A 51 y/o male presents to ortho clinic for R elbow pain that began suddenly 3 weeks ago after attempting to move a large compressor that was beginning to fall. He initially presented to Urgent Care, was given ibuprofen and then followed up with Occupational Medicine who then referred him to the orthopedic clinic. He rates his pain currently at the ortho clinic as 3/10 and also noted that he was having some weakness in his R elbow. Review of systems revealed no additional findings.
51 y/o male presenting to ortho clinic reports he developed sudden onset sharp anterior elbow pain when attempting to move a large air compressor that was starting to fall, approximately 3 weeks ago
The remainder of his history included a past medical history of CAD and gout. He had no significant past surgical history. His current medications included only a baby aspirin. He had no known drug allergies. He is currently married with one child and works as a supervisor for engineering services. He admits to occasional alcohol use, but denies tobacco use.
Physical exam revealed normal vital signs with the general appearance of a healthy middle-aged man in no acute distress. A

R elbow exam: some deformity of R antecubital fossa w/ tenderness over the biceps tendon. Strength 4/5 with supination. Strength 5/5 w/ thumb extension, finger adduction/abduction. Normal pronation, flexion & extension. Intact distal pulses.

2 view x-rays of his R elbow were obtained at clinic that revealed no significant findings that correlated with the patient’s physical exam. There was possible dystrophic calcification in region of common extensor tendon, possibly related to chronic calcific tendonitis or less likely old avulsion injury

The MRI findings showed:
Revealed discontinuity of distal biceps tendon suggestive of complete rupture and retraction, with distance between two ends ~3.5cm apart.

Possible avulsion of attachment site to radial tuberosity

Distal part of tendon with abnormal signal suggestive of pre-existing degeneration, which may have been predisposing factor to rupture

Minimal hypertrophy of the radial tuberosity

High signal density within biceps brachii tendon sheath and bicipital bursa suggestive of fluid

Minimal fluid within elbow joint

Minimal high signal also at insertion of brachialis tendon without evidence of tear or rupture

Other tendons and muscles appear normal. No bony abnormalities

Anatomy

The normal biceps brachii muscle functions to supinate and flex the forearm. It is innervated by the musculocutaneous nerve. The long head originates intra-articularly at superior glenoid tubercle (forming glenoid labrum) & extends down over head of humerus through intertubercular groove, while the short head originates at coracoid process along with coracobrachialis muscle (this later separates). The distal attachment sites include the biceps tendon to radial tuberosity and the bicipital aponeurosis (also known as the lacertus fibrosus), which covers the antecubital fossa, protecting the median nerve and brachial artery underneath. In distal biceps tendon rupture, aponeurosis serves to distribute force across elbow & lessen pull on radial tuberosity
Biceps Tendon Rupture
Biceps tendon rupture is classified according the location of the rupture: either proximal or distal. Ruptures typically occur in the dominant arm and happen in mostly in males at two different age distributions. Males > 40 yrs often have concurrent degenerative tendinosis, while younger males typically have isolated tendonitis. Clinical scenarios may describe biceps tendon rupture in rock climbers & weight lifters
Proximal rupture account for approximately 90-95% of biceps tendon ruptures, usually of the long head of the biceps. The typical location of the rupture from most common to least common is proximal long head, distal biceps tendon and proximal short head.
The location of the rupture also usually helps delineate its mechanism. Proximal ruptures usually occur from repeated injuries (ie impingement, instability, rotator cuff problems) that predispose them to a rupture. Distal ruptures, however, tend to occur in the acute setting, usually from trauma. The mechanism is often a sudden extension of a flexed elbow with a fully contracted biceps.

1. Simons, Stephen M. “Biceps tendinopathy and tendon rupture.” UptoDate.
2. Branch, Gary L. “Biceps Rupture.” Medscape.
3. Chew, et al. “Disorders of the Distal Biceps Brachii Tendon.” September 2005. RadioGraphics, 25, 1227-123
4. Kijowski, et al. “Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves.” Skeletal Radiol (2005) 34:1–18
5. http://eradiology.bidmc.harvard.edu/Classics/item.aspx?section=Emergency+Radiology&labelpk=33f0adab-853f-4010-a0e2-0756b3f1eac5&pk=468a2719-c9b7-4f6d-9c9e-cc181a5b059b