PROXIMAL BICEPS RUPTURE
Popeye Deformity | Associated Rotator Cuff Pathology | Tenotomy vs Tenodesis
ETIOLOGY CLASSIFICATION
Critical Must-Knows
- Popeye deformity is the classic clinical sign (distal migration of muscle belly)
- Minimal functional loss in most patients (supinator strength preserved by short head)
- Associated pathology (rotator cuff tear, SLAP) is common and must be evaluated
- Tenodesis offers better cosmetic outcome and strength but higher complication rate than tenotomy
- Tenotomy is simpler, faster rehab, but leaves deformity and potential cramping
Examiner's Pearls
- "Rupture often provides spontaneous pain relief from chronic biceps tendinitis ('autotenotomy')
- "Distal biceps rupture is a DIFFERENT pathology with significant weakness (needs repair)
- "Speed's and Yergason's tests usually positive prior to rupture, negative after
- "Always check the rotator cuff - isolated LHB rupture is rare in older adults
Critical Exam Points
Rule Out Cuff Tear
Proximal biceps rupture is a sentinel sign for rotator cuff pathology in patients over 40. Always examine the cuff thoroughly. Isolated rupture is rare in this demographic.
Functional Deficit
Patients lose minimal elbow flexion strength (approx 20%) and supination strength because the short head remains intact and brachialis is the primary flexor. This justifies non-operative management in low-demand patients.
Cosmetic Deformity
The "Popeye" deformity is the main complaint. Discuss this explicitly during consent. Tenotomy WILL result in deformity; tenodesis prevents it. Cramping is another potential sequela of tenotomy.
Don't Confuse Distal
Distal biceps rupture is a completely different injury requiring surgical repair in most active patients due to significant supination strength loss. Do not conflate the two management algorithms.
Quick Decision Guide - Management
| Patient Profile | Injury Pattern | Treatment | Rationale |
|---|---|---|---|
| Elderly (over 65), Low demand | Acute/Chronic Rupture | Non-operative (Benign Neglect) | Functional deficits minimal, avoids surgical risks |
| Middle age (40-60), Active | Rupture + Symptomatic RC Tear | Tenodesis + RC Repair | Addresses pathology, restores anatomy/cosmesis |
| Young (under 40), High demand/Laborer | Acute Traumatic Rupture | Tenodesis | Preserves maximal supination strength and endurance |
| Any age | Failed conservative / Cramping | Delayed Tenodesis | To resolve persistent cramping pain (cosmesis harder to fix late) |
SCARIndications for Tenodesis
Memory Hook:Tenodesis heals the SCAR of the rupture
LBSBiceps Anatomy and Function
Memory Hook:LBS (Pounds) of force - Biceps lifts heavy things
CCCComplications of Tenotomy
Memory Hook:Tenotomy is simple but has 3 C's
Overview and Epidemiology
Proximal biceps tendon rupture predominantly involves the long head of the biceps (LHB). It is frequently a degenerative process associated with chronic shoulder impingement and rotator cuff disease.
Pathophysiology:
- The LHB tendon intra-articular portion is vascularly compromised and subject to shear forces.
- Usually occurs at the proximal bicipital groove entrance or near the supraglenoid tubercle.
- "Autotenotomy": Spontaneous rupture often relieves the deep anterior shoulder pain of chronic biceps tendinitis.
The 'Sentinel' Sign
Consider proximal biceps rupture a marker of rotator cuff disease in patients over 40. In younger patients (under 30), it may be isolated trauma (weightlifting, contact sports), but this is much less common.
Risk Factors:
- Age over 40 (degenerative changes)
- History of rotator cuff tears (supraspinatus/subscapularis)
- Smoking
- Corticosteroid injections (weakens collagen)
- Overuse (overhead sports like tennis, swimming, baseball)
- Anabolic steroid use (in younger weightlifters)
Natural History: The long head of the biceps often undergoes a process of inflammation (tendinitis) followed by degeneration (tendinosis) and eventual rupture. This "autotenotomy" can be the final stage of a painful process. Once ruptured, the irritating intra-articular portion of the tendon is no longer under tension, often leading to significant pain relief. However, the resulting weakness and deformity must be weighed against the risks of surgical reconstruction. The cosmetic deformity ("Popeye" sign) does not improve with time and is permanent unless surgically addressed.
