Article title: Complete Rupture of the Long head of Biceps tendon and the distal Biceps tendon.
Author: PJ Oberholzer MBCHB, MMED (RadD)–Capital Radiology, Department of Radiology, University of Pretoria
Contact Details: Private Bag 24270 GEZINA 0031, [email protected] Tel: 012 460 3699
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Contribution: MRI Case report – Diagnosis, Images, Discussion.
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Complete Rupture of the Long head of Biceps tendon and the distal Biceps tendon.
Author: PJ Oberholzer MBCHB, MMED (RAD D)
Abstract
2 cases are discussed. Both athletes felt a sudden sharp pain in the upper arm at the shoulder and elbow end respectively and presented with a biceps muscle bump ( Popeye defect).
Introduction
After acute trauma, patients with biceps tendon rupture may complain of a wide variety of symptoms. Several report a sudden sharp pain in the anterior shoulder during activity. This may be accompanied by an audible “pop” or a perceived snapping sensation1.
The patient may present with a “Popeye” deformity, where the disruption of the normal biceps muscle attachment leads to its retraction distally in the arm. A
traumatic biceps tear is more common in younger patients but can occur at any age.
It can occasionally occur during heavy weightlifting, or from actions that cause sudden load on the arm, local trauma, rapid extension of the arm or a fall with the arm outstretched during competitive sports. It can also be injured by repetitive motion2. Patients may be able to use the biceps, because of the intact short head of biceps tendon which rarely tears3. Distal biceps tears will however invariably need to be repaired.
Case Reports
Case 1:
A 38-year-old male presented with a “Popeye” deformity and a clinical diagnosis of a ruptured long head of biceps tendon. The mechanism of injury occurred with the left arm in abduction and external rotatation. A magnetic resonance image (MRI) was aquired to evaluate the tendon.
An empty bicipital groove with intact transverse ligament on axial plane is diagnostic of rupture of the long head of biceps tendon (fig. 1). The position of the retracted tendon in the distal arm is demonstrated in the sagittal plane . (fig. 2). A proximal stump extending from the anchor is demonstrated in coronal plane (fig. 3).
Case 2:
A 28 year old professional rugby player sustained an injury to his arm and was
referred for a MRI. Distal biceps tendon rupture with retraction was identified on the sagittal plane image (fig.4).
Discussion
There are usually three areas of biceps tendon rupture4:
1. At the superior aspect of the bicipital groove and rotator interval which is most common, and is usually part of the impingement spectrum.
2. At the biceps anchor.
3. Rarely at the musculotendinous junction and is associated with violent trauma
A longitudinal tear usually involves the superior part of the tendon where a bifid tendon will extend inferior to the glenoid marginError: Reference source not found.
A clinical diagnosis of a self-attaching long head rupture without retraction is
challenging and is usually identified at the time of rotator cuff repair. An absent long
head of biceps tendon in its expected location in the bicipital groove (on axial or sagittal images) is diagnostic Error: Reference source not found.
The tendon is a weak flexor and passive stabilizer of the shoulder. Treatment of the proximal long head biceps tendon rupture consists of either a tenodesis, where the tendon is fixed in the bicipital groove, or a tenotomy (a release of the tendon)Error:
Reference source not found. The latter often results in a permanent “Popeye”
deformity.
MRI is sensitive in diagnosing complete tears of the distal bicep tendon tears, but less sensitive for partial tears5. MRI features of a partial tear includes intratendinous fluid signal, oedema in the radial tuberosity and increased fluid signal intensity in the tendon sheath. Determining the degree of retraction in partial tears may provide a diagnostic challenge .The diagnosis should therefore not rely on imaging studies alone. Integration of history and clinical findings is importantError: Reference source not found. The biceps muscle is a flexor of the elbow and the supinator of the forearm .Tendon repair is therefore generally always importantError: Reference source not found.
Conclusion
Complete tears of the biceps tendon are usually a clinical diagnosis. The teaching point to remember is that in bicep tendon tears, it is important to identify the site of tear and the amount of retraction as well as to evaluate the proximal stump. In complete tear of distal biceps tendon, the integrity of the lacertus fibrosis should be evaluated.
MRI reveals the degree of tear, distance of retraction and trauma to surrounding soft tissue and bone. The field of view should be sufficient to identify the retracted stump
Acknowledgements:
I thank Dr S Miller, Dr M Velleman, M Robbertse and D Coetzee for their contribution.
References
1 Branch GL, Wieting JMl. Biceps Rupture Clinical Presentation: Medscape, updated 2014 Feb 28 http://emedicine.medscape.com/article/327119- clinical
2 Alan M Reznik MD, The Orthopedic Group, LLC: Biceps Tendonitis, Partial Biceps Tears, Biceps Subluxation, Biceps rupture and Biceps Tenodesis, Revised 2011 Jul 3 http://www.togct.com/downloads/reznik
3 American Academy of Orthopeadic Surgeons. Biceps Tendon Tear at the Shoulder [Internet].Rosemont, Illinois: American Academy of Orthopeadic Surgeons; 2009 [updated 2009 may; cited 2014 July]. Available
from: http://orthoinfo.aaos.org/topic.cfm?topic=a00031
4 David W Stoller MD, FACR. Magnetic Resonance Imaging in Orthopaedics and Sports medicine. Ed 3,Vol 2, 8:1423-1424: Lippincott Williams & Wilkens 2007.
5. Festa A, Mulieri PJ, Newman JS, Spitz DJ, Leslie BM. Effectiveness of MRI in detecting Partial and complete distal Biceps Tendon ruptures. J Hand Surg Am. 2010 Jan;35(1):77-83.
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Legends
Fig.1: MRI PD TSE FS in the axial plane demonstrating an empty bicipital groove (arrow).
Fig. 2: MRI PD TSE FS in the sagittal plane demonstrating the retracted tendon in upper arm (arrow).
Fig. 3: MRI PD TSE FS in the coronal plane demonstrating complete rupture of biceps anchor (arrow).
Figure 4: MRI T2 FS in the sagittal plane demonstrating complete tear of the distal biceps tendon (arrow).
