Rupture of the biceps tendon in gymnastics A
case
report
PIZZO,*† M.D., L. A. NORWOOD,† M.D., F. W. JOBE,‡ M.D., M. E. BLAZINA,*M.D., AND J. M. FOX,*M.D., Sherman Oaks, California
WILSON DEL
Although
rupture of the long head of the biceps brachii tendon has been presented in the literature, very few reports have mentioned the process involving young patients. 1-4 The problem as it relates to athletics has seldom been discussed.5 This case report deals with the rupture of the proximal biceps brachii tendon in a young college gymnast. CASE HISTORY
G. W. was a male 22-year-old college gymnast. For 2 months he had complained of aching discomfort about the distal, anterior aspect of the right arm after gymnastic practices. On February 17, 1976, while working on the rings, he felt a sudden snap and pain about the anterior aspect of his right shoulder. He was unable to continue practicing, and subjectively felt he had sustained a serious injury. Examination 2 days later revealed a sharp convex bulge of the biceps brachii muscle on active elbow flexion.’ Tenderness was present over the long head of the biceps tendon and distally at the musculotendinous junction. The arm was swollen, the most swelling was distally. There was a mild amount of ecchymoses over the anterior, distal aspect of the arm. Pulses and neurologic status were intact.
His past medical history included a fracture of the right scaphoid in 1968 that required bone grafting for a nonunion in 1971. He also ruptured the medial collateral ligament of his left elbow in June 1975 and underwent surgical repair for that ligament. He returned to gymnastic competition after each surgery. At the time of surgery on February 20, 1976, a complete rupture of the long head of the biceps brachii tendon was found (Fig. 1). Hemorrhage was noted at the distal musculotendinous junction where there was a partial tear (Fig. 2). The intraarticular portion of the tendon was excised and a bicipital tenodesis performed.Histologic sections revealed degenerative changes and fibrosis within the tendon. The patient’s hospital course was uneventful, and he was discharged on the 3rd postoperative day. He returned to gymnastics in the spring of 1976. At 9 months postoperatively he was practicing 2 hr a day on an upper body strengthening program and teaching school. Subjectively he had some weakness while performing horizontal extensions of the arm and also had a mild amount of tightness in the arm that resolved with stretching exercises. DISCUSSION
* 4911 Van nia 91403.
Nuys Boulevard,
Sherman Oaks, Califor-
t Former Fellow in Athletic Medicine, National Athletic Health Institute,
f 575
East
Inglewood,
California.
Hardy Street, Inglewood,
California.
Rupture of the long head of the biceps tendon is usually associated with older patients, and is felt to be related to a degenerative process that commonly occurs in the tissues as one grows older. Our patient also had degenerative changes in his biceps tendon. It is felt that this process was related 283
Fig.
Fig. to the
1. The
ruptured biceps tendon is being held by the forceps.
2. At the musculotendinous junction, there
repetitive, large stresses that were applied to the tendon during gymnastic activities. The symptoms the patient experienced prior to tendon rupture were related to the ongoing degeneration and inflammation that were taking place within the tendon and surrounding tissues. We feel that this type of pathologic process occurs quite often in the tissues of athletes who are performing repetitive, strenuous activities. The athletes usually have symptoms and physical find284
was
hemorrhage and a partial tear.
ings referable to the area involved. We advocate early recognition of the problem, and would advise care consisting of oral anti-inflammatory, nonsteroidal medications, local ice application, and the athlete not performing those maneuvers that seem to be causing the symptoms. If the process did not respond to the initial form of treatment then we would advise complete rest. Bicipital tenodesis in a gymnast would seem to offer a guarded prognosis, since large amounts of
muscular power and endurance are required in this sport. Yet, the patient has made satisfactory progress and has returned to gymnastics. Thus, tenodesis is advocated once rupture of the biceps tendon has occurred. REFERENCES 1.
Butler, EF, Buck RM: Rupture of the long head of the biceps brachii. South Med J 51: 1153-1156, 1958 2. Gilcreest EL: The common syndrome of rupture,
3. 4. 5. 6.
