The biceps muscle is found on the front of your upper arm and bulges when you flex your elbow. This muscle bends the elbow and turns the forearm inwards, and also helps maintain the stability of the shoulder joint.
The biceps tendon connects the muscle to the bone. There is a biceps tendon at the shoulder joint (‘proximal’), and a biceps tendon at the elbow (‘distal’).
What is a biceps tendon rupture?
A tendon rupture or tear results in the separation of the muscle from its attachment at the bone. It can rupture at either end, proximal (near the shoulder) or distal (near the elbow)
A proximal biceps tendon rupture is the most common type, and usually affects patients over 60 years of age, and will often cause minimal symptoms. In fact, one of the treatments for particular types of shoulder pain is to release the biceps tendon in an operation called a biceps tenotomy.
In other cases, the rupture causes severe pain and difficulty using the elbow and shoulder. In these cases, pain-relief, physiotherapy and even surgery can be used as treatment.
Symptoms
The most common symptom is pain at the front of the shoulder. This usually comes on all of a sudden while using the shoulder and is sharp in nature. It can also be slower in onset, causing pain on-and-off over a period of months, during overhead activities. Occasionally the condition is not painful at all.
Sometimes people also notice a lump felt between the shoulder and the elbow. This, fittingly, is called the ‘Popeye’ sign, and is due to the bulk of the biceps muscle bunching up in the middle of the arm (it doesn’t mean that you’ve become stronger!).
Causes
Biceps tendon rupture at the shoulder is usually due to damage that has been accumulating over many years. When the shoulder becomes inflamed for any reason, microtears develop in the adjacent tendon. These frays gather over time, resulting in a weak tendon. It is then vulnerable to completely rupture with minor trauma.
Younger patients may experience a biceps tendon rupture at the shoulder during heavy weightlifting, although this is an unusual mechanism for this type of injury.
Risk Factors
Risk factors for proximal biceps tendon rupture include:
- Age – years of wear and tear cause minor fraying of the tendon at the shoulder, resulting in an inherent weakness in the tendon.
- Repeated overhead activities – for example, for work or during swimming
- Smoking
- Cortisone usage – cortisone or steroids are available in several forms, including tablets, creams and injections. Especially high risk of tendon injury is associated with direct injections of cortisone in and around the tendon.
Investigations
Usually, this condition is diagnosed on the basis of the symptoms and examination findings. Tests that may be requested to check for other conditions include:
- X-ray – this is a good test to look for damage to bony structures
- Ultrasound – this is used to evaluate soft-tissues in the shoulder or elbow
- MRI – this gives a very good picture of soft tissues in the arm
Complications
There are few complications of this condition. If it is not corrected with an operation, there can be a minor loss of strength in the affected arm with elbow-bending movements. This only becomes an issue if the arm is needed for weightlifting, or manual labour.
Treatment
There are two possible approaches to the treatment of a biceps tendon rupture at the shoulder. One involves an operation, and one does not.
Surgical treatment of biceps tendon rupture is the preferred option for people who require full strength of the affected arm. This includes athletes, manual labourers, and younger people in general. The surgery involves stitching the two torn ends of the tendon back together, or reattaching the tendon back to a bone in the shoulder.
Conservative treatment involves physiotherapy exercises that aim to increase strength in the affected arm. It is the preferred option for people middle-aged or older. The affected arm recovers to 80% of its original strength – this reduction in strength rarely impacts on normal activities.
Seeking Advice
The Physiotherapist
The physiotherapist will be able to examine your arm and suggest a diagnosis. They may also be able to provide you with:
- Pain relief
- Begin therapy
- Ask whether you need a medical opinion
Your Family Doctor (GP)
Your Family Doctor will be able to diagnose and help treat your problem. He or she will be able to
- tell you about your problem
- advise you of the best treatment methods
- prescribe you medications
- and if necessary, refer you to Specialists (Consultants) for further treatment
Prevention
Some simple preventative strategies include:
- Appropriate stretching prior to sporting activities
- Reduce smoking
- Reduce cortisone intake
F.A.Q. | Frequently Asked Questions
What is the lump in my upper arm?
When the long head of the biceps tendon ruptures at the shoulder, the muscle slides down the arm and bunches up above the elbow. This is called a Popeye sign. It is harmless and does not need treatment on its own.
Do I need surgery?
Usually not. The long head is one of two tendons at the top of the biceps and the other one keeps working, so most people lose very little strength. The pain settles over a few weeks. Surgery to reattach the tendon is sometimes done for younger people doing heavy work or those unhappy with the shape of the arm.
Why did it happen?
The tendon usually wears thin over years from rubbing inside the shoulder, often alongside rotator cuff problems, and then snaps with a small load. In younger people it can happen with heavy lifting.
Should my shoulder be checked?
Yes. A ruptured long head of biceps in someone over 50 often goes with a tear of the rotator cuff, so the shoulder should be examined and sometimes scanned.