Anatomy
Anatomical Course
The LHB originates from the supraglenoid tubercle and superior labrum. It exits the joint through the rotator interval, turning 90 degrees to enter the bicipital groove (intertubercular sulcus). This turn is a site of high stress and degeneration ('pulley lesion').
Key Structures:
- Origin: Supraglenoid tubercle (40-60% from superior labrum).
- Transverse Humeral Ligament: Holds tendon in groove (continuation of subscapularis tendon).
- Bicipital Groove: Between greater and lesser tuberosities.
- Short Head: Originates from coracoid process (remains intact in LHB rupture).
- Insertion: Radial tuberosity (common tendon).
Blood Supply:
- Anterior circumflex humeral artery branches.
- Proximal intra-articular zone is relatively hypovascular ("watershed zone").
Function:
- Elbow Flexion: Secondary to brachialis.
- Forearm Supination: Primary supinator (with supinator muscle).
- Shoulder Stability: Depresses humeral head (minor role), anterior stabilizer.
Classification
Etiological Classification
| Type | Mechanism | Demographics | Associated Injuries |
|---|---|---|---|
| Degenerative | Chronic wear/impingement | Older (over 50) | Rotator cuff tears, Impingement |
| Traumatic | Sudden eccentric load | Younger (under 40) | SLAP lesions, Labral tears |
Clinical Assessment
History
- "Pop" or "snap" reduced pain
- Sharp initial pain, then ache
- Bruising down the arm
- History of prodromal shoulder pain
Inspection
- Popeye Deformity: Muscle belly retracts distally
- Ecchymosis: Medial arm (tracks down gravity)
- Compare symmetry with uninjured side
Pain Relief
Patients often report that their chronic shoulder pain improved after the acute rupture event. This is because the pain generator (the inflamed tendon) is no longer under tension within the joint/groove.
Special Tests (Pre-rupture / Contralateral): Tests are often negative AFTER complete rupture.
- Speed's Test: Pain with forward flexion against resistance (elbow extended, supinated).
- Yergason's Test: Pain with supination against resistance (elbow 90 deg). Specific for groove pathology.
- Ludington's Test: Hands on head, flex biceps. Palpate for absence of tendon (specific for rupture).
Investigations
Diagnostic Workup
- AP, Scapular Y, Axillary Lateral
- Usually normal for biceps
- Rule out underlying OA, fractures
- Look for high-riding humeral head (chronic massive RC tear)
- Excellent for tendons
- "Empty groove" sign
- Can assess dynamic subluxation
- Operator dependent
- Gold Standard for associated pathology
- Confirms empty groove
- Evaluates Rotator Cuff integrity (crucial for management)
- Evaluates Labrum (SLAP)
MRI Appearance
Look for the "empty groove" sign on axial MRI slices. The LHB tendon should be visualized within the bicipital groove. Absence indicates rupture or dislocation (check medially!).
Management Algorithm
Treatment Selection
Non-Operative (Most Patients):
- Elderly / Low demand
- Willing to accept cosmetic deformity
- Minimal cramping/pain
- No repairable cuff pathology
Operative (Tenodesis/Tenotomy):
- Young / High demand
- Unacceptable cosmesis (Popeye)
- Persistent cramping
- Undergoing surgery for Rotator Cuff anyway
Tenotomy vs Tenodesis
Tenotomy: Cut the tendon. Fast, easy, no hardware. Risk: Deformity, cramping. Good for elderly/low demand. Tenodesis: Reattach tendon to humerus. Better cosmesis/strength. Risk: Failure, humerus fracture, pain. Good for young/active.
Surgical Technique
Tenodesis Approaches
Location:
- Supra-pectoral: Arthroscopic or open. High in the groove.