7.
dislocation and elongation of the long head of the biceps brachii. Surg Gynecol Obstet 58: 322-339, 1934 Kantor PJ, Callahan JF: Spontaneous rupture of the biceps brachii. Orthop Rev 4: 37-38, 1975 Waugh RL, Hathcock TA, Elliot JL: Ruptures of muscles and tendons. Surgery 25: 370-392, 1949 Blazina ME: Shoulder injuries in athletes. J Am Coll Health Assoc 15: 143-145, 1966 Froimson AI, Oh I: Keyhold tenodesis of biceps origin at the shoulder. Clin Orthopa, 112: 245-249, 1975 Hitchcock HH, Bechtol CO: Painful shoulder. Bone Joint Surg 30A: 263-273, 1948
EDITORIAL COMMENT
Dr. T. David Sisk: Although ruptures of the long head of the biceps brachii tendon are common in the older recreational athlete, it indeed is an unusual occurrence in my experience in the younger competitive athlete. The authors are congratulated for bringing it to our attention. The pathology and the mechanism of occurrence seems to be similar to those spontaneous ruptures of the tendoAchilles or the patella or quadriceps mechanisms, in that often prodromal symptoms precede the actual rupture and the microscopic pathology usually consists of degenerative changes within the tendon associated with varying degrees of inflammatory reaction. Tendons subjected to severe loading or severe stressing of that musculotendinous unit, such as the patella and tendo-Achilles, are the ones where spontaneous rupture is more likely to be seen and its surprising therefore that this is not a more common condition in the long head of the biceps, particularly in gymnasts and such athletes. Due to the frequent prodromal symptoms prior to rupture, patients often receive corticosteroid injections into the area, and I wonder if this patient had received such injections. The authors do not comment concerning this but this is often the case in my experience where ruptures of the tendo-Achilles and ruptures of the patella tendon occur. It is now widely recognized and accepted that corticosteroids injected into the area of tendinous tissue receiving great stresses may weaken
the
collagenous makeup
and
predispose
to
sponof injectable steroids around such tendons in athletes must be avoided. The authors do not mention specifically where the tendon ruptured, but I assume from their text that it was within the substance of the tendon rather than at its bony attachment or its musculotendinous junction. It has been my experience that this is the usual site where the degenerative process occurs and the usual site for rupture. I believe the authors were precisely correct in excising the interarticular portion of the tendon, since it may present a pedunculated type of body within the joint that may impair the function of the shoulder in a finely tuned athlete. Also, the authors did not specify where the long head of the biceps tendon was tenodesed. Numerous techniques and procedures for reanchoring the biceps tendon have been advocated, and I believe that it probably should be tenodesed in the proximal humerus as far proximally as possible and I prefer the keyhole type of technique. One is sometimes limited in the type of technique, depending upon the amount of available tendon that one has to work with. The technique of using the coricoid with its conjoined insertion of the short head of the biceps, the coracobrachialis, and the pectoralis minor has been advocated. However, I have seen two stress fractures in athletes following transfer of the long head of the biceps to the coracoid for a chronic pain syndrome. I have not seen it following spontaneous rupture of the long head of the biceps, however. I think for a young athlete subjecting his shoulder to vigorous stresses, the coracoid should be a &dquo;second best&dquo; site for tenodesis. For these reasons, I prefer the proximal humerus. If the rupture has occurred near the musculotendinous junction, it is difficult to tenodes it using the keyhole or a trap door type technique and suturing as far proximal to the facia and tendinous structure of the short head of the biceps brachii may well be the only alternative. I believe the principle message that the authors were bringing to us is that when this unusual condition occurs in the young athlete, that early surgery and tenodesis is indicated. As we all know, the condition is more frequently seen in the older recreational athlete and most believe that it does not justify surgery in the older patient. Although these patients may require several months to completely rehabilitate the shoulder and regain optimal strength, I have had no one who was signifitaneous
rupture. It is my belief that the
use
285
cantly impaired
Authors’
to make
hope
in strength or function sufficient surgery advisable. I believe that the authors are correct in indicating early surgery in the young athlete who wishes to return to a high level of competition. The authors, while advising early recognition and treatment, did not elaborate on what should be done in that young athlete with prodromal symptoms about the shoulder, nor did they elaborate on the postoperative treatment. I think it would be most interesting to hear specifically what the rehabilitation program was and at what time one should permit an athlete such as this one to really begin stressing his tenodesed repair. I believe this paper will call our attention to this unusual possibility in the young athlete with persistent painful shoulder symptoms.
