Biceps tendon tear: Causes, Symptoms, and Treatment

A biceps tendon tear is a complete or partial rupture of a tendon of the biceps brachii muscle. The bicep is a muscle of the upper arm and consists of two muscle parts – the short and the long head. These originate from two different parts of the shoulder and unite to form a common muscle belly where the muscle is visible from the outside. This is attached to the spoke, the thumb-side bone of the forearm, by a tendon. Tendons are the ends of muscles consisting of connective tissue that attach them to the bone. Due to its two-part structure, the biceps have three tendons.

In principle, a tear can affect all three tendons of the muscle. However, by far, the most frequently affected area is the tendon near the shoulder of the long biceps head (= “long biceps tendon”) on the dominant arm (up to 96% of all biceps tendon tears). With approx. 1%, tears of the tendon of the short muscle head (= “short biceps tendon”) are the rarest injuries. The tendon that connects the muscle belly with the forearm (= “distal/external tendon”) also tears relatively rarely, at approx—3 %.

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Symptoms of biceps tendon tear

A biceps tendon rupture results in restrictions of the muscle’s function to varying degrees, depending on the tendon affected. It is mainly responsible for the flexion and outward extension of the forearm, but also supports the lifting of the arm to the side and forward as well as the inward rotation of the whole arm. It should be noted that other muscles of the upper and forearm can at least partially take over these movements in the event of failure and compensate for the functional impairment caused by the tear.

During the tear itself, affected persons feel a sudden, stabbing pain. This can last but is usually not very strong. Swelling and bruising can also occur.

If one of the tendons near the shoulder is affected, one often sees a shift of the muscle belly in the direction of the elbow as well as a dent in the arm above the muscle. The limitation of muscle strength when lifting and turning the forearm is often only slight because the other biceps tendon can compensate for the corresponding movements. This often leads to the fact that the symptoms are only slightly pronounced at the beginning, and affected persons consult their doctor late.

If the distal tendon tears, the only connection between the muscle and the forearm is lost. This means that no more force can be transferred to the forearm, and severe functional limitations of up to 60% occur when lifting and turning the forearm outwards. Also, a shifting of the muscle belly towards the shoulder and a bulge formation under tension can then be observed.

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Pain with a biceps tendon tear

If the biceps tendon tears near the base of the shoulder joint (proximal part), this tear is generally accompanied by little pain. However, unspecific shoulder pain may occur. Besides, there is often pressure pain in the sulcus intertubercular. The sulcus intertubercularis is a groove on the upper arm in which the long biceps tendon runs. If the biceps tendon tears in the area of the insertion at the elbow (distal part), acute stabbing pain usually occurs, accompanied by weakness in the flexion of the elbow.

Bruise due to a rupture of the biceps tendon

The rupture of the tendon can lead to a bruise (hematoma). This usually becomes apparent after the rupture of the tendon after a very short time and can also be felt as a hard swelling in the area of the rupture. The bruise is also often painful when touched or pressed. A hematoma occurs more often when the distal tendon, which is located further to the elbow, tears.

Therapy of biceps tendon tear

Several options are available for the treatment of a biceps tendon rupture. When deciding on the final therapy, the doctor mainly depends on the affected tendon, the patient’s age, and the existing limitation. However, cosmetic changes can also be decisive in the decision to undergo surgery.

If the long biceps tendon is affected, a basic decision must be made as to whether surgery is necessary or not.

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Conservative therapy

Older people who can continue to cope with their everyday life with a slight reduction in the strength of the biceps and can accept the changed appearance of the upper arm are typically treated conservatively, i.e., without surgery, due to the increased risk of surgery in old age. The upper arm is immobilized in a bandage for about six days, and then a slow movement is carried out. The permanent loss of strength, when lifting and turning the forearm, is then usually only slight (up to 20%).

Surgical therapy

Younger people and athletes, on the other hand, should undergo an operation that almost completely restores the original strength level. During the operation, an incision is made at the front of the shoulder, and the tendon is prepared freely. It is then fixed either to the humerus (sometimes with the help of drill channels) or to the short biceps tendon. Only in a few cases is the torn tendon still long enough to be reattached to the shoulder. Sometimes it may be necessary to remove the remaining part of the tendon from the shoulder (e.g., in the case of a pinch-off) in an arthroscopy.

