Biceps tendinopathy and biceps tendon rupture

Biceps tendinopathy and biceps tendon rupture encompass a spectrum of disorders most commonly affecting the proximal long head of the biceps tendon (LHBT) at its origin on the glenoid. Biceps tendinopathy ranges from acute overuse injuries to degenerative changes. Early identification and effective treatment of biceps tendinopathy can prevent progression to proximal biceps rupture.

Biceps tendon rupture is the complete or partial severing of the tendon from the bone. Rupture is typically a result of chronic degenerative changes and may be precipitated by minor trauma. Proximal biceps tendon rupture is painful and usually does not cause significant loss of function. By contrast, a tear involving the distal insertion of the biceps is most often the result of trauma due to overloading, is acutely painful, and results in weakness in the elbow joint. Diagnosis of biceps tendon rupture is often clinical and may be supported by ultrasound and/or MRI. Tendinopathy or rupture involving the LHBT may be managed conservatively with rest and analgesics, with surgical management reserved for patients with refractory pain and/or higher physical demands. Distal biceps rupture requires surgical repair to restore functionality.

Biceps tendinopathy and biceps tendon rupture represent a spectrum of conditions sharing overlapping etiologies, manifestations, and management strategies.

• Biceps tendinopathy: tendinitis; (inflammation) or tendinosis; (degenerative process) of the biceps tendon, caused by chronic stress or repetitive microtrauma and most commonly affecting the LHBT at its origin from the glenoid ^[1][2]
• Proximal tendon rupture: : a partial or complete tear of the LHBT, typically resulting from minor trauma in a tendon weakened by tendinopathy or acute trauma in a healthy tendon ^[3]
• Distal tendon rupture: a partial or complete tear of the biceps tendon at its insertion on the radial tuberosity, usually caused by acute trauma involving eccentric loading (e.g., heavy lifting, sports injuries, or falls) ^[4]

Etiology is often multifactorial, and patients may have multiple risk factors.

• Tendinopathy
  • Repetitive overhead motions ^[2]
  • Postural or biomechanical issues that contribute to excessive stress on tendon ^[3]
  • Statins ^[5]
• Rupture ^[2][3][4]
  • Acute, high-impact trauma in healthy tendons (e.g., heavy lifting, fall on outstretched hand)
  • Minor trauma in bicep tendon weakened by tendinopathy
  • Medications: fluoroquinolones, corticosteroids ^[2]
  • Tobacco use
• Shared risk factors ^[1]
  • Microtrauma caused by repetitive overhead movement (e.g., sports, manual labor) ^[2]
  • Age-related degeneration ^[1]
  • Pre-existing shoulder pathology; (e.g., subacromial impingement, rotator cuff disease, rheumatoid arthritis). ^[1][6]
  • Acute injury ^[4]
  • Poor conditioning ^[1]

Tendinopathy

• Gradual development due to chronic stress or repeated microtrauma ^[2]
• Overuse → microtears in collagen fibers → tendon thickening → tendinosis ^[7]
• Altered biomechanics of the LHBT increase susceptibility to injury. ^[4]

Tendon rupture ^[3][4]

• Typically caused by trauma
• Degenerated or weakened tendon → partial or complete tear with minor trauma (e.g., forced flexion or supination)
• Acute trauma causes mechanical failure in a healthy tendon if force exceeds tensile strength.

Biceps tendon rupture can be classified by location and/or by extent.

• By location
  • Proximal biceps tendon rupture
    • At the origin of the LHBT (most common)
    • At the origin of the short head of the biceps (very rare)
  • Distal biceps tendon rupture: at the insertion of the biceps tendon (rare)
• By extent
  • Partial rupture
  • Complete rupture

Common symptoms include pain and tenderness in the shoulder or elbow during activity or weight-bearing. ^[6]

Biceps tendinopathy ^[6]

• Point tenderness at the bicipital groove when the arm is 10° internally rotated
• Gradual onset of anterior shoulder pain that worsens with lifting or overhead reaching

Biceps tendon rupture

Proximal biceps tendon rupture ^[2][4]

• Popping sound ^[2]
• Tenderness in the intertubercular sulcus
• No significant loss of function ^[2]
• Popeye sign: distal displacement of the biceps belly upon contraction ^[4]

Distal biceps tendon rupture ^[4][6]

• Acute, stabbing pain ^[4]
• Popping sound ^[4]
• Hematoma in the medial region of the cubital fossa ^[6]
• Limitation of flexion and partial or complete limitation of supination at the elbow joint ^[6]
• Swelling in the upper arm region created by the recoiled, shortened biceps muscle ^[6]
• Proximal displacement of the biceps belly upon contraction

General principles ^[4][6][8]

• Diagnosis is primarily clinical.
• Imaging may support the diagnosis and determine the extent and location of the rupture.
• Acute injury (e.g., traumatic rupture)
  • Obtain initial x-ray shoulder and/or elbow to evaluate for osseous injury.
  • Consider ultrasound for confirmation of tendon rupture, subluxation, or dislocation.
• Chronic injury or unclear diagnosis: Consult a specialist to guide further workup (e.g., MRI).

