Biceps is a muscle of the arm. It has two heads called the long and the short head. The muscle arises at the shoulder and attaches itself to the bone of the forearm, the radius. Bicep Brachii tendon rupture may occur at the proximal end, the shoulder. It can also occur at the distal end, where the muscle gets attached.

The biceps helps to supinate the forearm, the position of the forearm while holding a cup or bowl. It also helps to flex or bend the forearm.

The tendon of the biceps may tear under conditions that involve a sudden forceful contraction of the arm that acts opposite to the supination and flexion action of the biceps muscle.

The forearm is usually in a flexed position when the rupture occurs. For example, in instances when you are trying to catch something. The injury is often accompanied by a popping sound when the tendon separates from the bony attachment.

Intrinsic degeneration of the tendon release and wear and tear of the tendon belly also contribute to the injury. The degenerative processes usually occur due to improper training techniques or fatigue caused by repetitive movements.

Undue stresses placed on the biceps to compensate for other muscles can make the muscle vulnerable to injury. This results in slow wear and tear and functional failure, affecting the tendon substance or attachment point.

Anatomy of the bicep brachii muscle

The biceps brachii muscle comprises two parts;

• The long head
• The short head

The long head originates at the supraglenoid tubercle located at the scapula or the shoulder bone. It runs over the head of the humerus and follows the bicipital groove on the bone.

The muscle functions as an active stabilizer of the glenohumeral joint, keeping the head of the humerus depressed (preventing its upward dislocation).

The short head arises from the coracoid process of the scapula.

The two heads merge to form a distinct body attaching to the radial tuberosity of the radius.

The tendon differs in shape. The part inside the joint is wide and flat, while the part outside is rounder and smaller.

The muscle can act both on the shoulder joint as well as the elbow joint.

In the shoulder joint, both heads of the muscle partially carry out opposite movements. The long head pulls the arm away from the body, called abduction. It also turns the arm inwards in a rotatory motion.

On the other hand, the short head pulls the arm back towards the trunk, called adduction. When both heads contract at the same time, the arm goes into flexion or bends.

Both the muscles act together to bend or flex the forearm at the elbow joint and rotate it outwards in supination with the palms facing upwards.

Causes of biceps brachii tendon rupture

The most common causes of biceps brachii tendon rupture are a fall on the outstretched hand. It causes undue pressure on the biceps tendon.

Such falls most often occur in young adults. Individuals involved in sports activities like weightlifting, snowboarding, and contact sport like soccer may also encounter biceps brachii tendon rupture.

Injuries may happen in older people between 40-60 years of age. The underlying cause lies in degenerative issues. People with shoulder issues are more at risk of facing the injury.

The primary mechanism of injury includes sudden contraction of the biceps when resisted by elbow flexion and supination of the forearm. In addition, the degenerative process acts as a predisposing factor.

To sum it up;

• Heavy and forceful overhead movements
• Shoulder overuse
• Bending of the elbow forcefully against resistance as in performing chin-ups or biceps curls,
• Forceful arm elevation
• Gradual trauma to the tendon associated with repetitive or prolonged activities that place strain on the biceps tendon

Signs and symptoms of biceps tendon rupture

The signs and symptoms vary depending on the severity of the injury. However, a typical pop sound with the tendon rupture and a classic 'Popeye' appearance of the arm is seen with such an injury.

• A pop sound audible to the patient at the time of injury
• Pain in the anterior shoulder which is sharp may occur with or without a snapping sensation
• Pain with overhead movements of the arm
• The pain in the anterior shoulder pain gets worse at night
• Some associated underlying conditions may be present as rotator cuff tears, tendonitis, and shoulder impingement
• Popeye deformity of the arm

Diagnosis

Physical examination and history reveal the condition. The physical exam includes;

• Assessment of the shoulder and arm contour shows the Popeye sign.
• Descent of the biceps muscle in the middle part of the arm may also be seen, which becomes more evident in contraction.
• Muscle power of the shoulder and arm decreases.
• The range of motion of the shoulder and elbow is reduced.
• Special tests for biceps tendon rupture include Yergason's test, speed test, and hook test.
• MRI and ultrasound

Treatment and management of biceps brachii tendon rupture

Conservative treatment is usually undertaken for managing biceps tendon rupture. It is a safe module for older people in whom much supination strength is not required. It can also be advised in subacute or chronic cases of tendon rupture.

Conservative treatment usually takes 4-6 weeks to bring back the functionality of the arm and forearm.

1. Immediately after the injury to a week

1. RICER

Immediately after the injury, stop ant activity and rest the affected arm.

Apply cold compress or ice wrapped in a clean cloth to alleviate pain and swelling.

Apply gentle compression if there is no bruising and apparent wound.

Keep the arm supported with a sling to prevent swelling.

Refer to a specialist if the symptoms do not ease with time.

• Medication

Over-the-counter pain relievers and anti-inflammatory medications should be started.

