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Biceps Injuries
Injuries to the Biceps PPT
| Question | Answer |
|---|---|
| Distal Biceps Injuries | Tremendous stress to biceps during athletic & standard daily activities Injury to distal biceps fairly rare (3%, maybe 10%) |
| Distal Biceps Injuries | Tendon injuries in general increase in middle age group Athletes- generally weight lifters Only 2 cases of women |
| Distal Biceps Injuries | Majority in dominant extremity Traumatic in nature (Weightlifting, Sports, FOOSH) |
| Distal Biceps Injuries | Excessive eccentric tension as arm is forced from flexed position Length-Tension relationship; Force-velocity relationship |
| Length-Tension Relationship | Failure of muscle due to very shortened or very lengthened physiological position |
| Force-Velocity Relationship | Relationship b/t velocity of muscle contraction & force produced |
| Pathology | Poorly understood Combination of degeneration & mechanical factors (Tendonitis &/or pain; Overuse; Inadequate arterial supply; Smoking) |
| Pathology | Hx of tendonitis, overuse, &/or steroid use Steroids used for increasing muscle mass & strength cause tendon to become stiff & less elastic; unable to absorb as much energy |
| Differential Dx: Other causes of pain in antecubital fossa | Biceps bursitis Biceps tendonitis Partial distal avulsion Lateral antebrachial cutaneous nerve entrapment syndrome |
| Other causes of pain | Violent eccentric contraction superimposed on degenerative changes in tendon structure Narrow space b/t radius/ulna in pronation (50% loss in space b/t full sup/pro) Repetitive stress due to abnormal friction Sup/pro vs. local bony prominence at rad. t |
| MOI | Eccentric contraction or resisted flexion of elbow from weightlifting or FOOSH |
| MOI | Athlete usually hears "pop" Contour of upper arm appears abnormal |
| MOI | Male>Female Women have 45% smaller muscle cross-sectional area for biceps Women have 52% strength of males with use of elbow flexors Men have greater % fast-twitch fibers in biceps |
| Female Cases | 58 & 72 years old Athletically active women Sustained during sporting events |
| MOI | Distal tendon usually very easy to palpate in antecubital space Inability to palpate necessitates referral "Hook Sign" |
| Types of Ruptures | Partial- insertional, intrasubstance Complete- Acute; Chronic- intact aponeurosis, ruptures aponeurosis |
| Partial Ruptures | Pain in antecubital fossa Weakness with elbow flexion/forearm supination Biceps tendon palpable throughout length |
| Partial Ruptures | Loss of fxn less than complete tears Debridement not successful Excise reactive granulation tissue & releasing remaining attached tendon |
| Complete Ruptures | Usually hear "pop" Immediate pain, usually resolves quickly Contour of upper arm abnormal Weak: elbow flexion, forearm supination, shoulder flexion Edema & ecchymosis |
| Retraction of Biceps | Complete rupture Tendon retracts proximal Will scar to brachialis over time |
| Physical Presentation | Pain Edema Ecchymosis in upper arm/antecubital fossa Later onset of acute pain several days following injury probably rupture of lactus fibrosus |
| Physical Presentation | Edema in area may make palpation difficult If can see acute before edema occurs, may be easier to palpate tendon |
| Surgical Methods | Surgical repair preferred method of treatment for active individuals Athletes & Laborers |
| Non-Surgical Methods | No surgical (conservative) treatment 40% loss supination strength, 30% loss of flexion 86% decrease supination endurance 61% flexion strength, 65% supination strength w/o repair |
| Conservative Non-Surgical Treatment | Elderly, sedentary pts or those too ill to have surgery Possible activity related pain Decreased flexion & supination strength |
| Surgical Treatment Options | 1 incision (Henry) 2 incision (Boyd Anderson)- minimize risk of neurovascular injury; caused HTO & synostosis from bleeding Endobutton repair Tenodesis Graft repair |
| Surgical Repair Selection | No superior method of repair Surgeon discretion |