Clinical examination

• Proximal biceps tendinopathy ^[3][6]
  • Pain with palpation over the bicipital groove ^[3][6]
  • Weakness and/or pain on provocation tests, e.g., Yergason test, Speed test (see “Examination of the LHBT”) ^[6]
• Proximal biceps tendon rupture: Ludington sign ^[2]
  • The patient places both arms behind the head and contracts the biceps muscles.
  • In the affected arm, the muscle belly of the biceps moves distally.
• Distal biceps tendon rupture
  • Hook test ^[4]
    • The patient actively flexes the elbow at 90° and fully supinates the forearm.
    • The clinician places their index finger under the lateral edge of the biceps tendon in the cubital fossa.
    • The clinician attempts to “hook” the tendon (pull it upward) with the index finger.
    • In an intact or partially torn biceps tendon, the clinician feels resistance; a ruptured tendon allows unrestricted movement.
  • Biceps squeeze test: The clinician squeezes the biceps with the elbow flexed at 60–80° and the forearm pronated; lack of forearm supination indicates distal biceps tendon rupture. ^[9]

Imaging

X-ray ^[4][6]

• Indication: acute upper extremity injury
• Limitation: suboptimal soft tissue evaluation
• Views ^[2]
  • Shoulder: anteroposterior, trans-scapular lateral (Y view), axillary lateral
  • Elbow: anteroposterior, lateral; oblique view as needed
• Findings
  • Often normal ^[3][4][6]
  • Distal biceps tendon rupture: Avulsion of the radial tuberosity may be visible. ^[4]

Ultrasound ^[4][6][8]

• Indication: suspected biceps tendon pathology
• Limitation: lower sensitivity for partial ruptures or tendinopathy
• Findings
  • Tendinopathy
  • Tenosynovitis
  • Partial and/or complete rupture
  • Tendon subluxation and dislocation

MRI ^[4][6][8]

• Indications: inconclusive inital imaging findings, chronic injury, and/or unclear diagnosis
• Limitation: increased cost and time requirement
• Findings:
  • Tendinopathy
  • Ruptures
    • May distinguish between complete and partial ruptures
    • Rupture location and amount of retraction
  • Comorbid shoulder pathologies (e.g., rotator cuff tears, SLAP lesions)

MR arthrography has better accuracy than standard MRI in diagnosing pathologies of the LHBT. ^[4][6]

Approach

Treatment is based on the nature and location of injury.

• Biceps tendinopathy ^[3][6][8]
  • Often improves with conservative management
  • Refractory pain: Consider steroid injections and/or surgical referral.
• Proximal biceps tendon rupture ^[3][4][6]
  • Initiate conservative management.
  • Refer the patient to orthopedics or sports medicine for further evaluation and potential surgical management.
• Distal biceps tendon rupture ^[4][6]
  • Refer the patient to orthopedics for surgical management.
  • Consider nonsurgical management for sedentary patients who can tolerate loss of function or those with significant comorbidities.

Conservative management ^[3][4][6]

• Analgesia (NSAIDs, ice packs)
• Immobilization with arm sling
• Activity modification and physical therapy

Surgical management

• Proximal biceps pathology
  • Biceps tenotomy: release of the long head of the biceps tendon from the glenoid labrum ^[3]
  • Biceps tenodesis: reattachment of the long head of biceps tendon to either soft tissue or the proximal humerus to prevent retraction ^[4]
• Distal biceps rupture: anatomic repair ^[4]

Arrange orthopedic follow-up for surgical repair as soon as possible after distal biceps tendon rupture; delays can lead to fibrosis and muscle shortening, which hinder reattachment. ^[4][6]

• Shared complications of tendinopathy and rupture
  • Chronic pain ^[3][6]
  • Loss of function (more marked in distal rupture than in proximal pathology) ^[2][4]
• Biceps tendinopathy: rupture ^[3]
• Rupture (proximal and distal): cosmetic deformity ^[4]

We list the most important complications. The selection is not exhaustive.