us to be able to do this motion with the hand in any position. The third joint is the pivot
joint which is between the radius and ulna (proximal radioulna joint). This helps with
supination/pronation of the forearm (Elbow 2011). In appendix A figure 2 it shows where the
bicep tendon inserts and attaches to the bone.
There are three main ligaments that attach and support the elbow. These ligaments are
the medial collateral ligament, also known as the ulnar collateral ligament. These consist of two
ligaments which run anterior and posterior. Both of these pass through the middle of the elbow
joint. The next ligament is the lateral collateral ligament. This ligament is also sometimes
known as radial collateral ligament and is a short, narrow band which passes through the base of
the lateral epicondyle to the annular ligament. The last main ligament is the annular ligament,
which are fibers which circle around the head of the radius. This helps maintain contact between
the radius and humerous. All of these ligaments help make the elbow work and function
correctly (Elbow 2011).
There are many muscles that run across or by the elbow to help with flexion, extension,
supination, and pronation. Some of the main muscles that help with these movements are the
biceps brachii. This muscle arises from the coracoids process and supraglenoid tubercle and
travels down the arm, crosses the elbow joint and inserts on the radius. It helps with flexion of
the elbow joint and supination of the forearm. Triceps brachii is the muscle that originates from
the scapula and back surface of the humerous to cross the elbow and attach to the olecranon
process (posterior Ulna). This muscle helps with extension. Brachialis is the strongest elbow
flexor when the palm is pronated. It arises from the lower half of the front of the humerous and
inserts on the coronoid process of the ulna. Brachloradialis is the muscle that is at the outer edge
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of the lower third of the humerous, crosses the joint and inserts at the lower end of the radius. It
helps to flex the elbow and aid pronation and supination. Pronator teres originates just above the
medial epicondyle and inserts on the outer surface of the radius. The muscle helps in flexion of
the elbow and pronation of the forearm. Extensor carpi radialis brevis is the muscle that arises
from the lateral epicondyle of the humerous and inserts on the third metacarpal of the hand. This
helps in extending the wrist and extension of the elbow. All of these muscles are huge factors
for full range of motion and strength.
Predisposing factors
Things that can lead to injuries are known as predisposing factors.
There are many
different things that can lead to bicep tendon injuries. Extrinsic factors include the lack of
muscular strength around the joint, and the coordination of the athlete. Smoking is also a risk
factor to injuries because smoking can affect the tendons’ nutrition. Also if the athlete were to
use Corticosteroid medications, this could weaken the tendon and muscles (Biceps 2009). The
athlete could also have intrinsic factors that lead to injury of the bicep tendon. These could
consist of lax joints or loose tendons and ligaments. All of these could be predisposing factors
for an athlete to distally tear the bicep tendon. There is always a chance of an injury occurring
because of trauma. This could be cause from many outside injuries. The bicep tendon can also
be injured from an outside force. This can occur when someone or something else stops the
movement of the arm at a direct stop and an injury is occurred.
Mechanism of Injury
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There are not many ways that the distal Bicep Tendon can be ruptured. The biggest way
that the tendon can be ruptured is by the athlete or patient not being properly fit for the task they
are trying to do. Injuries to the bicep tendon at the elbow region usually occur when the elbow is
forced straight against resistance. This injury can also occur from trauma from an outside force
too (Bicep 2009). Another way that the tendon can be injured is if the patient attempts to pick up
something heavy and there arm is forced into the straight position and there is too much stress
put onto the tendon and it tears away from the bone (Bicep 2009). In Nick’s injury, he was
participating in the discus throw. He was getting ready to release the disc into the arm at the top
of his swinging motion when Nick felt a pop at his highest point. This pain radiated up his arm
and he then felt as if he had lost some strength in his right arm.
Signs and Symptoms
The most obvious signs and symptoms of a bicep tendon rupture include the athlete will
hear a pop or snap and will have severe pain. This pain will subside after a week or so. The
patient will also experience swelling that will form at the front of the elbow and will have
discoloration in the elbow and forearm. Elbow flexion will be reduced and the patient will have
muscle weakness in forearm supination.
A noticeable sign will be the bicep coiling up the arm
towards the shoulder. The bicep will stay shortened if not repaired quickly. Another sign is a
good sized gap anteriorly because the tendon will no longer be present (Bicep 2009).
Surgery Options
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There are two surgical approaches physicians use when they repair the distal end of the
bicep tendon. The surgical approach used is based on the physician’s preference. They can use
the one incision method or the two incision method. There are advantages and disadvantages for
each method.
