Biceps Rupture: Overview

A professional football player attempts an arm tackle and hears a pop in his upper arm. A weightlifter doing curls suddenly feels his shoulder "bubble." A woman rearranging the living room furniture gets a sharp pain in her shoulder. Each of these individuals just ruptured their biceps tendon.

Tendons attach muscle to bone. The biceps muscle in the upper arm splits near the shoulder into a long head and a short head. Both attach to the shoulder in different places. At the other end of the muscle, the distal bicep tendon connects to the smaller bone (radius) in the lower arm. These connections help the muscle stabilize the shoulder, rotate the lower arm and accelerate or decelerate the arm during overhead motions such as pitching.

The long head of the biceps tendon is vulnerable to injury because it travels through the shoulder joint to its attachment point. If it tears, you may lose some strength in your arms and be unable to turn your arm from palm down to palm up. Because the torn tendon can no longer keep the muscle taut, you may also notice a bulge in the upper arm (Popeye muscle). If the distal tendon tears, you may be unable to lift items or bend your elbow.

Possible Causes

Ruptures of the distal tendon near the elbow are rare. They usually occur when an unexpected force is applied to a bent arm. For example, a snowboarder can rupture the distal biceps tendon if he uses the arm to try to break a fall during a turn.

The proximal biceps tendons near the shoulder tear more easily. Tears can be either partial or complete. Often, these tendons are already frayed, particularly if you are over 40 years old, have a history of shoulder pain, and participate in activities that involve overhead motions. Among the elderly, biceps tendon ruptures near the shoulder are often associated with rotator cuff tears.

Signs and Symptoms

Conservative treatment for biceps tendonitis can include:

• sudden, sharp pain in the upper arm
• an audible snap (sometimes)
• a bulge in the upper arm above the elbow, and a dent closer to the shoulder
• bruising from the middle of the upper arm down toward the elbow
• pain or tenderness at the shoulder

Your physician will examine your arm and ask you to bend the arm and tighten the bicep muscle. The doctor may apply pressure to the top of the arm to see if there is any pain. If you have a history of shoulder pain, your doctor may request an magnetic resonance imaging (MRI) scan or a special x-ray called an arthrogram to see if you have also torn the rotator cuff muscle.

Treatment Options

Conservative treatment is usually all that is needed for tears in the proximal biceps tendons. Ice applications keep down the swelling, and nonsteroidal anti-inflammatory medications (NSAIDS) such as ibuprofen reduce pain.

You should rest the muscle, limiting your activity when you feel pain or weakness. To keep the shoulder mobile and strengthen the surrounding muscles, your doctor may prescribe some flexibility and strengthening exercises.

Complete tears of the distal biceps tendon require surgery to reattach the tendon to the bone. Range of motion exercises can begin as early as two weeks after surgery, although forceful biceps activity is often restricted for four to six months. Partial tears of the distal biceps tendon may be treated either conservatively or surgically. You and your orthopaedic surgeon should discuss the options for your specific case.

Surgical repair of a complete tendon tear can be done for younger individuals whose work involves heavy labor or lifting.

How can I prevent a biceps rupture?

The best way to prevent reoccurrences of a biceps rupture is to only return to practice and competition when all symptoms of the injury are gone and strength of the affected arm has returned to normal. Furthermore, the rehabilitation exercises should be continued to ensure protective strength, range of motion, and stability of the injured joint. Other prevention techniques include:

• maintain flexibility by performing proper stretching exercises before and after playing sports
• maintain strength by exercising regularly
• take extra caution when weightlifting and don't lift more than you can handle
• listen to your body and know when to take a rest

Improving Sports Performance

The key to improving sports performance after recovering from a biceps rupture is a proper a rehabilitation program, and adhering to some of those same principles after the injury is gone.

The single most important aspect of improving performance is stretching before and after you step onto the field, court, ice, or golf course.

Benefits derived from stretching include:

• increased physical efficiency and performance
• decreased risk of injury
• increased blood supply and nutrients to joint structures
• increased coordination
• improved muscular balance and postural awareness
• reduced stress
• enhanced enjoyment

Rehabilitation for a biceps rupture

As an athlete, your number one concern is getting back to full strength as soon as possible so that you can return to training and competition. That is why appropriate rehabilitation is extremely important. The most common rehabilitation for a biceps rupture often includes the following:

• Rest
  Avoid activity during the acute phase. Refrain from forceful biceps use such as weightlifting until arm is fully healed.
• Ice
  Apply ice or a cold pack to the biceps muscle for 15 to 20 minutes, 4 times a day for several days to keep swelling down. Wrap the ice or cold pack in a towel. Do not apply the ice directly to your skin.
• Medication
  Take ibuprofen to help reduce inflammation and pain.
• Stretching
  When the acute pain is gone, start gentle stretching exercises as recommended by your doctor. Stay within pain limits. Hold each stretch for about 10 seconds and repeat 6 times.
• Strengthening
  Begin strengthening exercises for your biceps and arm muscles as recommended by your doctor.
• Gradual Return to Your Sport
  Begin light arm motions of your sport or activity as recommended by your doctor. (For example: passing a football, throwing a baseball, tennis strokes, golf swings). Refrain from forceful biceps use such as weightlifting, until arm is fully healed.
• Surgery
  Surgical repair may be necessary for of a complete tendon tear.

