Rupture of biceps tendon (LHBT) – can we help?

Biceps tendonWhere is the biceps tendon long head?


The biceps brachii is the main flexor at the elbow joint and a powerful rotator of the lower arm when the elbow is in a flexed position. It also aids with shoulder flexion, stabilization of the humeral head during deltoid contraction, and can assist in other movements of the upper arm.


What can cause us to rupture our biceps tendon?


The older we get, the more likely we are to rupture a tendon – particularly where it joins a muscle, so age is a big factor.  The tendon of the biceps muscle long head (LHBT) connects your shoulder down the front of your upper arm to just below your elbow joint and functions to flex your forearm at the elbow and to turn your forearm over so your palm faces upwards.


When you get a bit older – in your 50’s or 60’s onwards, something as simple as throwing a heavy bag or falling forcefully onto an outstretched arm could cause the biceps tendon to tear.


Younger tennis players and ballplayers van experience this injury, as a result of frequent swing and excessive weightlifting or rapid stress upon the tendon, which can cause an acute tendon rupture. In younger people biceps tendon ruptures are caused by a single traumatic event that typically involves lifting a heavy object while the elbow is bent at a 90-degree angle. Weightlifters  who use anabolic steroids are at an increased risk of sustaining a rupture at the tendon.


As you might expect, a person’s dominant arm is more often affected and particularly if you have been or are a keen tennis or overhead sports player who has performed that movement repeatedly for years. It can just wear out eventually!


Smoking, rheumatoid arthritis, steroid medications, fluoroquinolones and statin therapy can affect this tendon and increase the risk of spontaneous rupture, as well.

How do you know you have a rupture?

Diagnosis of long head of the biceps tendon (LHBT ) rupture is challenging. Although rupture is most often due to an overload, it can happen after ages of vague and inconsistent problems in the area and physical testing is often unreliable on its own

Pain is usually felt immediately if you overload your muscle and tendon and this goes along with weakness of rotating the lower arm at the elbow so that the palm turns upwards and also flexing the lower arm at the elbow. Often a bulge can be seen  at the front, so your arm looks like ‘Popeye’! This is because the muscle belly retracts, causing a prominent ‘lump’ or fullness and bulging of the upper arm—what’s called “Popeye” biceps.


What should you do first?


After a physical examination and questioning, there are several options to check if you really have ruptured your biceps. These include:
A standard shoulder series can be useful for diagnosing and/or excluding other bony pathologies, but have not been shown to be useful in the diagnosis of LHBT pathology.

US has been shown to have up to 100% specificity and 96% sensitivity in diagnosing biceps tendon dislocation or subluxation, but is less useful for diagnosing tears, especially partial tears However, its effectiveness when compared to other techniques has not been studied.

Advantages to the use of US include lower cost when compared to other forms of advanced imaging, the fact that it is non-invasive, and the ability to perform the test in the office. The main disadvantage is the extent to which its usefulness is dependent on the skill of the technician.

Magnetic resonance imaging (MRI):
MRI has also been shown to incompletely evaluate the LHBT.
Despite the limitations of MRI, some other features detectable on MRI have been shown to be highly indicative of LHBT pathology, with the presence of cystic changes on or around the lesser tuberosity strongly associated with LHBT and subscapularis tears . As well, MRI has shown 100% sensitivity in the diagnosis of subluxation or dislocation of the LHBT.

Arthroscopy is commonly used as the gold standard in studies of LHBT diagnosis. However, it too has its limitations. Gilmer et al.  compared arthroscopy to open observation in patients undergoing biceps tenodesis and found that arthroscopy only evaluated 32% of the biceps tendon, and only identified 67% of pathology found on open examination. This calls the use of arthroscopy as the gold standard into question. However, while open examination may be the most accurate, it is also the most invasive.
Further research is clearly needed.  There needs to be further guidance on how injury location and characteristics may guide treatment selection. At this time, there is not a lot of literature to direct the application of manual or conservative treatment for LHBT conditions.