- Sub-pectoral: Open (mini-incision). Distal to groove.
Technique (Sub-pectoral):
- Position: Beach chair.
- Approach: Small incision in axillary fold, medial to pec major tendon.
- Identify: Locate tendon (often retracted). Retrieve.
- Preparation: Whipstitch distal end of tendon.
- Drilling: Drill hole in humerus (centered, unicortical or bicortical depending on fixator).
- Fixation: Interference screw, suture anchor, or cortical button.
- Tension: Restore physiologic tension (elbow 90, forearm supinated).
Pros: Removes tendon from groove (eliminates groove pain), strong fixation. Cons: Humerus fracture risk (torsion), neurovascular risk (musculocutaneous n.).
Tenotomy vs Tenodesis
| Feature | Tenotomy | Tenodesis |
|---|---|---|
| Surgical Time | Fast | Longer |
| Cosmesis | Popeye Deformity | Restored |
| Strength | Slight Decrease | Near Normal |
| Rehab | Immediate | Protected |
| Cost | Low | Implants required |
| Complications | Cramping | Fracture/Fail/Pain |
Complications
Surgical Complications
| Complication | Risk Factor | Management |
|---|---|---|
| Popeye Deformity | Tenotomy | Accept or Tenodesis if symptomatic |
| Cramping Pain | Tenotomy | Physio, stretching, late tenodesis |
| Humerus Fracture | Tenodesis (Screw) | ORIF |
| Musculocutaneous Nerve Injury | Retractor placement | Explore/Repair |
| Failed Fixation | Poor bone quality | Revision or Conversion to Tenotomy |
| Stiffness | Prolonged immobilization | Physio/MUA |
Sub-pec Danger
In sub-pectoral tenodesis, vigorous medial retraction can injure the musculocutaneous nerve. The nerve enters the coracobrachialis medial to the operative field.
Postoperative Care
Rehab Protocol (Tenodesis)
- Sling for comfort (wean earlier than RC repair)
- Passive elbow flexion
- No active elbow flexion against resistance
- Passive shoulder ROM
- Active assist range of motion
- Begin light active flexion
- No lifting heavier than 1-2 lbs
- Full active ROM
- Progressive resistance training (biceps curls)
- Gradual return to activities
- Unrestricted activity
- Return to sport
Note for Tenotomy: Immediate active ROM is allowed as tolerated. No specific restrictions other than pain.
Outcomes and Prognosis
Evidence Summary:
- Most studies show no significant difference in functional scores (ASES, Constant) between tenotomy and tenodesis.
- Tenodesis has significantly less deformity and cramping.
- Tenodesis has slightly higher supination strength (statistically significant, clinical relevance debated).
- Complication rate is lower for tenotomy.
Evidence Base
- RCT comparing tenotomy vs tenodesis.
- No difference in functional shoulder scores.
- Cosmetic deformity significantly higher in tenotomy group.
- No difference in elbow flexion strength.
- Described hypertrophic entrapment of intra-articular biceps.
- Cannot slide into groove, causing locking and pain.
- Tenotomy relieves mechanical block.
- Tenodesis vs Tenotomy meta-analysis.
- Tenodesis: Less deformity, less cramping.
- Tenotomy: Shorter OP time, fewer complications.
- Equivalent functional scores.
- Systematic review of tenodesis vs tenotomy.
- Tenodesis showed a trend toward better supination strength restoration.
- Tenotomy had significantly higher rate of cosmetic deformity.
- Pain relief was equivalent between both procedures.
- Incidence of complications in open subpectoral tenodesis.
- Overall complication rate 2.0%.
- Specific risks: cosmetic deformity (rare), persistent pain, and infection.
- Neurovascular injury (MCN) is a rare but catastrophic risk in open approaches.
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Chronic Rupture in Elderly
"A 72-year-old male presents with sudden arm pain and bruising 2 weeks ago while gardening. Now pain has settled, but he notices a bulge in his arm. He has full range of motion. Examination reveals a Popeye deformity. How do you manage him?"
