THE CLINICAL SYNDROME

• It is much less common for the distal tendon of the biceps to rupture as opposed to the rupture of the long head of the biceps.

• More than 97% of biceps tendon ruptures are caused by a proximal rupture of the tendon of the long head of the biceps tendon, whereas ruptures of the distal portion of the biceps tendon occur less than 3% of the time.

• The disruption of the distal biceps tendon is a condition that affects men most frequently between the ages of 40 and 60 and is typically the result of an acute traumatic event that is secondary to a sudden eccentric load that is placed on the tendon.

• Some examples of this condition include attempting to start a lawn mower that is difficult to start, practicing an overhead tennis serve, lifting weights, or performing an overaggressive follow-through when driving golf balls.

• Abuse of anabolic steroids in athletes is another factor that has been linked to tears and ruptures of the distal biceps tendon.

• Falls on an elbow that is flexed and supinated have also been linked to this condition.

SIGNS AND SYMPTOMS

• Pain of a distal biceps tendon tear typically comes on suddenly, can be quite excruciating at times, and is accompanied by a popping or snapping sound in the majority of patients.

• The pain is severe and constant, and it is centered in the area that surrounds the antecubital fossa.

• Patients who have a complete tear of the distal biceps tendon in their biceps experience weakness in the flexion and supination of their upper extremities.

• In patients who have suffered a complete rupture of the distal biceps tendon, the antecubital fosa will exhibit a noticeable and palpable deficiency.

• A Popeye sign that reads in reverse is frequently seen.

TESTING

• Radiographs in the plain format should be taken of every patient who comes in complaining of elbow pain.

• The clinical presentation of the patient may suggest the need for additional testing, which may include an evaluation of the patient's complete blood count, erythrocyte sedimentation rate, and antinuclear antibody levels.

• The patient is experiencing pain and functional disability, and ultrasound imaging may help further delineate the extent of the tendinopathy and identify other abnormalities that are responsible for the patient's discomfort.

• If there is a suspicion of tendinopathy or a partial tear or complete rupture of the biceps tendon, magnetic resonance imaging of the elbow is the test that should be performed.

DIFFERENTIAL DIAGNOSIS

• In most cases, a tear of the distal biceps tendon can be easily diagnosed through clinical examination.

• The diagnosis may be complicated, however, if the patient also has elbow tendinitis or bursitis as a result of overuse or improper use.

• When dealing with certain clinical scenarios, it is important to take into account the possibility of primary or secondary tumors involving the elbow.

• In addition, the diagnosis might be made more difficult by nerve entrapments in the elbow or the forearm.

TREATMENT

• The initial treatment for the pain and functional disability associated with a distal biceps tendon tear consists of a combination of physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors.

• Both of these classes of medications are known as COX-2 inhibitors.

• The application of heat and cold to specific areas of the body may also be beneficial.

• Careful injection with a local anesthetic and steroid is a reasonable next step for patients who do not respond to these treatment modalities and who appear to have significant local pain in the region of the distal biceps tendon.

• In order to administer an injection for a distal biceps tendon tear, the patient must first be positioned in a sitting position with their elbow flexed to an angle of approximately ninety degrees.

• By palpating at the antecubital fossa, one can easily determine whether or not the distal biceps tendon is still intact.

• When the tendon is missing, the location of the defect can be determined.

• A sterile marker is used to mark the point that is located directly above the distal tendon or defect.

• After receiving an injection, the patient should wait several days before beginning any physical modalities.

• These modalities should include local heat as well as gentle range-of-motion exercises.

• Exercises that are too strenuous for the patient should be avoided because doing so will make their symptoms even worse.

• The tendon may be surgically repaired on occasion if the patient is experiencing a significant functional disability or is dissatisfied with the cosmetic defect caused by the retracted tendon and muscle.

• This is the case if the patient is also unhappy with the cosmetic defect.

COMPLICATIONS AND PITFALLS

• If the clinically relevant anatomy is carefully considered before administering the injection, this method does not pose a safety risk.

• In order to prevent infection, sterile technique must be utilized, and universal precautions must be taken in order to lessen the likelihood that the operator will be put in harm's way.

• If pressure is applied to the injection site immediately after the injection, this can help reduce the risk of complications such as ecchymosis and hematoma formation.

• Infection is the most serious risk associated with this method of injecting, but if proper asepsis procedures are followed, the likelihood of contracting an infection should be extremely low.

• There is also the possibility that the injection itself will cause injury to the tendon of the distal biceps.

• If a tendon that is already severely inflamed or has been damaged in the past is given an injection directly, there is a risk that it will rupture.

• This complication can usually be avoided if the clinician employs a gentle technique and ceases injecting the patient as soon as they encounter significant resistance.

• Patients should be made aware of the possibility that they may experience a temporary increase in pain after receiving an injection, as this affects approximately one quarter of all patients.