286
to
Reply: In our final comments, we would of the specific questions that
answer some
were raised by Dr. Sisk. The patient had not received any corticosteroid injection in the involved area of the shoulder. He had been applying some ice packs following practice sessions to the anterior aspect of his shoulder. The biceps tendon ruptured within the substance of the tendon. The tenodesis of the tendon was performed at the proximal portion of the humerus in the bicipital groove area. The tenodesis was performed as far proximally as possible on the humerus without causing any impingement type problem with regards to the corticoacromial ligament or acromium process. We attempted to point out in the paper, by sighting the references, which type of general
technique we preferred.
case
report
PIZZO,*† M.D., L. A. NORWOOD,† M.D., F. W. JOBE,‡ M.D., M. E. BLAZINA,*M.D., AND J. M. FOX,*M.D., Sherman Oaks, California
WILSON DEL
Although
rupture of the long head of the biceps brachii tendon has been presented in the literature, very few reports have mentioned the process involving young patients. 1-4 The problem as it relates to athletics has seldom been discussed.5 This case report deals with the rupture of the proximal biceps brachii tendon in a young college gymnast. CASE HISTORY
G. W. was a male 22-year-old college gymnast. For 2 months he had complained of aching discomfort about the distal, anterior aspect of the right arm after gymnastic practices. On February 17, 1976, while working on the rings, he felt a sudden snap and pain about the anterior aspect of his right shoulder. He was unable to continue practicing, and subjectively felt he had sustained a serious injury. Examination 2 days later revealed a sharp convex bulge of the biceps brachii muscle on active elbow flexion.’ Tenderness was present over the long head of the biceps tendon and distally at the musculotendinous junction. The arm was swollen, the most swelling was distally. There was a mild amount of ecchymoses over the anterior, distal aspect of the arm. Pulses and neurologic status were intact.
His past medical history included a fracture of the right scaphoid in 1968 that required bone grafting for a nonunion in 1971. He also ruptured the medial collateral ligament of his left elbow in June 1975 and underwent surgical repair for that ligament. He returned to gymnastic competition after each surgery. At the time of surgery on February 20, 1976, a complete rupture of the long head of the biceps brachii tendon was found (Fig. 1). Hemorrhage was noted at the distal musculotendinous junction where there was a partial tear (Fig. 2). The intraarticular portion of the tendon was excised and a bicipital tenodesis performed.Histologic sections revealed degenerative changes and fibrosis within the tendon. The patient’s hospital course was uneventful, and he was discharged on the 3rd postoperative day. He returned to gymnastics in the spring of 1976. At 9 months postoperatively he was practicing 2 hr a day on an upper body strengthening program and teaching school. Subjectively he had some weakness while performing horizontal extensions of the arm and also had a mild amount of tightness in the arm that resolved with stretching exercises. DISCUSSION
* 4911 Van nia 91403.
Nuys Boulevard,
Sherman Oaks, Califor-
t Former Fellow in Athletic Medicine, National Athletic Health Institute,
f 575
East
Inglewood,
California.
Hardy Street, Inglewood,
California.
Rupture of the long head of the biceps tendon is usually associated with older patients, and is felt to be related to a degenerative process that commonly occurs in the tissues as one grows older. Our patient also had degenerative changes in his biceps tendon. It is felt that this process was related 283
Fig.
Fig. to the
1. The
ruptured biceps tendon is being held by the forceps.
2. At the musculotendinous junction, there
repetitive, large stresses that were applied to the tendon during gymnastic activities. The symptoms the patient experienced prior to tendon rupture were related to the ongoing degeneration and inflammation that were taking place within the tendon and surrounding tissues. We feel that this type of pathologic process occurs quite often in the tissues of athletes who are performing repetitive, strenuous activities. The athletes usually have symptoms and physical find284
was
hemorrhage and a partial tear.
ings referable to the area involved. We advocate early recognition of the problem, and would advise care consisting of oral anti-inflammatory, nonsteroidal medications, local ice application, and the athlete not performing those maneuvers that seem to be causing the symptoms. If the process did not respond to the initial form of treatment then we would advise complete rest. Bicipital tenodesis in a gymnast would seem to offer a guarded prognosis, since large amounts of
muscular power and endurance are required in this sport. Yet, the patient has made satisfactory progress and has returned to gymnastics. Thus, tenodesis is advocated once rupture of the biceps tendon has occurred. REFERENCES 1.
Butler, EF, Buck RM: Rupture of the long head of the biceps brachii. South Med J 51: 1153-1156, 1958 2. Gilcreest EL: The common syndrome of rupture,
3. 4. 5. 6.
