172. Distal Biceps Tendon Rupture: Recognition, Assessment, and Treatment for PTs

Host Kasey introduces PT Snacks, a bite-size podcast for physical therapists and students, and covers distal biceps tendon ruptures. The episode reviews relevant anatomy, typical injury mechanism, classic symptoms, and common risk factors and patient profile. Kasey outlines key differentials, exam findings and tests, imaging options, and treatment pathways, emphasizing that timely recognition improves surgical outcomes.

00:00 Welcome to PT Snacks

00:18 Episode Overview

01:14 What the Rupture Is

01:44 Mechanism and Symptoms

02:29 Anatomy Refresher

03:37 Risk Factors and Who Gets It

05:13 Patient Story and Red Flags

06:13 Differential Diagnosis

07:02 Exam Tests and Imaging

08:05 Treatment Options

08:48 Surgery and Rehab Timeline

09:35 Key Takeaways and Outro

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Transcript

 Hey, welcome to PT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bite-size segments of time. If you're not a pt, you're still welcome. Just know that this is who that's catered for. Now for today's episode, we're gonna be talking about distal bicep tendon ruptures, which is not the most common thing in the world, but helpful in case somebody walks into your clinic with some of these symptoms to know. Okay. Is this someone that maybe needs surgery? Do they have this? Can they be treated conservatively? All that kind of stuff. So when we are talking about distal biceps tendon rupture, again, this is something that's relatively uncommon, but it is something that can have some classic presentation features that make it pretty important to be able to recognize quickly, because for some patients who have this, uh, surgery might be the best answer for them. If you work with athletes, manual laborers, or active adults, chances are you'll maybe eventually see one. So in this episode, we're gonna be covering relative anatomy. What this actually is, how do we assess for it, and how do we treat it? What is a distal biceps tendon rupture? This actually is something that happens when the tendon that's attaching the biceps muscle to the radial tuberosity of the radius actually just completely tears away from the bone. So unlike proximal biceps injuries, which are actually a bit more common, distal ruptures involve the tendon near the elbow and tend to cause more functional loss. So something to keep in mind if someone walks in with this condition in your clinic. Usually it's gonna happen with some sort of sudden eccentric load when the elbow is forced into extension while the biceps is actively contracting. So think of situations kind of like trying to catch a falling object. Deadlifting or heavy curls can be involved. And when the tendon ruptures, the patient usually experiences pretty sudden pain at the elbow. They might say, I had this popping sensation that happened. Bruising, swelling, weakness with elbow flexion and forearm supination. So supination strength is usually affected the most because remember that the biceps brachii is a primary supinator of the forearm. It is an elbow flexor, but it's a weaker one. So reviewing anatomy, remember that the biceps brachii has two heads. So the long head originates from the supra glenoid tubercle, and the short head originates from the corocoid process. So these two heads combine into a muscle belly and then insert distally via the distal biceps tendon onto the radial tuberosity. So functionally the biceps contributes to forearm supination as the primary role, and then elbow flexion. Secondly. It does help contribute to shoulder stability via the long head. Um, but another structure to keep in mind would be the lacertus fibrosis or bicipital aponeurosis. So this is a fascial expansion that helps to basically stabilize the tendon and can help limit retraction after a rupture, which is good. So clinically this matters because if the lacertus fibrosis is intact. Tends to have less tendon retraction. If it's torn, the tendon usually retracts proximally, and surgical repair becomes a bit harder. So in terms of risk factors for who could get this, some risk factors increase the likeliness of a distal bicep rupture. So biggest risk factors include things like age. Most injuries happen between 35 to 54 years old. It's more common in men, as in like 95% of cases occur in men. For smokers, nicotine impacts tendon vascularity and healing quite a bit. So someone's a smoker. It's not as great for tissue healing as if they were a non-smoker. And then higher BMI and obesity are also associated with tendon degeneration as well as repetitive loading or overuse, especially if there's a lot of heavy lifting. Medication. Can have A play here like corticosteroids, anabolic steroids, certain antibiotics like fluoroquinolones degenerative changes plus sudden force are usually what ultimately lead to rupture. So who gets this? Well, the classic patient profile is gonna be a middle-aged