The one incision or the Henry Approach to the Forearm is considered a safer and the
preferred method by the surgeons. The one incision method involves a direct approach and it
avoids a posterior interosseous nerve (PIN) injury. A disadvantage to this method is a possibility
of damage to the radial nerve if the surgeon attempts to pass the tendon thru drill holes made in
the radius. The incision is made either medially or laterally on the biceps and extends
transversely over the antecubital fossa. The tendon is then stretched out to the appropriate length
and position to be reattached. A pin is then used to keep the tendon anchored in place. A
common mistake that is made during this surgery is positioning the anchor proximal to the
tuberosity. This mistake is made because the arm was not positioned correctly for the procedure
(clinical 2010). In appendix B in figure 1 there image of the one incision method.
The second option used to repair the distal bicep tendon is the two incision method. This
method involves two incisions and the anchor is positioned differently. The proximal incision is
a 3 cm incision made over the distal biceps tendon sheath. The second incision is an incision
that passes through the sheath and goes down between the radius and ulna. There are advantages
and disadvantages to the two incision method. Advantages that come from having the two
incision method instead of the one incision method is in the two incision method there is
limitations to the anterior dissection and this will limit pain. There is also a less chance to injury
the radial nerve, which is more common in the one incision method. Rerupture is very unlikely
in the two incision method. There are also disadvantages to the two incision method. Supinator
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may have to be attached to the ulna for this method which may weaken the supination strength.
They will also have two scars instead of just the one minor scar. These are the two methods that
the doctors use to repair the distal Bicep Tendon (Clinical 2010). In appendix B figure 2 there is
an image of the two incision method.
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Post Operation/Pre Rehab
After surgery is complete, Nick will be in a sling and immobilizer for 4-6 weeks. After
surgery we will work on reducing the pain and minimizing the swelling with ice and stem.
During this time I want Nick to work on strengthen his legs and core within pain free range.
Nick can also improve his cardio-vascular by riding a bike or if the pool is available he can put a
life jacket on and trend water with his legs and opposite arm.
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Outline of Rehab Protocol
Phase 1: (Weeks 1-3)
Goals for phase one:
The goal is to achieve 40 degrees of extension and 110 degrees of flexion. You want to decrease
the pain and protect the incisions from being infected. Increase scar mobility after incision is
closed.
Precautions:
The athlete has to make sure not to be lifting or carrying any objects on the injured side.
Week 1:
ModalitiesIce and stem (pre-mod) within comfort of the patient
Warm Up –
Hot pack
Stretch
Range of Motion (ROM) –
PROM/AAROMFlexion-100 degrees
Extension-60 degrees
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Supination
Pronation
Cardio Vascular (CV)Biking – 10’
Single leg rowing – 5’
Core –
Lower abdomen drawing in – make sure to keep abdomen tight
Leg rises while lying on back
Cool Down –
Stretch – 5’
Ice
Week 2:
Modalities:
E-stim for pain and muscle reeducation
Scar massage if stitches are removed
Warm up –
Stretch 5’
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Hot Pack
PROM – take a min of rest in between each exercise
Extension
Flexion
AAROM –
Flexion – the athlete will perform flexion actively and then apply manual force to the arm into
further flexion.
CV –
Bike for 10’
Core –
Supine Knee Tucks
Supine Leg Raises
Cool Down –
Stretch 5’
Ice
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Week 3:
Modalities:
E-stim for pain and muscle reeducation
Scar Massage
Warm up –
Stretch
Heat
PROM –
Extension
Flexion
AAROM –
Flexion – athlete will perform active flexion and then we will force the arm further in flexion
Extension – athlete will perform extension and then we will force the arm further into extension
CV –
Biking 10’
Aquatics – Appendix C
Core –
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Ball sit ups – 3 x 10
Supine bicycle kicks (legs only)
Leg Lifts 3x 10
Cool Down –
Stretch 5’
Ice
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Week 4:
Modalities –
E-stim for pain and muscle reeducation
Heat
Warm up –
Stretch
Heat
PROM –
Extension – hold for 30 sec
Flexion – Hold for 30 sec
Pronation
Supination
AROM –
Flexion – 110 degrees
Extension – 20-30 degrees
CV –
Biking for 10’
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Aquatics – Appendix C
Core –
Stabilizaition on core on medicine ball
Ball sit ups 3 x 10
Supine leg lifts 3 x 10
Supine bicycle kicks (1 min)
Cool Down –
Stretch
Ice
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Appendix A
Figure 1
Anatomy
Figure 2
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Appendix B
Figure 1
Surgery Incisions
Figure 2