| Post-Op Care for One Incision/Modified Henry Approach | Elbow immobilized in 90 deg flexion for 2 wks (Progressive increase hinged brace) Passive supination/pronation with elbow at/or >90 flexion allowed >2 wks Active flexion starts at 8 wks |
| Advantages/Disadvantages of 1 incision approach | Ad: Direct approach; Avoids posterior interosseous n.; Minimal ectopic bone formatio n(radioulnar synostosis) Dis: may injure radial n if surgeon passes tendon thru drill holes made in radius |
| Post-Op Weeks 1-2 | Forearm in supination or neutral Elbow 90 deg flexion Splint/cast Full passive flexion allowed Scar immobilization |
| Weeks 1-2 Ex's | PROM elbow flex AROM elbow ext within splint to 90 Forearm AAROM from pronation to neutral at 90 Supination PROM to only about 30 |
| Weeks 1-2 Ex's | Wrist flex/ext AROM & ex's with wrist in neutral Light grasp ex's (with elbow safely flexed) |
| 3 wks Ex's | Splint to allow 60 Supination AROM to 45 AROM of shoulder Continue scar massage |
| 4-5 weeks | Adjust elbow splint to 30 deg Begin AAROM flex AAROM supination to 55 deg |
| 6 weeks | Wean off splint AROM elbow flexion Place & hold isometric ex's for flexion Full supination AAROM-AROM Allow light ADL's |
| 8 weeks | DC splint during the day More aggressive means of obtaining full AROM/PROM PRN Heat, more aggressive joint mobs |
| 9-10 weeks | Begin PROGRESSIVE, not aggressive strengthening |
| Full Return Dependent on Activity | For sports w/o contact or max resistance forces- 3 months Sports w/ contact & max resistance after 6 months following surgery if strength & ROM appropriate |
| Proximal Biceps Ruptures | Proximal ruptures of LHB account for 96% all ruptures In those >40 years usually represents RTC disease & impingement |
| Proximal Biceps Ruptures | May be minor trauma Presents painlessly at times Biceps retracts into a ball Localized swelling & ecchymosis |
| Conservative Treatment | >40 years old Return to activites- usually 2-3 months |
| Surgery | Preferred for young adult w/o RTC disease Suture to bicipital groove |
| Post-Op Weeks 0-4 | Shoulder sling/immobilizer Pendulum ex's AAROM elbow 0-145 with gentle ROM into extension Shoulder PROM- flex, ER, IR |
| Weeks 4-8 | Light shoulder PRE's |
| Weeks 8+ | Progress to isotonic PRE's |
| Grading of Biceps Integrity | Grade I- minor fraying involving <25% Grade II- <50% fibers Grade III- >50% fibers Grade IV- Complete rupture |
| Indications for biceps tenodesis | >25-50% partial thickness tears of LHB; Subluxation; Disruption of biceps groove or soft tissue stabilizers; Chronic atrophy of tendon; Biceps disease; Avoid deformity of tenotomy |
| Biceps Tenodesis Approaches | Tenodesis of biceps tendon to coracoid process; To lesser tuberosity using sutures; Post technique with transosseous sutures; Into bicipital groove using an osteal periosteal flap; Froimson keyhole technique; Interference screw fixation |
| Post-Surgical Rehab | Dependent on other surgical procedures RTC repair, Capsular Plication, Subscapularis repair |
| Weeks 0-6 | Sling use to limit elbow motion outside PT Shoulder ext limited to anterior to frontal plane Limitation of terminal elbow ext |
| Weeks 0-6 | Scapular strengthening initiated early within first few weeks Arms at side in side-lying RTC isometrics initiated early |
| Weeks 6+ | Progressive RTC & biceps strengthening program Some concerns of fwd flexion motions |
| D/C Criteria | Similar to other surgeries Elevation & rotational strength = to contralateral side Successful pt satisfaction on subjective ratings |
| Outcomes | Failure in 6/20 pts Sometimes becomes chronic- esp w/o associated acromioplasty Many pts require add'l tx Moderate pain at 7 yr F/U |
| What should be performed in addition to tenodesis? | Acromioplasty |
| Positive Outcome Study | Isolated tenodesis withou acromioplasty 94% good to excellent results Excluded pts included instability, RTC tears |
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1190550002
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