Can a chiropractor help?


This depends on whether your job involves upper arm strength or whether you need to play sports or whether it is not so important that you have full strength in your upper arm.


Because the rupture involves only the long head tendon of the biceps and not the short head tendon, the biceps still functions, so you may be able to live perfectly fine without putting yourself through an operation to repair it.


The immediate thing to do is to stop overhead work or lifting of anything heavier than 10 lb with the affected arm. You then need soft tissue work, therapeutic ultrasound and then you need to gradually exercise regularly to maximise your recovery. With luck you may still recover enough strength to do most things you want or need to do without pain.



Whether to pursue surgery or conservative management remains a subject of debate in the medical literature. There are no studies that demonstrate the superiority of one approach over the other and surgery can always carry risks.


This is why  it is so important that you – the patient’s individual circumstances are taken into account and discussed. Clinicians at the clinic will consider your occupation, lifestyle, and age when recommending a course of action.


Published clinical guidelines usually recommend surgical repair for young athletes who require maximum supination strength in daily activities. Although the size of the Popeye deformity does diminish after conservative treatment, surgery is often recommended for patients who are unwilling to accept the cosmetic defect seen after the tendon ruptures and those who are approaching middle age but want to carry on a physical job such as carpenters, bricklayers etc and who need full strength in their arms.


The surgical procedure, called tenodesis, involves reattaching the torn section of the tendon to the bone.


Tenodesis usually restores full biceps function, gave excellent cosmetic results, and allows people to return to their job or sport.


Conservative treatment by Chiropractors


A conservative approach is the appropriate for older patients and is very well tolerated, which reduces the risk of serious complications and the cost of surgery.

Immediate surgical repair was thought to be the recommended course of action due to the fact that muscle weakness results from these tears. However delayed surgical treatment (3 weeks to 5 months after diagnosis) has been shown to be equally beneficial in long term follow‐up results when compared to patients operated on early (within 8 days of initial injury). Therefore it may well be worth trying a course of conservative treatment to potentially save more pain and longer rehabilitation.

Pro’s of Conservative Care only


Avoiding surgery  permits patients to return to work much sooner. Patients may, however, still lose up to 20% of their supination strength with conservative treatment but this approach does not cause weakness in grip, pronation, or elbow extension. Nor does it affect patients’ activities of daily living, which may explain why more patients are treated conservatively than with surgery.


This approach needs a period of between 4 to 6 weeks, physical therapy 2 to 3 times per week to be most effective and can involve joint mobilization and flexibility exercises to improve the range of motion in the shoulder.


Then strengthening exercises and stretching exercises will restore the strength of the biceps and elbow muscle. By 8 weeks full range of movement can be expected and good enough strength to be restored to do most things.


If you suffer a complete long head biceps tendon rupture, you need to discuss options and consider what your needs are day to day. If you work in sedentary occupations usually do not need a high degree of supination or physical strength in your upper extremities, this is a worthwhile treatment option for you.

Complete rupture of the distal tendon of the biceps brachii is relatively rare and there is little information to guide therapists in rehabilitation after this injury and subsequent surgical repair.

After surgery

A regimented physical rehabilitation program of resistance training and stretching is warranted for patients who sustain a distal biceps tendon rupture and undergo surgical reattachment of the tendon and in the opinion of some who deal with these injuries, such a protocol may be effective in promoting full recovery and return to functional and athletic activities.


How long may it take to recover?


For a complete tear in which surgery is needed, return to full sports participation may take 4-6 months. Supervised physical therapy is typically advised. Partial tears usually heal within 3-6 weeks. Regular training for your sport or job should only be resumed when you have normal shoulder and upper arm strength, full range of motion, and no pain.

Once torn, the biceps tendon at the elbow will not grow back to the bone and heal.  To return arm strength to near normal levels, surgery to repair the torn tendon is usually recommended. However, nonsurgical treatment is a reasonable option for patients who may not require full arm function.