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DISTAL BICEPS TENDON PAIN

What is Distal Biceps Tendinopathy?

  • Distal biceps tendinopathy refers to a condition affecting the the biceps brachii tendon at the elbow. Biceps tendinopathy at the elbow is primarily caused by a combination of mechanical, include overuse, repetitive strain, or acute trauma, and anatomical factors.

    • Mechanical impingement: The distal bicep tendon inserts into the radial tuberosity at the elbow, and during forearm pronation there is increased pressure on the distal biceps tendon [Rausch et al, 2020].

    • Anatomical factors can include a larger radial tuberosities and smaller radioulnar spaces predisposing the tendon to tendinopathy or tears [Boyle et al, 2022].

    • Overuse and repetitive strain are additional contributing factors. Chronic overuse can lead to microtrauma and degenerative changes within the tendon, overwhelming its reparative capacity and resulting in tendinopathy [Järvinen et al, 1997; Almekinders et al, 2003].

  • Distal biceps tendinopathy is a degenerative process rather than an inflammatory one, which is why the term "tendinopathy" is preferred over "tendinitis" [Khan et al, 1999; Millar et al, 2021]. Histopathologic findings include:

    • Disorganization of Collagen Fibers: The collagen fibers in the tendon become discontinuous and disorganized, losing their normal parallel alignment.

    • Increased Ground Substance: There is an increase in the amount of mucoid degeneration, indicative of extracellular matrix dysregulation.

    • Cellular Changes: Tenocytes, the resident cells in the tendon, often become enlarged (hypertrophic) and there is also an increase in cellularity, with a conspicuouspresence of fibroblasts and myofibroblasts.

    • Absence of Inflammatory Cells: Unlike tendinitis, which involves inflammation, tendinopathy is generally a non-inflammatory condition. Histopathological examination typically shows an absence of inflammatory cells.

How do you know if you have a partial Distal Biceps Tear?

  • The diagnosis of distal biceps tendinopathy is primarily a combination of clinical evaluation and imaging studies is essential.
    • Clinically, patients may present with pain localized to the antecubital
      fossa, weakness in elbow flexion and supination, and sometimes a
      palpable mass or tenderness over the distal biceps tendon [Durr et al, 2000; Ramsey, 1999].
    • In some cases the tendon can fully rupture in a sudden injury that forces the elbow straight against resistance pulling the tendon off the bone. Often there is a sensation or audible “pop” at the elbow, and subsequent swelling and bruising over the front of the elbow. Patients often have weakness and a bulge in the front of the upper part of the arm with full-thickness tears. In partial tears, patients may only have pain over the front of the elbow.
  • Imaging Studies can include:
Ultrasound image of the distal biceps tendon (arrows) in a "cobra view" position and a interstitial tear (star).

What are the treatments for distal biceps tendon partial tears or tendinopathy?

The treatment for partial tears or tendinopathy of the distal biceps tendon involves a combination of conservative and surgical approaches, depending on the severity and response to initial treatments.

Conservative Management

  • Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): These are commonly used to manage pain and inflammation [Hegmann et al, 2013].
  • Physical Therapy: Eccentric exercise-based physical therapy is recommended to promote tendon healing and improve function [Skjong et al, 2012; Yang & Chen, 2020].
  • Activity Modification: Reducing activities that exacerbate symptoms is crucial.
  • Platelet-rich plasma (PRP) injections have shown efficacy in refractory cases, providing significant pain relief and functional improvement [Sanli et al, 2016; Barker et al, 2015].
    • Sanli et al. presented a series of 12 patients with chronic distal biceps tendonitis confirmed on magnetic resonance imaging and treated with a single ultrasound-guided injection of PRP. At a median follow-up of 47 months (36-52 months), all patients showed significant improvement in pain and functional outcome after the PRP injection.

    • Barker et. al. studied 6 patients who underwent an ultrasound-guided PRP injection, which showed to be a safe and effective treatment for recalcitrant cases of distal biceps tendinopathy.

  • Learn more about PRP injections here

Surgical Management

Surgery may be indicated if there is a failure of conservative management, a job requiring a high level of physical demands or a desire to return to high physical activity levels. In cases with a larger tear involving greater than 50% on MRI may also be predictive of a need for surgical intervention [Bauer et al, 2018]. Surgical options include:

  • Endoscopic Debridement: For low-grade partial tears, endoscopic debridement can be effective, resulting in symptom resolution and functional improvement [Bhatia et al, 2024].
  • Surgical Repair: High-grade partial tears may require surgical repair. Techniques such as the dual-anchor onlay repair have demonstrated long-term structural integrity and functional outcomes [Bhatia et al, 2024].
  • Graft Reconstruction: In cases where primary repair is not feasible, autografts may be used [Bhatia et al, 2024].

