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Biceps Injuries

Injuries to the Biceps PPT

Distal Biceps Injuries Tremendous stress to biceps during athletic & standard daily activities Injury to distal biceps fairly rare (3%, maybe 10%)
Distal Biceps Injuries Tendon injuries in general increase in middle age group Athletes- generally weight lifters Only 2 cases of women
Distal Biceps Injuries Majority in dominant extremity Traumatic in nature (Weightlifting, Sports, FOOSH)
Distal Biceps Injuries Excessive eccentric tension as arm is forced from flexed position Length-Tension relationship; Force-velocity relationship
Length-Tension Relationship Failure of muscle due to very shortened or very lengthened physiological position
Force-Velocity Relationship Relationship b/t velocity of muscle contraction & force produced
Pathology Poorly understood Combination of degeneration & mechanical factors (Tendonitis &/or pain; Overuse; Inadequate arterial supply; Smoking)
Pathology Hx of tendonitis, overuse, &/or steroid use Steroids used for increasing muscle mass & strength cause tendon to become stiff & less elastic; unable to absorb as much energy
Differential Dx: Other causes of pain in antecubital fossa Biceps bursitis Biceps tendonitis Partial distal avulsion Lateral antebrachial cutaneous nerve entrapment syndrome
Other causes of pain Violent eccentric contraction superimposed on degenerative changes in tendon structure Narrow space b/t radius/ulna in pronation (50% loss in space b/t full sup/pro) Repetitive stress due to abnormal friction Sup/pro vs. local bony prominence at rad. t
MOI Eccentric contraction or resisted flexion of elbow from weightlifting or FOOSH
MOI Athlete usually hears "pop" Contour of upper arm appears abnormal
MOI Male>Female Women have 45% smaller muscle cross-sectional area for biceps Women have 52% strength of males with use of elbow flexors Men have greater % fast-twitch fibers in biceps
Female Cases 58 & 72 years old Athletically active women Sustained during sporting events
MOI Distal tendon usually very easy to palpate in antecubital space Inability to palpate necessitates referral "Hook Sign"
Types of Ruptures Partial- insertional, intrasubstance Complete- Acute; Chronic- intact aponeurosis, ruptures aponeurosis
Partial Ruptures Pain in antecubital fossa Weakness with elbow flexion/forearm supination Biceps tendon palpable throughout length
Partial Ruptures Loss of fxn less than complete tears Debridement not successful Excise reactive granulation tissue & releasing remaining attached tendon
Complete Ruptures Usually hear "pop" Immediate pain, usually resolves quickly Contour of upper arm abnormal Weak: elbow flexion, forearm supination, shoulder flexion Edema & ecchymosis
Retraction of Biceps Complete rupture Tendon retracts proximal Will scar to brachialis over time
Physical Presentation Pain Edema Ecchymosis in upper arm/antecubital fossa Later onset of acute pain several days following injury probably rupture of lactus fibrosus
Physical Presentation Edema in area may make palpation difficult If can see acute before edema occurs, may be easier to palpate tendon
Surgical Methods Surgical repair preferred method of treatment for active individuals Athletes & Laborers
Non-Surgical Methods No surgical (conservative) treatment 40% loss supination strength, 30% loss of flexion 86% decrease supination endurance 61% flexion strength, 65% supination strength w/o repair
Conservative Non-Surgical Treatment Elderly, sedentary pts or those too ill to have surgery Possible activity related pain Decreased flexion & supination strength
Surgical Treatment Options 1 incision (Henry) 2 incision (Boyd Anderson)- minimize risk of neurovascular injury; caused HTO & synostosis from bleeding Endobutton repair Tenodesis Graft repair
Surgical Repair Selection No superior method of repair Surgeon discretion
