Biceps Rupture

What is a biceps rupture?

A biceps rupture is a condition characterized by complete tearing of one or more tendons or muscle bellies of the biceps muscle.

The muscle at the front of the upper arm is known as the biceps. The biceps originates from the front of the shoulder blade (attaching here via the short and long head of biceps) and inserts into the forearm via the distal biceps tendon (figure 1). The biceps has two muscle bellies known as the short and long head of biceps.

During contraction of the biceps, tension is placed through the biceps muscle and tendons. When this tension is excessive due to too much repetition or high force, damage to the biceps muscle or tendons may occur. Occasionally, this may cause the biceps tendon (or rarely the muscle belly) to rupture. When this occurs, the condition is known as a biceps rupture.

Biceps ruptures are more common in the older patient with a history of biceps injury or tendonitis. The long head of biceps tendon is by far the most commonly ruptured biceps tendon.

Causes of a biceps rupture

A biceps rupture most commonly occurs due to sudden or excessive contraction of the biceps muscle. This may occur with heavy lifting (particularly overhead), forceful arm elevation activities or bending of the elbow forcefully against resistance (such as performing chin ups or biceps curls). Occasionally a biceps rupture may occur due to gradual trauma associated with repetitive or prolonged activities placing strain on the biceps tendon. This may weaken the biceps tendon, predisposing it to a complete tear with minimal trauma. Biceps tendon ruptures are relatively common in weight lifting or sports requiring forceful use of the upper limb and biceps.

Signs and symptoms of a biceps rupture

Patients with a biceps rupture typically experience a sudden onset of pain in the front of the shoulder, upper arm or elbow. This is usually associated with a sudden snapping or tearing sensation. Symptoms may settle quickly leaving the patient with an ache that is particularly prominent at night or first thing in the morning. Sometimes, there may be little or no pain. Obvious deformity of the biceps muscle is usually noted especially when compared to the non-injured side. This may become more obvious during contraction of the biceps muscle. The deformity appears as a bunching of the biceps muscle in the lower part of the upper arm.

Stiffness, swelling and bruising may also be present and may become more prominent the next morning and over the coming days. Weakness of the shoulder or elbow is another common feature that may be particularly prominent during lifting, elevation activities or bending the elbow against resistance. Many patients with a long head of biceps tendon rupture, however, maintain the majority of their biceps and shoulder strength.

Diagnosis of a biceps rupture

A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a biceps rupture. Further investigations such as an Ultrasound, X-ray or MRI are often required to confirm diagnosis and rule out other injuries.

Prognosis of a biceps rupture

Most patients with a long head of biceps rupture heal well with appropriate physiotherapy and return to relatively normal function in a number of weeks. Since the ruptured biceps tendon does not repair on its own some weakness may persist although this is usually minimal.

Patients seeking the highest level of function (such as power sport athletes) or those with a ruptured distal biceps tendon may require surgical intervention to ensure an optimal outcome and a lengthy rehabilitation period to follow, lasting many months.

Treatment for a biceps rupture

For those patients with a distal biceps tendon rupture, treatment typically involves surgery to reattach the biceps tendon. This is usually followed by a period of rest to protect the repair and rehabilitation under guidance of the surgeon and treating physiotherapist.

Patients with a long or short head of biceps tendon rupture seeking the highest level of function (e.g. some athletes) may also undergo surgery to repair the ruptured tendon. Most patients, however, have a very good outcome with conservative measures and appropriate rehabilitation under physiotherapy guidance.

The success rate of treatment for a biceps rupture is largely dictated by patient compliance. One of the key components of treatment is that the patient rests from any activity that increases their pain until they are symptom free. This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.

Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to further damage and a prolonged recovery. Immediate, appropriate treatment in patients with a biceps rupture is essential to ensure a speedy recovery.

Patients with a biceps rupture should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities, regular icing, the use of a compression bandage and keeping the arm elevated (provided this is comfortable). Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.

Patients with a biceps rupture should undergo a graduated flexibility and strengthening program to ensure an optimal outcome. This can usually commence once the orthopedic specialist and physiotherapist have indicated it is safe to do so. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.

Manual "hands-on" therapy from the physiotherapist such as massage, joint mobilization, dry needling, stretches and electrotherapy can also assist with improving range of movement and function following a biceps rupture. This can generally commence once the orthopaedic specialist or physiotherapist has indicated it is safe to do so.

In the final stages of rehabilitation, a gradual return to activity or sport can occur as guided by the treating physiotherapist provided there is no increase in symptoms.