Scenario 2: Acute Rupture in Bodybuilder
"A 28-year-old bodybuilder feels a snap doing heavy deadlifts. Acute pain anterior shoulder. MRI shows complete LHB rupture and superior labral tear. He is worried about appearance and strength."
Scenario 3: Cramping after Tenotomy
"You performed a rotator cuff repair and biceps tenotomy on a 55-year-old carpenter 6 months ago. He is happy with the shoulder, but complains of painful cramping in the biceps muscle belly after repetitive hammering. It is affecting his work."
Scenario 4: Failed Tenodesis
"A 35-year-old weightlifter had a subpectoral biceps tenodesis 6 weeks ago. While doing a heavy eccentric curl against advice, he felt a painful 'pop' and noticed the muscle belly retract distally again. He is distraught about the appearance. What happened and how do you manage it?"
MCQ Practice Points
MCQ Focus: Nerve Injury
Q: Which nerve is most at risk during open sub-pectoral biceps tenodesis? A: The Musculocutaneous Nerve. It enters the coracobrachialis muscle medial to the operative field and is vulnerable to vigorous medial retraction.
MCQ Focus: Strength Loss
Q: What is the expected functional deficit after non-operative management of a proximal biceps rupture? A: Approximately 10-20% loss of supination strength and endurance. Elbow flexion strength is largely preserved due to the intact brachialis.
MCQ Focus: Yergason's Test
Q: What does a positive Yergason's test indicate? A: It indicates pathology of the LHB in the bicipital groove or instability of the transverse humeral ligament. It is performed by resisting supination with the elbow at 90 degrees.
MCQ Focus: Popeye Deformity
Q: A patient presents with a 'Popeye' deformity. Where has the tendon likely ruptured? A: Proximal Long Head of Biceps. The muscle belly retracts distally, creating a prominent bulge in the lower arm. Distal biceps ruptures cause the muscle to retract proximally.
MCQ Focus: Imaging
Q: What is the most appropriate imaging to rule out associated pathology in a 60-year-old? A: MRI of the Shoulder. This is the gold standard to evaluate the rotator cuff (supraspinatus/subscapularis), which is torn in a high percentage of elderly patients with biceps rupture ("Sentinel Sign").
Australian Context
- PBS Indications: MRI Criteria often require specialist referral or X-ray first.
- WorkCover: Common injury in manual laborers. "Accepted claim" status may depend on differentiating acute vs degenerative.
- Choosing Wisely: Avoiding MRI for obvious Popeye deformity in elderly unless cuff repair is contemplated.
Proximal Biceps Rupture Cheat Sheet
High-Yield Exam Summary
Key Anatomy
- •Origin: Supraglenoid tubercle
- •Groove: Intertubercular sulcus
- •Function: Supinator dominant vs Flexor
- •Nerve: Musculocutaneous (C5-6)
Clinical Signs
- •Popeye Deformity (distal bunching)
- •Ecchymosis (medial arm)
- •Ludington's test positive
- •Usually painless after acute phase
Management Rules
- •Elderly/Low Demand to Non-operative
- •Young/High Demand to Tenodesis
- •Cuff Repair to Tenotomy or Tenodesis
- •Cosmetic concern to Tenodesis
Tenotomy vs Tenodesis
- •Tenotomy: Fast, easy, safe, but deformity/cramps
- •Tenodesis: Strong, cosmetic, but longer rehab/risks
- •Evidence: Equal functional scores
- •Rehab: Immediate (Tenotomy) vs Protected (Tenodesis)
Surgical Risks
- •Deformity (Tenotomy)
- •Cramping (Tenotomy)
- •Humerus Fracture (Tenodesis)
- •Musculocutaneous Nerve Injury
Key Exam Pearls
- •Always check Rotator Cuff - sentinel sign of cuff disease
- •Distal rupture DIFFERENT - needs surgical repair
- •Minimal functional loss - short head compensates
- •Cosmesis main concern - counsel pre-op