Post-Op Care for One Incision/Modified Henry Approach Elbow immobilized in 90 deg flexion for 2 wks (Progressive increase hinged brace) Passive supination/pronation with elbow at/or >90 flexion allowed >2 wks Active flexion starts at 8 wks
Advantages/Disadvantages of 1 incision approach Ad: Direct approach; Avoids posterior interosseous n.; Minimal ectopic bone formatio n(radioulnar synostosis) Dis: may injure radial n if surgeon passes tendon thru drill holes made in radius
Post-Op Weeks 1-2 Forearm in supination or neutral Elbow 90 deg flexion Splint/cast Full passive flexion allowed Scar immobilization
Weeks 1-2 Ex's PROM elbow flex AROM elbow ext within splint to 90 Forearm AAROM from pronation to neutral at 90 Supination PROM to only about 30
Weeks 1-2 Ex's Wrist flex/ext AROM & ex's with wrist in neutral Light grasp ex's (with elbow safely flexed)
3 wks Ex's Splint to allow 60 Supination AROM to 45 AROM of shoulder Continue scar massage
4-5 weeks Adjust elbow splint to 30 deg Begin AAROM flex AAROM supination to 55 deg
6 weeks Wean off splint AROM elbow flexion Place & hold isometric ex's for flexion Full supination AAROM-AROM Allow light ADL's
8 weeks DC splint during the day More aggressive means of obtaining full AROM/PROM PRN Heat, more aggressive joint mobs
9-10 weeks Begin PROGRESSIVE, not aggressive strengthening
Full Return Dependent on Activity For sports w/o contact or max resistance forces- 3 months Sports w/ contact & max resistance after 6 months following surgery if strength & ROM appropriate
Proximal Biceps Ruptures Proximal ruptures of LHB account for 96% all ruptures In those >40 years usually represents RTC disease & impingement
Proximal Biceps Ruptures May be minor trauma Presents painlessly at times Biceps retracts into a ball Localized swelling & ecchymosis
Conservative Treatment >40 years old Return to activites- usually 2-3 months
Surgery Preferred for young adult w/o RTC disease Suture to bicipital groove
Post-Op Weeks 0-4 Shoulder sling/immobilizer Pendulum ex's AAROM elbow 0-145 with gentle ROM into extension Shoulder PROM- flex, ER, IR
Weeks 4-8 Light shoulder PRE's
Weeks 8+ Progress to isotonic PRE's
Grading of Biceps Integrity Grade I- minor fraying involving <25% Grade II- <50% fibers Grade III- >50% fibers Grade IV- Complete rupture
Indications for biceps tenodesis >25-50% partial thickness tears of LHB; Subluxation; Disruption of biceps groove or soft tissue stabilizers; Chronic atrophy of tendon; Biceps disease; Avoid deformity of tenotomy
Biceps Tenodesis Approaches Tenodesis of biceps tendon to coracoid process; To lesser tuberosity using sutures; Post technique with transosseous sutures; Into bicipital groove using an osteal periosteal flap; Froimson keyhole technique; Interference screw fixation
Post-Surgical Rehab Dependent on other surgical procedures RTC repair, Capsular Plication, Subscapularis repair
Weeks 0-6 Sling use to limit elbow motion outside PT Shoulder ext limited to anterior to frontal plane Limitation of terminal elbow ext
Weeks 0-6 Scapular strengthening initiated early within first few weeks Arms at side in side-lying RTC isometrics initiated early
Weeks 6+ Progressive RTC & biceps strengthening program Some concerns of fwd flexion motions
D/C Criteria Similar to other surgeries Elevation & rotational strength = to contralateral side Successful pt satisfaction on subjective ratings
Outcomes Failure in 6/20 pts Sometimes becomes chronic- esp w/o associated acromioplasty Many pts require add'l tx Moderate pain at 7 yr F/U
What should be performed in addition to tenodesis? Acromioplasty
Positive Outcome Study Isolated tenodesis withou acromioplasty 94% good to excellent results Excluded pts included instability, RTC tears
Created by: 1190550002



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