case report Acute Distal Biceps Tendon Rupture During Weightlifting Practice: Clinical Case
Ana Costa Pinheiro*, Carlos Mateus, Nuno Ferreira, Nuno Sevivas, Manuel Vieira da Silva
Serviço de Ortopedia, Hospital De Braga, Braga, Portugal
*Corresponding author: Ana Costa Pinheiro, Serviço de Ortopedia, Hospital De Braga, Braga, Portugal. Tel: +351914335860; Email: ana.alexandra.pinheiro@gmail.com
Received
Date: 01 August, 2018; Accepted Date: 06 September, 2018; Published Date: 12 September, 2018
Citation:
Pinheiro AC, Mateus C, Ferreira N, Sevivas N,
Silva MVD (2018) Acute Distal Biceps Tendon Rupture During Weightlifting
Practice: Clinical Case. J Orthop Muscular Syst Res: JOMSR-102.
DOI:10.29011/JOMSR-102.100002
Abstract
Distal biceps tendon
ruptures (DBTR) usually occur in the region where the tendon inserts into the
radial tuberosity and constitute 3% of all ruptures of this tendon. The aim of
this study is to present a case of acute rupture of the distal biceps tendon
during the weightlifting practice, and to review the literature on the most
appropriate treatment for this type of injury. A 33-year-old male was recruited
to the Emergence Service for an indirect right elbow injury with a 1-day
evolution, referring to elbow pain after lifting a weight of about 7.5 kg during bicipital training in the gym. He performed an ultrasonography
that confirmed a total rupture of the distal biceps tendon. He was submitted to
surgical treatment with reinsertion of the distal biceps tendon with button and
screw system (Arthrex Distal BicepsButton™, USA), without intercurrences in the
immediate or late postoperative period. The patient presented, in the final
evaluation at 6 months of follow-up, complete joint range of motion, without
pain or weakness, and with unlimited return to daily life activities, obtaining
an excellent functional result. The total rupture of the distal tendon of the
brachial biceps in young and in individuals with high physical demand presents
better results with the surgical treatment when compared with the conservative
treatment. Thus, complete injury of this tendon at the osteotendinous junction
is of preferential surgical treatment through reinsertion of the tendon,
allowing for a morphological reestablishment and a complete functional recovery
of the affected upper limb.
Keywords: Acute Tendon Rupture; Distal Biceps; Elbow; Elbow Injury;
Tendon; Treatment
Introduction
The lesion of the distal brachial biceps
insertion is uncommon, with an incidence of 1.2 per 100,000 patients per year. [1]
Stark was the first to describe the rupture of the distal brachial biceps, in
1843, and in 1987, Johnson completed the first successful reintegration. [1,2]
Distal Biceps Tendon Ruptures (DBTR) usually occur in the region where the
tendon inserts into the radial tuberosity and constitute 3% of all ruptures of
this tendon. [2,3] They usually occur in middle-aged men in the dominant upper
limb when an eccentric extension load is applied to the elbow. Several studies
refer some risk factors related to rupture including regular tobacco usage,
anabolic steroid use and weightlifting. The incidence of distal biceps rupture
has increased due to increased practice of sports activities. [2,4-6] In cases
of complete rupture, the muscle retracts proximally giving rise to the
so-called "reverse Popeye" sign. [7] Diagnostic auxiliary exams, such
as magnetic resonance imaging or ultrasonography, are relevant in
differentiating the degree of tendon rupture lesion (partial vs. complete
rupture). [8,9] Surgical treatment provides better clinical and functional
results than conservative treatment, since this usually leads to muscle
strength deficit, mobility disorders, and aesthetic deformities. [10-15] The
aim of this study is to present a case of acute rupture of the distal biceps
tendon during the weightlifting practice, and to review the literature on the
most appropriate treatment for this type of injury.
