Truckee, CA. 📷 Jason Hsieh
You’re at the crux. Left elbow is locked off at your side, right hand clutching a shallow intermediate. You‘ve been here before, numerous times in fact. Bumping the right hand to the above edge will surely get you the send. You release your right hand to bump—pop. Left hand releases from the wall as you free fall. You immediately grasp your left arm as pain overcomes your elbow. You inspect your arm and notice something is off. You try to bend your elbow and notice it is hard to lift. As minutes pass you notice some swelling around the elbow and the severe pain you felt minutes ago slowly subsides to a dull ache. What happened?
The scenario above describes a climbing specific mechanism of injury to the biceps tendon when a lengthening bicep muscle is subjected to excessive loads and detaches from one or more of its attachments. Although this type of injury is rare among climbing athletes, this article provides both climbers and clinicians a guideline to identify the injury if it occurs. Additionally, it provides a guideline to help understand the course of conservative rehab following surgical intervention of a distal biceps tendon rupture.
Signs and Symptoms
Figure 1 Anatomy of biceps brachii. McGraw-Hill Companies Inc.
To make sense of the signs and symptoms following this injury, we need to explore the muscle’s anatomy and function.
The biceps muscle (known formerly as biceps brachii) begins as two distinct muscle bellies from its origin and converges near the mid-shaft of the humerus into a single muscle where it inserts onto the forearm bone (Figure 1). The inner belly is the short head while outer belly is the long head. The short head originates from the coracoid process of the scapula, whereas the long head originates from the supraglenoid tubercle, tucked in a thick connective tissue that envelopes the rim of the shoulder joint. This comprises the “socket” portion of the “ball and socket” shoulder joint. This makes the proximal tendon of the long head of the biceps brachii unique because it is continuous with the shoulder labrum. By contrast, most tendons attach directly to bone. Once past the mid-shaft of the humerus, both muscle bellies converge inferiorly to a single muscle tendon where it inserts onto the radial tuberosity of the forearm.
The biceps brachii is a multi-joint muscle, spanning across at least two joints (shoulder and elbow) to allow various functional motions. Elbow flexion is the primary action of the biceps. Its lesser-known actions include, forearm supination, distally, and minor shoulder flexion, proximally. The biceps muscle allows us to perform daily tasks, such as bring food to your mouth (elbow flexion), tightening a screw with a screwdriver with the right hand (forearm supination), and raising your arm to give your climbing partner a fist bump (shoulder flexion).
Figure 2 Most common bicep rupture sites. Source: www.5280cryo.com
Upon rupture of the biceps tendon, a distinct clinical presentation will exist. Figure 2 depicts the most common sites where the biceps tendon is likely to rupture.
These associated signs and symptoms of complete biceps tendon rupture may include:
- Pain and tenderness
- Marked weakness at the elbow and shoulder
- Limited elbow ROM
- Upper arm deformity
If you present with a cluster of these specific signs and symptoms, you should seek professional help from a medical practitioner. Upon examination, several tests and measures exist to confirm the diagnose of biceps tendon rupture.
Diagnosing a biceps tendon rupture begins with a detailed subjective history of the trauma, followed by a thorough physical examination that include palpation of the affected region and performance of a cluster of special tests.
Some subjective complaints may include:
- Hearing a loud pop
- Immediate severe pain around elbow/shoulder region following trauma
- Severe pain subsiding to a dull ache after 20 minutes of rest
- Inability to bend elbow
Observation and palpation:
- Tenderness over the anterior region of the elbow (distal injury)
- Inability to flex elbow through ROM
- Upper arm deformity due to a retracted bicep muscle belly (“popeye deformity”)
Your physical therapist or other healthcare professional may perform a cluster of the following special tests when a biceps tendon rupture is suspected:
- Biceps squeeze test
- Bicipital aponeurosis flex test
- Hook test
- Passive forearm pronation test
- Biceps crease interval test
If a qualified clinician requires further confirmation, diagnostic imaging may be required such as dynamic ultrasound or magnetic resonance imaging (MRI).
Once a biceps tendon rupture has been confirmed, treatment almost always results in surgical intervention unless impairments do not severely restrict participation in functional activities, like in some cases of proximal biceps tendon ruptures.1 However, it is recommended that most individuals with a prior high level of functional activity undergo surgery to regain their desired performance.
The type of surgery depends on if the rupture occurred proximally or distally. Distal biceps rupture typically involves refixation of the tendon onto the radial tuberosity using a combination of absorbable anchors and/or sutures. This procedure is minimally invasive, low risk of complications and associated with good clinical outcomes.2 While a standard procedure for distal biceps tendon repair exists, consensus for proximal biceps tendon repair is lacking; therefore, there are several options. Widely used for its favorable biomechanical conditions is a biceps tenodesis where the long head tendon is fixated proximally on the humeral bone. Another technique, known as the bicep tendon transfer, adjoins the long head tendon with the short head tendon at the coracoid process. Caution should be taken with the latter technique as some studies have linked it to the development of subacromial impingement.3
As always, surgical candidates should discuss their long-term goals with their surgeon as well as weigh the pros and cons of all available surgical methods to maximize recovery potential and ensure return to desired functional activity.
The Rock Rehab Pyramid
Following surgery, one can expect a relatively moderate length of rehabilitation requiring physical therapy anywhere from 8 to 14 weeks before engaging in low-level sport-specific activity. The rehabilitation outlined below follows and is adapted from the Brigham and Women’s Hospital distal biceps tendon repair protocol.4 The protocol closely resembles the principles of the Rock Rehab Pyramid that begins by addressing the inflamed tissue then gradually introducing mobility, strength and, in the late stage, movement. These guidelines serve as a general outline for recovery and should not replace the clinical decisions made by your surgeon or physical therapist. Progressions to, adaptations to or dosage of rehabilitation should be made based on the individual’s progress, objective physical exam findings, and/or presence of post-operative complications.
AROM: active range of motion
PROM: passive range of motion
ROM: range of motion
Phase I (Post-operative days 5 – 7)
The focus of phase I is to allow enough time for the surgical site to heal. To ensure uninterrupted healing, surgeons will place the elbow in a splint to restrict its motion that would otherwise place unwanted tension on the surgical attachment site. A rigid, posterior splint, shown in Figure 3, is commonly used to place the elbow in 90 º of flexion with the forearm in neutral.