Stretching Exercises

The major objectives of rehabilitation from a biceps rupture are to improve the elasticity of the biceps muscle and to gradually increase pain-free range of motion. The exercises below stretch the muscles of the forearm and upper arm. These exercises should be performed once or twice daily. Exercises include:

• Bicep stretch
  Stand erect with arms raised to shoulder height and palms up. Press arms backward until stretch is felt. Hold this position for three to five seconds, then relax for 3 to 5 seconds. Perform this exercise 10 times. The bicep is stretched by this exercise as well as the muscles of the shoulder and upper chest.
• Wrist flexor stretch
  Extend affected arm forward with palm up and elbow straight. Place fingers and palm of opposite hand across palm and fingers of the extended hand and draw back with it until stretch is felt in the forearm. Hold this position for 3 to 5 seconds, then relax for three to five seconds. Perform this exercise 10 times.
• Wrist extensor stretch
  Extend affected arm forward with palm down, elbow straight, and fingers slightly curled. Grasp the affected side hand with other hand and draw affected side hand down until stretch is felt in the forearm. Hold this position from 3 to 5 seconds, then relax for 3 to 5 seconds. Perform this exercise 10 times.
• Pronation/Suppination stretch
  Extend affected arm forward in a hand-shaking position with palm facing up. Slowly rotate the hand from a palm-up position to a palm-down position. Hold for 3 to 5 seconds and then rotate back. Perform this exercise 10 times. When you work your way up to strength training, you may use a small weight while rotating the hand and wrist.
• Tricep stretch
  Stand erect with feet at about shoulder width. Raise injured arm at the shoulder with elbow bent and place the forearm behind the head. Grasp the injured elbow with opposite hand and draw it toward the center of the body until stretch is felt. Hold this position for 3 to 5 seconds, then relax for 3 to 5 seconds. Perform this exercise 10 times.
• Strengthening exercises
  The following exercises develop strength of the muscles of the forearm and upper arm. It's important to get your doctor's permission before beginning strengthening exercises. To maintain symmetry of the arms in terms of strength and appearance, perform these with the uninjured arm as well as the injured arm.
• Arm curls
  Either standing or sitting, grasp a 2- to 4-pound dumbbell in one hand. With palm up, flex elbow and draw the dumbbell up to the same side shoulder while maintaining erect posture. Do not bend at the waist or swing the dumbbell. Lower dumbbell slowly and with control to the starting position. Repeat this exercise 10 times. Use a heavier dumbbell as strength increases.
• Wrist extension
  Sit in a chair with forearm resting on the end of a table, palm down. Grasp a light weight dumbbell and raise the weight up as high as possible while maintaining contact with the table top. Hold this position for 3 to 5 seconds. Relax for 3 to 5 seconds. Repeat this exercise 5 to 10 times. Substitute a heavier dumbbell as strength increases.

Alternative exercises

During the period when normal training should be avoided, alternative exercises may be used. These activities should not require any actions that create or intensify pain at the site of injury. They include:

• swimming (if pain allows)
• jogging
• stationary bicycle

Rehabilitation after surgery

Your biceps rupture may require surgery to reattach the tendon to the bone. Keep in mind that the soft tissue needs time to heal before exercise can begin. A physical therapy program usually begins with range-of-motion and resistive exercises, then incorporates power, aerobic and muscular endurance, flexibility, and coordination drills.

Finally, patients develop speed and agility through sport-specific exercise routines.

The ultimate goal of surgery is to provide dynamic stability while maintaining full range of motion, so that athletes can return to competitive or recreational sports. Progress is assessed by the patient's perception of how stable the biceps muscle feels and by comparing the strength and stability of the injured and uninjured arms.

How long will the effects of my injury last?

The goal of rehabilitation is to return you to your sport or activity as soon as is safely possible. If you return too soon you may worsen your injury, which could lead to permanent damage. Everyone recovers from injury at a different rate. Return to your activity is determined by how soon your biceps rupture recovers, not by how many days or weeks it has been since your injury occurred.

It also depends on how serious the injury is. Instances where you have a complete tear of the distal biceps tendon, and reconstructive surgery is required, may require up to 6 months before you can return to full participation. For patients with a partial tear, you may be back to normal activity in 2 to 3 months.

A good rule is to allow pain to dictate when you're ready to return to activity. You should return in moderation, and back off if you feel any pain.

You may safely return to your sport or activity when you have full strength and range of motion in the injured arm compared to the uninjured arm.

When can I return to my sport or activity?

Gentle rehabilitation exercises may be performed within a few weeks, but keep in mind that forceful biceps activity is often restricted for 4 to 6 months. Of course, time for return to activity is much longer when surgery is necessary.