Case Report
Male, 33 years old, lawyer, with no relevant
medical history, namely smoking habits, and without consumption of medications,
namely anabolic steroids. He recruited the Emergence Service because of an
indirect right elbow injury, with 1 day of evolution, referring to pain in the
elbow, after lifting weight of about 7.5 kilograms, during bicipital training
in the gym. The objective examination in the Emergence Service showed edema and
pain on palpation of the antecubital region, with loss of the normal contour of
the distal biceps and palpable gap. The range of motion of the elbow was
complete and showed a decrease in the force on the supination of the forearm
and flexion of the right elbow. He also presented positive squeeze test of the
biceps and hook test positive for DBTR. He performed ultrasonography that
confirmed a total rupture of the distal biceps tendon.
He was submitted to surgical treatment with reinsertion of the distal biceps tendon with a button and screw system (Arthrex Distal BicepsButton™, USA, (Figures 1-7), without intercurrences in the immediate or late postoperative period (Figure 8). After surgery, the elbow was immobilized in 90° flexion with the forearm placed on supination for about 10 days. After this period, he began a progressive functional rehabilitation program. The patient presented, in the final evaluation at 6 months of follow-up, complete joint amplitude, without pain or weakness, and with unlimited return to the activities of daily living and physical activity, obtaining an excellent functional result, according to the Andrews-Carson and Mayo Elbow Performance Score (MEPS-100 points).
Discussion
There are several therapeutic options
(conservative and surgical) for the treatment of acute distal biceps tendon
rupture, and patients who have been treated conservatively tend to have obvious
clinical deficits. [10,11] Good to excellent results were described for early
surgical treatment, with complete functional recovery and high degree of
patient satisfaction. [12-15] Total acute rupture of the distal biceps tendon
in young and in individuals with high physical demands presents better results
with the surgical treatment when compared to the conservative treatment. Thus,
complete acute injury of this tendon at the osteotendinous junction is of
preferential surgical treatment through reinsertion of the tendon, allowing a
morphological reestablishment and a complete functional recovery of the
affected upper limb. [16] It should be noted that anatomically there are 2
distinct bicipital muscle, short (flexor) and long (supinator) muscle inserts,
which should be considered during surgical treatment.
Several surgical techniques have been
described for the reinsertion of the distal biceps tendon, using double or
single approaches and with different methods of fixation, among which we can
mention the most used: the bone tunnel, the interference screw, the end button
and the suture anchor. Clinical studies have demonstrated advantages in the use
of single approach, with excellent results in repair with suture anchors. [17-19]
Henry and colleagues compared the surgical technique through an incision or two
surgical incisions and found no difference in supination and flexion between
the two techniques. [20] Biomechanical studies have tested the strength of
various techniques. The cortical button technique exhibits the maximum load
until failure in vitro, and the anchors and interosseous screw techniques
produce the least deviation. Surgical complications include sensory and motor
neuropraxia, infection, and heterotopic ossification. Current trends in
postoperative rehabilitation include an early return to motion and activities
of daily living. [21]. Regarding tendon fixation, Lemos et al. compared the use
of bone tunnels with anchor suture fixation in biomechanical studies in
cadavers and reported that the elastic force of the suture anchor fixation is 263
N and 203 N in bone tunnel. [18] Conservative treatment of acute DBTR typically
results in loss of flexion and supination force. Non-operative treatment is
reserved for elderly patients with low functional demand and for those patients
with significant medical comorbidities, resulting in an unacceptably high risk
for surgery.
Conclusion
The surgical treatment of acute DBTR seems to
be safe and effective in repairing rupture of the distal tendon of the brachial
biceps. Our results show that anatomical repair offers good results.
Figures 1-3: Intraoperative
images of the identification and reference of the proximal portion of the
distal.
Figures 4-7: Intraoperative images of the
surgical treatment with reinsertion of the distal biceps tendon with button and
screw system of interference (Arthrex
Distal BicepsButton™, USA).
Figure 8: Postoperative
image at 8 weeks.
3.
Morrey BF (1999) Biceps
tendon injury. AAOS Instr Course Lect 48: 405-410.
5.
Fischer WR, Shepanek
LA (1956) Avulsion of the insertion of the biceps brachii; report of a case. J
Bone Joint Surg Am 38: 158-159.
6.
Leavitt DG, Clements
JH (1935) Avulsion of the distal biceps brachii tendon. Am J Surg 30: 83-85.