Elbow Tendinopathies: Chronic Biceps Ruptures

Introduction

Distal biceps tendon ruptures are relatively rare injuries, with a reported incidence of about one per 100,000 persons per year. Most injuries occur in male laborers and athletes, with a peak incidence in the fourth and fifth decades. Several risk factors have been identified for distal biceps tendon rupture including smoking, mechanical impingement or overuse, and fluoroquinolone use. Early repair is preferred as delayed repair of chronic biceps tendon ruptures have a higher reported complication rate.

Chronic injuries have been defined as those diagnosed 1 month or more after acute rupture. Nevertheless, controversy still exists as to the precise definition of what represents an acute or chronic tear. We realize that precise time-based definitions are arbitrary. However, in our experience, injuries persisting for more than 1 month often have extensive scarring, making excavation of the radial tunnel, biceps tendon, and muscle belly itself at this juncture difficult. Because a delay to this extent increases the complications and the complexity of the repair, it provides the basis for our definition of chronic being more than 1 month after injury.

Chronic injuries typically represent an acute injury that has gone untreated or undiagnosed, and although many theories of the etiology abound, a proportion of these injuries likely begin with an underlying degenerative tendinopathy. Evidence for this stems from the observation that some acute ruptures have degenerative or poor quality frayed tissue at the time of repair even if fixed acutely ( Fig. 64.1 ). This observation suggests that, similar to rotator cuff pathology, some tears may represent as acute on chronic injuries.

Surgical technique for primary repair continues to be debated, but that operative treatment for return of functional strength in both flexion (30% improvement) and supination (40% improvement) is generally accepted. In comparison, chronic ruptures also improve functionally. Patients have been shown to return to work and recreation with few complications, when compared to primary repair of acute injuries. This chapter will deal with treatment options for the chronic distal biceps tendon rupture.

Presentation

Patients with chronic distal biceps tendon ruptures may report a distant injury with a sudden sharp or tearing type of pain following an eccentric load to the elbow. There may be an associated reverse Popeye deformity and swelling and ecchymosis, which have resolved by the time of presentation. However, some patients may not remember the original injury but present with cramping or poor endurance during repetitive supination activities, such as turning a screwdriver. Chronic pain with activity is a common complaint of patients who did not undergo operative repair early, which underscores the importance of early diagnosis and treatment. It is important to recognize that myotendinous junction tears or tears in continuity, which separate the long and short heads of the biceps tendon, also present in a similar manner. Such tears may require advanced imaging as these injuries have even been confused with soft tissue tumors.