Resources:

  1. Almekinders LC, Weinhold PS, Maffulli N. Compression etiology in tendinopathy. Clin Sports Med. 2003 Oct;22(4):703-10.
  2. Barker SL, Bell SN, Connell D, Coghlan JA. Ultrasound-guided platelet-rich plasma injection for distal biceps tendinopathy. Shoulder Elbow. 2015 Apr;7(2):110-4.
  3. Bauer TM, Wong JC, Lazarus MD. Is nonoperative management of partial distal biceps tears really successful? J Shoulder Elbow Surg. 2018 Apr;27(4):720-725.
  4. Bhatia DN, Malviya P. All-endoscopic approachfor distal biceps tendon pathology: analysis of long-term outcomes in partial and complete ruptures. J Shoulder Elbow Surg. 2024 Jul;33(7):1601-1614.
  5. Boyle AB, George CM, MacLean SBM. Anatomic factors associated with partial distal biceps tendon tears: a comparative control study. J Shoulder Elbow Surg. 2022 Jun;31(6):1224-1230.
  6. Chew ML, Giuffrè BM. Disorders of the distal biceps brachii tendon. Radiographics. 2005 Sep-Oct;25(5):1227-37.
  7. Dürr HR, Stäbler A, Pfahler M, Matzko M, Refior HJ. Partial rupture of the distal biceps tendon. Clin Orthop Relat Res. 2000 May;(374):195-200.
  8. Festa A, Mulieri PJ, Newman JS, Spitz DJ, Leslie BM. Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture. J Hand Surg Am. 2010 Jan;35(1):77-83.
  9. Hegmann KT, Hoffman HE, Belcourt RM, Byrne K, Glass L, Melhorn JM, Richman J, Zinni P 3rd, Thiese MS, Ott U, Tokita K, Passey DG, Effiong AC, Robbins RB, Ording JA; American College of Occupational and Environmental Medicine. ACOEM practice guidelines: elbow disorders. J Occup Environ Med. 2013 Nov;55(11):1365-74.
  10. Järvinen M, Józsa L, Kannus P, Järvinen TL, Kvist M, Leadbetter W. Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports. 1997 Apr;7(2):86-95.
  11. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999 Jun;27(6):393-408.
  12. Koh JS, Mohan PC, Howe TS, Lee BP, Chia SL, Yang Z, Morrey BF. Fasciotomy and surgical tenotomy for recalcitrant lateral elbow tendinopathy: early clinical experience with a novel device for minimally invasive percutaneous microresection. Am J Sports Med. 2013 Mar;41(3):636-44. doi: 10.1177/0363546512470625. Epub 2013 Jan 9. PMID: 23302261. https://journals.sagepub.com/d...

  13. 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.

  14. Lynch J, Yu CC, Chen C, Muh S. Magnetic resonance imaging versus ultrasound in diagnosis of distal biceps tendon avulsion. Orthop Traumatol Surg Res. 2019 Sep;105(5):861-866.

  15. McShane JM, Nazarian LN, Harwood MI. Sonographically guided percutaneous needle tenotomy for treatment of common extensor tendinosis in the elbow. J Ultrasound Med. 2006 Oct;25(10):1281-9. doi: 10.7863/jum.2006.25.10.1281. PMID: 16998100.

  16. Millar NL, Silbernagel KG, Thorborg K, Kirwan PD, Galatz LM, Abrams GD, Murrell GAC, McInnes IB, Rodeo SA. Tendinopathy. Nat Rev Dis Primers. 2021 Jan 7;7(1):1.
  17. Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg. 1999 May-Jun;7(3):199-207.
  18. Rausch V, Kahmann SL, Baltschun C, Staat M, Müller LP, Wegmann K. Pressure Distribution to the Distal Biceps Tendon at the Radial Tuberosity: A Biomechanical Study. J Hand Surg Am. 2020 Aug;45(8):776.e1-776.e9.
  19. Sanli I, Morgan B, van Tilborg F, Funk L, Gosens T. Single injection of platelet-rich plasma (PRP) for the treatment of refractory distal biceps tendonitis: long-term results of a prospective multicenter cohort study. Knee Surg Sports Traumatol Arthrosc. 2016 Jul;24(7):2308-12.
  20. Skjong CC, Meininger AK, Ho SS. Tendinopathy treatment: where is the evidence? Clin Sports Med. 2012 Apr;31(2):329-50.
  21. Van Melkebeke L, Brauns A, van den Bekerom MPJ, van Riet R, Duerinckx J, Caekebeke P. Evaluation of MRI Signal Changes of the Distal Biceps Tendon in Asymptomatic Patients. J Hand Surg Am. 2022 May;47(5):454-459.
  22. Yang SM, Chen WS. Conservative Treatment of Tendon Injuries. Am J Phys Med Rehabil. 2020 Jun;99(6):550-557.


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