“I may not be a smart man but I know what love is Jenny.”
from the movie “Forrest Gump”
One of the more common injuries that occurs around the elbow is to rupture the biceps tendon. This is usually a very dramatic event that causes pain, swelling and bruising around the elbow. For some reason this injury occurs almost solely in men. I have never treated a biceps rupture in a women, and there are only a few cases of these found if you dig through the medical literature.
This injury usually occurs when someone is lifting a heavy object or lifting against a lot of resistance. I’ve seen patients who ruptured their biceps while working out and doing curls, but most people are using their arm during normal activities and there is a sudden force on their arm which causes the rupture. A lot of people hear a pop and they are usually aware that something significant has happened to their arm. Most of the time the diagnosis is pretty obvious, and no tests other than an x-ray are needed. Sometimes the diagnosis is not as clear and an MRI can show if a partial or complete tear has occurred.
The biceps muscle runs from the shoulder, down the front of the arm, and attaches on a bone in the forearm called the radius. The muscle has two attachments at the shoulder (called the short head and the long head) and a single attachment just past the elbow. Most people think of the biceps as the main muscle that flexes or bends the elbow. Actually the muscle that does most of that work is under the biceps and is called the brachialis muscle. The biceps attaches in such a way that the motion that it is responsible for is called supination. The way to visualize this motion wound be to place your hand in front of you with the palm facing the floor. The motion of turning your palm towards the ceiling is called supination. The biceps comes into use with what doctors call “power supination”. The best example of this would be to open a tight jar.
Although there is usually some pain and swelling with rupture of the biceps, this will eventually subside and go away. The biggest problems people have when their biceps is ruptured is the associated weakness. On average people lose over 40% of their supination power and up to 30% of their flexion power at the elbow and for the group of people who have this injury, which is mainly men in their 40’s and 50’s, that’s too much strength for them to give up. Therefore most patients usually choose to have surgery to repair and reattach the tendon.
The goal of the surgery is to reattach the tendon back where it belongs but there are a number of ways to do this. The surgery is difficult and it requires a good deal of knowledge about the anatomy around the elbow since several major nerves and arteries run close to the biceps. If the surgery is done by an experienced surgeon then you can usually expect few complications and a good outcome. Most patients regain all or almost all of their motion, and many patients regain all or most all of their strength. The surgery can be done through one incision on the front of the elbow or through two separate incisions. Each technique has it’s proponents and each technique has some unique complications associated with it. I don’t think one technique is better than the other so it’s best to go with the one that your surgeon is most comfortable with.
It takes a long time to recover from this surgery. The tendon doesn’t regain it’s normal strength for at least three months, and it is probably another 3 months or so before the whole are regains it’s normal strength. There are new techniques that use small metal buttons to reattach the tendon, and so I’ve been letting patients use their arm earlier in their recovery than I used to, but I still urge people to be very cautious.
In general patients who have ruptured their biceps do well with surgery and regain a lot of their motion and strength. If the patient lives a sedentary life and doesn’t need much strength, then it can make sense in a rare case not to repair the tendon. This is a pretty hard surgery to do, so I would recommend that if you have ruptured your biceps tendon to seek out a surgeon who has experience treating this injury.