Contributing factors to the development of a biceps rupture

There are several factors which can predispose patients to developing a biceps rupture. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:

• joint stiffness (particularly the shoulder or elbow)
• muscle tightness (particularly the biceps or triceps)
• inappropriate or excessive training
• inadequate warm up
• muscle weakness
• history of a biceps injury or tendonitis
• inadequate rehabilitation following a previous biceps injury
• poor posture

Physiotherapy for a biceps rupture

Physiotherapy treatment for a biceps rupture is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of future injury. Treatment may comprise:

• soft tissue massage
• electrotherapy (e.g. ultrasound)
• dry needling
• stretches
• joint mobilization
• ice or heat treatment
• exercises to improve strength, posture and flexibility
• education
• anti-inflammatory advice
• activity modification advice
• a gradual return to activity program

Other intervention for a biceps rupture

Despite appropriate physiotherapy management, some patients with a biceps rupture do not improve adequately. When this occurs the treating physiotherapist or doctor will advise on the best course of management. This may include further investigations such as X-rays, ultrasound, MRI or CT scan, pharmaceutical intervention, corticosteroid injection or referral to appropriate medical authorities such as an orthopedic specialist who will advise on any intervention that may be appropriate to improve the condition.

Exercises for a biceps rupture

The following exercises are commonly prescribed to patients with a biceps rupture. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. These can usually begin once the orthopedic specialist or physiotherapist have indicated it is safe to do so. Generally, they should be performed 2 - 3 times daily and only provided they do not cause or increase symptoms.

Elbow Bend to Straighten

Bend and straighten your elbow as far as possible and comfortable pain-free. Aim for no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms (figure 2).

Figure 2 – Elbow Bend to Straighten (left side)

Flexion with Stick

Begin standing tall with your back and neck straight. Use a broom handle to gently push your arm forwards and up as far as you can comfortably go pain free (figure 3). Aim for no more than a mild to moderate stretch. Repeat 10 times provided there is no increase in symptoms.

Figure 3 – Flexion with Stick (right side)

Static Biceps Contraction

Begin this exercise with your elbow at your side and bent to 90 degrees, palm up as demonstrated (figure 4). Push up against your other hand, tightening your biceps. Hold for 5 seconds and repeat 10 times as hard as possible without pain.

Figure 4 – Static Biceps Contraction (right arm)

Bicep Stretches

Bicep Stretch

Begin with your back and neck straight and your arm supported behind you on a bench or table. Gently lower your body, allowing your arm to move further behind you until you feel a mild to moderate stretch pain-free (figure 2). Hold for 15 seconds and repeat 4 times.

Figure 2 – Bicep Stretch (left side)

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Biceps Self Massage Exercises

The following biceps self massage exercises are designed to improve the flexibility of the biceps muscle and are an excellent addition to the above biceps stretches. You should discuss the suitability of these exercises with your physiotherapist prior to commencing them. 

Foam Roller Biceps Release

Place the roller under your biceps (upper arm muscle) as demonstrated (figure 3). Using your arm and legs, slowly move your body side to side allowing the roller to massage your biceps muscle. Breathe normally keeping your arm relaxed. Repeat this process for 15 – 90 seconds provided it is comfortable and does not cause pain.

Figure 3 – Foam Roller Biceps Release

Bicep Strengthening Exercises - Basic

To begin with, the following Basic Bicep Strengthening Exercise should be performed approximately 10 times, 3 times daily. As your bicep strength improves, the exercise can be progressed by gradually increasing the repetitions and strength of contraction provided it does not cause or increase pain.

Static Biceps

Begin this bicep exercise with your elbow at your side and bent to 90 degrees, palm up as demonstrated (figure 2). Push up against your other hand tightening your biceps. Hold for 5 seconds and repeat 10 times as hard as possible without pain.

Figure 2 – Static Biceps (right arm)

 

Bicep Strengthening Exercises - Intermediate

The following Intermediate Bicep Strengthening Exercises should generally be performed 1 - 3 times per week provided they do not cause or increase pain. Ideally they should not be performed on consecutive days, to allow muscle recovery. As your bicep strength improves, the exercises can be progressed by gradually increasing the repetitions, number of sets or resistance provided they do not cause or increase pain.

Resistance Band Bicep Curls

Begin this bicep strengthening exercise with a resistance band under your feet and around your hands as demonstrated (figure 3). Your back and elbows should be straight. Slowly bend your elbows against the resistance band tightening your biceps. Perform 3 sets of 10 repetitions as far as possible and comfortable without pain.

Figure 3 – Resistance Band Bicep Curls

Resistance Band Bicep Curls with Extension

Begin this bicep strengthening exercise holding a resistance band with your arms slightly behind your body and your elbows straight as demonstrated (figure 4). Keeping your back straight and upper arms still, slowly bend your elbows against the resistance band tightening your biceps. Perform 3 sets of 10 repetitions as far as possible and comfortable without pain.

Figure 4 – Resistance Band Bicep Curls with Extension

Kneeling Row with Resistance Band

Begin this biceps strengthening exercise in standing or kneeling with your back straight and holding a resistance band as demonstrated (figure 5). Slowly pull your arms backwards, squeezing your shoulder blades together and tightening your biceps as demonstrated. Hold for 2 seconds and perform 3 sets of 10 repetitions provided it does not cause or increase pain.

Figure 5 – Kneeling Row with Resistance Band