7.
dislocation and elongation of the long head of the biceps brachii. Surg Gynecol Obstet 58: 322-339, 1934 Kantor PJ, Callahan JF: Spontaneous rupture of the biceps brachii. Orthop Rev 4: 37-38, 1975 Waugh RL, Hathcock TA, Elliot JL: Ruptures of muscles and tendons. Surgery 25: 370-392, 1949 Blazina ME: Shoulder injuries in athletes. J Am Coll Health Assoc 15: 143-145, 1966 Froimson AI, Oh I: Keyhold tenodesis of biceps origin at the shoulder. Clin Orthopa, 112: 245-249, 1975 Hitchcock HH, Bechtol CO: Painful shoulder. Bone Joint Surg 30A: 263-273, 1948
EDITORIAL COMMENT
Dr. T. David Sisk: Although ruptures of the long head of the biceps brachii tendon are common in the older recreational athlete, it indeed is an unusual occurrence in my experience in the younger competitive athlete. The authors are congratulated for bringing it to our attention. The pathology and the mechanism of occurrence seems to be similar to those spontaneous ruptures of the tendoAchilles or the patella or quadriceps mechanisms, in that often prodromal symptoms precede the actual rupture and the microscopic pathology usually consists of degenerative changes within the tendon associated with varying degrees of inflammatory reaction. Tendons subjected to severe loading or severe stressing of that musculotendinous unit, such as the patella and tendo-Achilles, are the ones where spontaneous rupture is more likely to be seen and its surprising therefore that this is not a more common condition in the long head of the biceps, particularly in gymnasts and such athletes. Due to the frequent prodromal symptoms prior to rupture, patients often receive corticosteroid injections into the area, and I wonder if this patient had received such injections. The authors do not comment concerning this but this is often the case in my experience where ruptures of the tendo-Achilles and ruptures of the patella tendon occur. It is now widely recognized and accepted that corticosteroids injected into the area of tendinous tissue receiving great stresses may weaken
the
collagenous makeup
and
predispose
to
sponof injectable steroids around such tendons in athletes must be avoided. The authors do not mention specifically where the tendon ruptured, but I assume from their text that it was within the substance of the tendon rather than at its bony attachment or its musculotendinous junction. It has been my experience that this is the usual site where the degenerative process occurs and the usual site for rupture. I believe the authors were precisely correct in excising the interarticular portion of the tendon, since it may present a pedunculated type of body within the joint that may impair the function of the shoulder in a finely tuned athlete. Also, the authors did not specify where the long head of the biceps tendon was tenodesed. Numerous techniques and procedures for reanchoring the biceps tendon have been advocated, and I believe that it probably should be tenodesed in the proximal humerus as far proximally as possible and I prefer the keyhole type of technique. One is sometimes limited in the type of technique, depending upon the amount of available tendon that one has to work with. The technique of using the coricoid with its conjoined insertion of the short head of the biceps, the coracobrachialis, and the pectoralis minor has been advocated. However, I have seen two stress fractures in athletes following transfer of the long head of the biceps to the coracoid for a chronic pain syndrome. I have not seen it following spontaneous rupture of the long head of the biceps, however. I think for a young athlete subjecting his shoulder to vigorous stresses, the coracoid should be a &dquo;second best&dquo; site for tenodesis. For these reasons, I prefer the proximal humerus. If the rupture has occurred near the musculotendinous junction, it is difficult to tenodes it using the keyhole or a trap door type technique and suturing as far proximal to the facia and tendinous structure of the short head of the biceps brachii may well be the only alternative. I believe the principle message that the authors were bringing to us is that when this unusual condition occurs in the young athlete, that early surgery and tenodesis is indicated. As we all know, the condition is more frequently seen in the older recreational athlete and most believe that it does not justify surgery in the older patient. Although these patients may require several months to completely rehabilitate the shoulder and regain optimal strength, I have had no one who was signifitaneous
rupture. It is my belief that the
use
285
cantly impaired
Authors’
to make
hope
in strength or function sufficient surgery advisable. I believe that the authors are correct in indicating early surgery in the young athlete who wishes to return to a high level of competition. The authors, while advising early recognition and treatment, did not elaborate on what should be done in that young athlete with prodromal symptoms about the shoulder, nor did they elaborate on the postoperative treatment. I think it would be most interesting to hear specifically what the rehabilitation program was and at what time one should permit an athlete such as this one to really begin stressing his tenodesed repair. I believe this paper will call our attention to this unusual possibility in the young athlete with persistent painful shoulder symptoms.
286
to
Reply: In our final comments, we would of the specific questions that
answer some
were raised by Dr. Sisk. The patient had not received any corticosteroid injection in the involved area of the shoulder. He had been applying some ice packs following practice sessions to the anterior aspect of his shoulder. The biceps tendon ruptured within the substance of the tendon. The tenodesis of the tendon was performed at the proximal portion of the humerus in the bicipital groove area. The tenodesis was performed as far proximally as possible on the humerus without causing any impingement type problem with regards to the corticoacromial ligament or acromium process. We attempted to point out in the paper, by sighting the references, which type of general
technique we preferred.