male performing heavy physical activity. For example, our weightlifters are manual laborers, mechanics, firefighters, recreational athletes. In a lot of cases, the injury occurs in the dominant arm. Overall incidence is low, roughly two to five cases per a hundred thousand people in a year. So it does make it pretty uncommon in the general population, but in an orthopedic or sports setting, it shows up a little bit more frequently. So let's say this patient's walking to our clinic and we're trying to figure out what's going on here. In terms of what it sounds like, typically this injury's gonna have a pretty classic story when you ask your patients about it. So they'll usually say something to the lines of, I was lifting something heavy and I felt a pop in my elbow. They might have sharp, sudden pain at the anterior elbow, loud popping or snapping sensation, breath, uh, swelling or bruising in the elbow or forearm weakness. When the palm is termed upward. So remember. The biceps is a supinator. And then a visible deformity at the biceps muscle called a Popeye sign. So the deformity happens at, again, the distal biceps tendon because the muscle retracts up towards the shoulder. The patients might also have a hard time with using like a screwdriver, opening jars, carrying objects was their palm up again in supination, because those all rely a lot on supination strength. Now, something to keep in mind when you are assessing these patients is not necessarily assuming immediately, I know they have a distal biceps tendon rupture, but to have some differentials in mind so that when you're examining, you're not necessarily biased. Some include a distal biceps tendinopathy. Difference there is the tendons attached versus not. Uh, it's painful, but no rupture, right? We could have a brachial strain, so they could have pain with elbow flexion, but preserved supination strength, a partial distal biceps tear, so often, a lot harder to detect clinically, uh, especially if there's a trauma involved. Elbow flexor strain. It's more of a muscular injury rather than a tendon rupture. And that's why, again, a careful exam is important. And then when we're moving into our exam, to actually test for this, we're looking at history, observation. Do they have any bruising in the antecubital fossa? Is there a loss of distal tendon contour proximal biceps bulge? And then physical test, uh, we'll do a hook test, which is a pretty well known test. Essentially, the clinician hooks their finger under the distal biceps tendon from the lateral side. So if you can't hook it, that strongly suggests rupture. And then looking at muscle testing, we would expect weakness in what. Forearm supination and nobo flexion 'cause that's the job of the, of the biceps. Now supination weakness, again, is much more significant. These patients might get an MRI to help confirm if there's a rupture or a differentiate between partial and complete tears. Ultrasounds are also cheaper and more dynamic, but operator dependent in terms of accuracy. And then x-rays can help to rule out fractures. So. What do we do about these patients? Right? It depends on several factors. One would be the patient's age, their activity level, tear severity, functional demands if there's any non-operative management that they can do and is typically considered for a partial tears older adults with low functional demands whereas treatment might include rest and activity modification or NSAIDs. Now physical therapy can help with restoring motion and in the surrounding muscles. However, patients who avoid surgery often experience persistent weakness, especially of supination. So for that case, a lot of times the distal biceps tendon is treated. Surgically. So surgery is gonna reattach the tendon to the radial tuberosity. and outcomes are usually good, especially if it occurs with like the first two to three weeks of the injury. If you have delays that can delay the, that can lead to tendon retraction and may require reconstruction instead of a simple repair. So generally, if someone's going through this post-op. They will have a protective phase where we're gradually adding range of motion. And then they're slowly adding more and more strain and, uh, motion depending on the healing timelines, right? So early recognition with these patients is really important because surgical repair often leads to the best functional outcomes, um, especially for active adults. Now, what you should have taken away from this episode was just a brief review over what is it in the elbow, how do we assess for it, and how do we treat it essentially? So something in the elbow, other than tennis elbow or something. Now if you have any questions, feel free to reach out@ptsnackspodcast.com or you can just shoot me a DM on Instagram. I have a YouTube channel now, so go ahead and follow that if you aren't already. But other than that, I hope you guys have a great rest of your day. Until then, thanks and until next time. Okay.