Bicep Tendon Rupture

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biceps-rupture-prevA 45-year-old-male presents with sudden onset of right arm pain. He reports that he was lifting a heavy piece of machinery when he heard a sudden popping sound and now complains of significant swelling to his right arm.

“Popeye” deformity makes bicep ruptures relatively easy to spot — but treatment is less obvious



A 45-year-old-male presents with sudden onset of right arm pain. He reports that he was lifting a heavy piece of machinery when he heard a
sudden popping sound and now complains of significant swelling to his right arm [pictured].

Biceps tendon rupture


The biceps brachii muscle is involved in supination and flexion of the forearm. The biceps muscle has two proximal tendon insertions onto the scapula— the long head and the short head. The long head originates at the supraglenoid tubercle and extends over the humeral head into the intertubercular groove of the humerus. The short head originates from the coracoid process along with the coracobrachialis muscle medial to the long head tendon. The distal tendon of the biceps muscle attaches to the radial tuberosity.

The vast majority of biceps tendon ruptures occur at the proximal insertion and almost always involve the long head [1]. Most commonly, these ruptures occur at the bony attachment or the tendon-labral junction. Distal tendon ruptures are rare but can occur at the insertion on the radial tuberosity. Tendon ruptures also can occur at the short head insertion on the acromion, although this is far less common.


Individuals age 40-60 years with a history of shoulder problems that cause chronic strain on the tendon are at the highest risk for biceps tendon rupture [2]. Traumatic ruptures that occur in a younger population are usually the result of acute strain on the tendon, such as heavy weightlifting or a traumatic fall. These often are the result of the forced extension of the elbow from a supinated and flexed position. Other risk factors for tendon ruptures include chronic disease states such as diabetes, chronic kidney disease, systemic lupus erythematosus,
rheumatoid arthritis, chronic steroid use, fluoroquinolone use, and cigarette smoking [3].


The diagnosis of these injuries is usually a clinical one. Patients typically present after an acute traumatic event where the patient experienced a sudden onset of pain, heard a “pop,” and noticed bruising or swelling. Since many patients with biceps tendon rupture also have a history of chronic shoulder pain due to nerve impingement some may note improvement in their shoulder pain after long head biceps tendon rupture.

Physical examination involves inspection of bilateral upper extremities to evaluate for asymmetry, deformity, and neurovascular impairment. A biceps tendon rupture often presents as a visible or palpable mass and is referred to as a “Popeye” deformity. A thorough examination of the affected arm should be done, noting any tenderness along the biceps tendon and muscle belly. 

The examiner should assess range of motion at the shoulder and elbow joints and test upper extremity strength, especially of the biceps muscle itself. The “Ludington” sign is used to evaluate for a long head tendon tear. This physical exam maneuver is accomplished by having the patient clasp their hands behind their neck and flex their biceps muscle. Asymmetry between the two biceps muscles demonstrates a long head tendon tear.

To evaluate for a distal biceps tendon tear the “Hook” test is used. This exam technique involves the patient actively supinat- ing the flexed elbow. The examiner palpates or hooks his or her index finger under the biceps tendon from the lateral side. If there is a distal biceps tendon rupture the examiner will be unable to hook or palpate the cord-like structure [4].

Plain radiography is generally not diagnostic but can aide in the diagnosis by ruling out other bony injuries. Ultrasound has been described as a reliable indicator of biceps tendon ruptures [5,6]. MRI is often considered the “gold standard” and will be able to help illustrate the anatomy of the biceps tendon rupture, but is usually not indicated in the emergency department setting.


There is debate about the ultimate treatment of biceps tendon ruptures. In the emergency department treatment should focus on analgesia, anti-inflammatories, and comfort measures such as muscle rest with use of a sling. Prompt orthopedic or sports medicine follow up is warranted for these patients for non-emergent imaging and evaluation for possible surgical management. Some biceps tendon ruptures, especially those involving the long head, can be managed conservatively with pain control and physical therapy [7].

In patients who rely on upper body strength, such as athletes or highly active individuals, surgical repair is often recommended. Estimates of up to 20% of function can be lost with long head ruptures which may be acceptable in an older patient population, but severely debilitating for younger patients. Distal biceps tendon ruptures almost always need urgent surgical repair as the patient may lose significant functioning of the affected arm [8].

Case Resolution

This patient was correctly diagnosed with a long head biceps tendon rupture. He was placed in a sling for comfort and given pain medicine. He followed up in the orthopedic clinic three days later where the decision was made for surgical repair given his occupation as a mechanic.

Michael Breyer, MD is an Associate Program Director at the Denver
Health Emergency Medical Residency Program. Leah Jacoby, MD is a fourth year resident at the Denver Health Emergency Medical Residency Program. Peter Pryor, MD, MPH worked at Denver Health from 2008-2014. Amanda Kao is at the Denver Health Emergency Medical Program

Elser F, Braun S, Dewing CB, Giphart JE, Millett PJ. Anatomy, function, injuries, and treatment of the long head of the cipes brachii tendon. Arthroscopy. Apr 2011; 27(4):581-92

Carter AM, Erickson SM. Proximal biceps ten- don rupture primarily an injury of middle age. Physician Sports Med. 1999; 27:95-102

Marx JA, Hockberger, RS, Walls RM, Adams J, Rosen P. Rosen’s Emergency Medicine. 8th edition, 2014;[1].

O’Driscoll SW, Goncalves LB, Dietz P. The hook test for distal biceps tendon avulsion. Am J Sports Med. 2007 Nov;35(11):1865-9.

Skendzel JG, Jacobson JA, Carpenter JE, Miller BS. Long head of biceps brachii tendon evaluation: accuracy of preoperative ultrasound. AJR Am J Roentgenol. 2011 Oct; 197(4):942-8

Lobo Lda G, Fessell DP, Miller BS, Kelly A, Lee JY, Brandon C, Jacobson JA. The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings. AJR Am J Roentgenol. 2013 Jan;200(1):158-62.

Mariani EM, Cofield RH, Askew LJ, Li GP, Chao EY. Rupture of the tendon of the long head of the biceps brachii. Surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1988 Mar; (228): 223-9.

Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg.1999 May-Jun;7(3):199-207.

1 Comment

  1. Should a nurse practitioner and a MD in A hospital ER be able in 6 hrs to ascertain that a distal bicep tendon was ruptured in a 63 year old male? This person presented with rThe classical signs of this injury yet sent Him home with instructions to take ibuprifen and ice the arm. “Elbow pain” was the diagnosis written after x-ray ruled out bone break. First possible visit back to hospital orthopedist yielded a fast diagnosis of dis tal bice tendon rupture based ob visual observation alone (reverse Popeye effect). Palpation and MRI confirmed. Arthrex tenodesis scheduled at last for day 6 was beyond injury. This delay confirmed by orthopedist as less than optimum for satisfactory treatment.

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