If the distal tendon is torn, a surgical procedure is almost always chosen due to the severe limitation in flexion and outward rotation of the forearm, which would largely remain without surgery. A small incision is made in the crook of the arm, and the torn tendon is located. It is then fixed to the spoke as stably as possible. This can be done directly by suturing to the bone or using stabilizing anchors. If the operation is performed on a torn tendon that has already existed for weeks, transplantation of the tendon of another, less important muscle may be necessary.

Typically, operations on biceps tendons are performed under general anesthesia. Besides, local anesthesia of the nerve plexus of the arm can be performed to reduce pain. This takes place at the neck because the nerves move from there to the arm. A drainage, i.e., a tube with a collecting vessel at the outer end, is often placed in the wound. It is used to drain off the wound fluid and thus reduce swelling in the operated area.

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The patient is discharged from the hospital approximately two days after the operation. Although the arm must be spared, it must also be exercised early. Physiotherapy must be started a few days after the operation at the latest. This can prevent permanent movement restrictions in the elbow and shoulder joint. Sports without stress on the arm can be started after approx. four weeks, a greater stress after 12 weeks at the earliest. In the case of occupational activities with heavy strain on the arm, an incapacity to work for at least three months must, therefore, be expected.

In addition to the typical surgical risks such as bleeding, injuries to the soft tissue or nerves, and infections, the fixation of the tendon to the arm may not be strong enough and become loose. This may make a new operation necessary. If the radial nerve running through the operating area is injured when the distal tendon is torn, a (usually only temporary) weakness in lifting the fingers and thumb may occur.

Exercises for a biceps tendon rupture

Exercises should be used to maintain the mobility of the arm and to strengthen and train the remaining muscles. However, it should be noted that after a biceps tendon tear close to the shoulder, no exercises should be performed for at least one week, and after a tendon tear close to the elbow for at least four weeks. After the rest period, strengthening and stretching exercises can be performed.

To stretch the biceps, for example, the hands can be brought together behind the back with the palms pointing to the floor. In this position, the arms are stretched upwards until a stretching of the biceps is felt. For strengthening, the arms are stretched out to the side at shoulder level and in the stretched state are lifted above the head and lowered again to shoulder level. In the beginning, the exercise should be repeated 15 times and increased over time. The exercise can be supplemented by weights bit by bit.

To maintain mobility in the shoulder joint, circular movements of the shoulders and arms can be performed. The exercise is performed in a standing position, with the arms hanging next to the body. To train the distal biceps tendon, bending exercises in the elbow and rotation exercises of the forearm should be performed.

Sports such as yoga and Pilates are also beneficial for strengthening, stretching, and mobility in the arm and can support faster healing.

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Causes of biceps tendon tear

The long biceps tendon usually tears as a result of wear and tear even at low loads. Often, minor traumas such as those that occur when lifting a medium-heavy object or under light load during sports are enough to cause the already damaged tendon to tear. In contrast to the other biceps tendons, the long biceps tendon runs inside the shoulder joint. There, wear and tear can be promoted by various factors (such as tightness due to swelling, bony outgrowths, pre-existing injuries, etc.). Besides, the tendon runs along the upper arm in a bone channel in which the tendon can be “chafed.” The wear and tear is particularly pronounced in older people and (former) sportsmen and women, where the tendon is subject to heavy strain over many years (weight training, throwing sports).

On the contrary, the distal tendon usually tears due to trauma, in which the muscle is severely strained or overstretched. At the same time, the arm is bent and rotated outwards, and the tendon is therefore tensed. Exemplary situations are lifting or catching, or pulling heavy objects falls from great heights. Young men with strong muscles are often affected. An increased risk of such a tear exists in strength athletes who take steroids. In a few cases, a blow to the tendon or a cut is the cause.

The short biceps tendon usually tears due to accidents.

Prognosis of biceps tendon tear

After the operation, one must expect only a slight reduction in strength, especially during lifting and external rotation of the forearm.

After a conservative therapy, the loss of strength is usually somewhat greater, but is compensated by other muscles and allows a regular daily routine.

How long does it take to heal a biceps tear?

The time until complete healing varies and depends on various factors. The form of therapy, whether a complete or only partial rupture of the biceps tendon, was present, and the patient’s cooperation determines the healing time. Therefore, the treatment can take several weeks or even months. After surgical therapy, the arm must be protected for three to four weeks until it can be loaded again. During this time, however, physiotherapy and exercises should be performed under supervision. If the arm is loaded too early, this can significantly delay the healing process. Afterward, several weeks of build-up exercises should be expected.

If no surgical therapy is necessary, the arm should still be spared for at least one week. After the rest period, physiotherapy and home exercises are very important.

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