• TENS

In the absence of any apparent injury and after the initial symptoms have subsided, TENS may help alleviate pain in the shoulders and adjoin muscles as biceps arise from the shoulder.

• Surgery

Surgery involves repairing the tendon and attaching it back to the bone; a process called a tenotomy. It resolves the function and muscle power disability and corrects the arm's aesthetic by removing the Popeye look.

Surgery is often recommended for;

• Young and athletic people
• Individuals requiring maximum supination strength
• Patients who lose up to 20% of supination strength with a biceps tear
• Patients who find it hard to accept Popeye deformity, celebrity athletes, etc.
• Few weeks after the injury

• Massage

In the first three weeks following the injury, soft tissue massage helps to reduce scar formation. Between the third and sixth week time, soft tissue massage helps relieve the tension of the bicep muscle.

An arm soft tissue massage focuses on alleviating the tension and pain using a variety of techniques, including;

1. Deep Strokes
   1. Frictions
   1. Kneading
   1. Lymphatic drainage

This helps to;

• Counteract delayed onset muscle soreness (DOMS) after an injury
• Post Event muscle soreness and tightness
• Pre-event range of motion increase, and fewer chances of injury
• Tight muscles

The benefits of an arm massage for biceps tendon rupture are;

• Enhanced performance
• Increased range of movement and flexibility
• Decreased pain
• Prevention of injury

• Therapeutic ultrasound

Therapeutic ultrasound helps the healing and repair of the tissue surrounding the muscle. In addition, the therapy increases the range of motion and strengthens the biceps.

Care should be taken that no apparent wound is present.

• Active rehabilitation

Post-operative rehabilitation requires the patient to wear a sling for the first 10-14 days. Passive movement is allowed.

Light exercise is allowed from 2-6 weeks. Between the 6th to 8th weeks, functional activities involving the active participation of the biceps are carried on. Heavy load and full force are prohibited for the first few months. Resistance training can be done if tolerated by the patient.

After the conservative treatment, active rehabilitation should be adopted two to three times a week. It may take 4-6 weeks of rehabilitation to bring the muscle to total functioning capacity.

Mobilization and flexibility exercises are advised to improve the range of motion of the shoulder. Strength and stretching exercises are done in addition to the muscle being static trained.

Home-based exercises include extension, flexion and supination, and pronation. Most people return to work after 2-3 weeks, yet the work needs to be modified and adapted.

After eight weeks, the range of motion and strength resolves. However, the Popeye malformation may remain.

Elbow Bend to Straighten

• Sit or stand comfortably.
• Raising your arms as per your comfort level, not going above the waist, however.
• Alternately, bend and straighten your elbow as far as possible.
• If you feel any pain, stop there and continue moving your arm in your comfort zone.
• Bend and straighten your elbow as far as possible and comfortable pain-free.
• Repeat ten times. You should be able to feel a mild to moderate stretch.

Elbow Supination Pronation

• Begin the exercise seated or standing.
• Keep your elbow at your side and bent it at a 90-degree angle.
• Rotate your arm so as your palm faces upwards and down alternately.
• Repeat ten times.
• There should be mild to moderate stretch.

Static Biceps Contraction

• Keep your elbow at your side.
• Bend your elbow at 90 degrees.
• Keep the palm facing up?
• Place your healthy hand on your affected forearm and push your affected arm against that resistance.
• You should feel a tightening of your biceps.
• Hold for 5 seconds.
• Repeat ten times with maximum effort but without any pain.

Bear hug

• Stand tall and inhale.
• As you open your arms out wide while inhaling.
• Start exhaling and cross your arms at the same time in a slow controlled movement.
• Bring the movement in such a way that your right arm is placed over your left shoulder, and your left arm is placed over your right shoulder as if you are hugging yourself.
• Take deep breaths and use your hands to draw your shoulders forward. You should be able to feel a stretch in your shoulders.
• Hold this stretch for 30 seconds.
• To release, open your arms while inhaling.
• Open your arms back open wide.
• Exhale and repeat the movement with your left arm on top.

Biceps Stretch

• Face a wall at about a distance of 6 inches.
• With your palm facing down, raise the affected arm and touch the thumb side of your hand to the wall.
• Making sure that your arm is straight, turn your body away from your raised arm. Stop when you feel a stretch in the biceps.
• Hold this stretch for about 15 seconds.
• Complete 2 more repetitions.

Prevention of biceps brachii tendon rupture

Some preventive tips to safeguard against biceps tendon rupture include;

• Adopt appropriate exercises to maintain proper strength in the shoulder, elbow, and forearm.
• Avoid repetitive movements requiring overhead lifting.
• Use caution during general overuse of the shoulder. For example, forceful pushing or pulling activities or lifting heavy objects. Lifting weights or things more than 150 pounds can be dangerous for older adults.
• Special care should be taken while performing activities as lowering a heavyweight down on the ground.
• Avoid smoking and steroid use because both these activities weaken the muscles and tendons.