When is a conservative approach best for proximal biceps tendon rupture?

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Applied Evidence

When is a conservative approach best for proximal biceps tendon rupture?

J Fam Pract. 2013 March;62(3):134-136

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References

1. Carter AN, Erikson SM. Proximal biceps tendon rupture: primarily an injury of middle age. Phys Sportsmed. 1999;27:95-101.

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3. Brunelli MP, Gill TJ. Fractures and tendon injuries of the athletic shoulder. Orthop Clinic N Am. 2002;33:497-508.

4. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of the tendon. A controlled study of 891 patients. J Bone Joint Surg Am. 1991;73:1507-1525.

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9. Gaskin CM, Anderson MW, Choudhri A, et al. Focal partial tears of the long head of the biceps brachii tendon at the entrance to the bicipital groove: MR imaging findings, surgical correction and clinical significance. Skeletal Radiol. 2009;38:959-965.

10. Busconi BB, DeAngelis N, Guerrero PE. The proximal biceps tendon: trick and pearls. Sports Med Arthrosc Rev. 2008;16:187-194.

11. Freeman CR, McCormick KR, Mahoney D, et al. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Joint Surg Am. 2009;91:2329-2334.

12. Roukoz S, Naccache N, Sleilaty G. The role of the musculocutaneous and radial nerves in elbow flexion and forearm supination: a biomechanical study. J Hand Surg Eur. 2008;33:201-204.

13. Curtis AS, Snyder SJ. Evaluation and treatment of biceps tendon pathology. Orthop Clin North Am. 1993;24:33-43.

14. Mariani EM, Cofield RH, Askew LJ, et al. Rupture of the tendon of the long head of the biceps brachii: Surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1988;228:233-239.

15. Tangari M, Carbone S, Callo M, et al. Long head of the biceps tendon rupture in professional wrestlers: treatment with a mini-open tenodesis. J Shoulder Elbow Surg. 2011;20:409-413.

Published clinical guidelines usually recommend surgical repair for young athletes who require maximum supination strength in daily activities. Although the size of the Popeye deformity does diminish after conservative treatment, surgery is often recommended for patients who are unwilling to accept the cosmetic defect seen after the tendon ruptures. And finally, operative treatment is indicated for middle-aged carpenters and manual laborers whose occupations require full supination and arm strength.^2,12-14

The surgical procedure, called tenodesis, involves reattaching the torn section of the tendon to the bone.^5,15 A recent study involving 5 professional wrestlers injured while performing noted that tenodesis restored full biceps function, gave excellent cosmetic results, and allowed all of the young men to return to wrestling.¹⁵

Conservative treatment. A conservative approach is appropriate for older patients when their profession and lifestyle do not demand a high degree of supination and upper arm strength.^5,8,13,14 In addition, the more conservative approach is very well tolerated, which reduces the risk of serious complications and the cost of surgery.¹¹ Avoiding surgery also permits patients to return to work much sooner.

Patients may, however, lose up to 20% of their supination strength with conservative treatment.¹⁴ But this approach does not cause weakness in grip, pronation, or elbow extension. Nor does it affect patients’ activities of daily living,¹⁴ which may explain why more patients are treated conservatively than with surgery.^5,11 Additionally, some experts recommend nonoperative treatment of distal biceps tendon ruptures for people who are wary of surgery or present late with the injury.¹¹

CASE Two orthopedic surgeons examined our patient and both supported our recommendation to pursue conservative treatment for Mr. A.

FAST TRACK

Consider a patient’s occupation and lifestyle before choosing between biceps tendon repair surgery and more conservative therapy.

Over the next 4 to 6 weeks, he received physical therapy 2 to 3 times per week. With the help of the physiotherapist, Mr. A performed joint mobilization and flexibility exercises to improve the range of motion in his shoulder. The therapist also helped him with strengthening and stretching exercises to restore the strength of his biceps and elbow muscle.

At home, our patient’s regimen included elbow bend and straighten movements, elbow supination and pronation movements, and static biceps contractions.

Over time, his pain diminished and the strength in his left arm improved. Mr. A was able to return to work with modified duty, 2 to 3 weeks after his injury. By Week 8, he had full range of motion in his left arm and normal strength. He was able to do his job as a high school science teacher without any restrictions, but continued to have the Popeye deformity.

Our experience treating Mr. A serves as a reminder to physicians that complete long head biceps tendon rupture can be successfully treated conservatively. Patients working in sedentary occupations usually do not need a high degree of supination or physical strength in their upper extremities, making this a worthwhile treatment option for them.

CORRESPONDENCE
Sofya Pugach, MD, PhD, MPH, Complete Med Care, 8989 Forest Lane, Dallas, TX 75243; Drpugach@yahoo.com

When is a conservative approach best for proximal biceps tendon rupture?

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