4/12/2016. Goals. Anatomy. Basic Anatomy. Biomechanics. Function. Traumatic Rupture of Proximal Biceps: In-season Rehabilitation and Management

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1 Goals Traumatic Rupture of Proximal Biceps: In-season Rehabilitation and Management Thomas F. LaPorta, MD To understand the anatomy of the biceps at the shoulder To present the mechanism, signs and symptoms, and diagnosis of proximal bicep ruptures To discuss the treatment options for proximal bicep ruptures in season with a focus on conservative management 1 2 Basic Anatomy 2 origins Long Head Biceps (LHB): 9 cm long Intra-articular, passes over humeral head then exits the groove Vascular intra-articular and avascular extra-articular Alpantaki et al. found a net-like pattern of rich LHB innervations Anatomy Soft-tissue sling stabilizes Biceps reflection pulley coracohumeral ligament, superior glenohumeral ligament (SGHL), parts of the subscapularis tendon Subject to mechanical stresses in the groove, at the pulley, by pathology of the rotator cuff and subacromial space Braun et al. show the LHB slides up to 18 mm in and out of the joint 3 4 Function Unclear and controversial Difficulty of performing studies limitations of cadaveric testing in re-creating dynamic interplay of anatomy Studies focus on contributions to GH stability and restraining abnormal translations Superior restraint/humeral head depressor? Do not know how much load is physiologic for the LHB tendon Strain does occur in the groove in adduction and at bicep labrum complex in 90 degrees abduction Biomechanics Biomechanical studies indicate the LHB contributes to stability of the GH joint in all directions Pagnani et al. = decreased humeral head translations anteriorly, superiorly, and inferiorly Itoi et al. = anterior stabilizer to the GH joint in abduction and external rotation Rodosky et al. = anterior stability to the GH joint increases resistance to torsional forces in the vulnerable abducted and externally rotated position 5 6 1

2 Incidence/Etiology/Risks Ruptures most common age > 50 years Dominant arm LHB ruptures > short head or distal tendon 96% of all biceps brachii injuries Most common sites of tendon rupture: the tendon s origin and at the exit of the bicipital groove near the musculotendinous junction Risks: age, heavy overhead activities, shoulder overuse (i.e. laborers and athletes), smoking, steroids, male gender 7 Mechanism of Injury Causes: Acute injury/overuse Acute: sudden contraction/bending of elbow with resisted flexion and supination of the forearm heavy lifting, particularly overhead, or forceful arm elevation activities falling forcefully on an outstretched arm making an "arm tackle" Overuse Direct: wearing down and fraying of the tendon over time Indirect: RTC tendonitis, impingement, RTC tear places puts more stress 8 Signs and Symptoms Clinical Examination Sudden, sharp pain in the upper arm An audible pop or snap Cramping of the biceps with strenuous use Bruising Pain or tenderness at the shoulder Weakness in the shoulder and the elbow Difficulty turning the arm palm up or palm down Ecchymosis Popeye deformity Palpable defect in groove 10 degrees IR ROM at the shoulder and elbow Strength at elbow The Ludington test Speed test and Yergason may have partial tears 9 10 Diagnostic Imaging Treatment Ultrasound MRI Most LHB ruptures cause very little symptoms and do not require treatment Some ruptures relieve pain and improve function What about high demand athletic patients?

3 Success without a LHB Case Study OLB (21 years old; 6 ft 1 in, 190 Ibs); no hx of UE problems HPI: making an "arm tackle" severe, sharp pain in the anterolateral aspect of the arm PE: painful elbow flexion and extension; weakness and pain with resisted elbow flexion and shoulder flexion; palpable, visible defect in the upper-middle 1/3 of the biceps with resisted elbow flexion Rehab Protocol Historic paper Modern twist Discussed protocol in detail with Andrews Institute Rehabilitation ATCs Inflammatory phase (Week 1) : Protect healing tissue Decrease pain and inflammation Retard Muscle atrophy Re-establish non-painful ROM All exercises should be pain free Avoid: Excess ER, flexion and horizontal ABD shoulder ROM Active shoulder/elbow flexion exercises Carrying loads Week 1 Therapy ROM Appropriate joint mobilization to restrictive tissues Multi-directional pain free shoulder PROM Pain free PROM and AAROM for elbow flex/ext Multidirectional shoulder isometrics Rhythmic stabilization exercises (ER/IR) Pain free scapular strengthening Gripping exercises Modalities: Ice (and heat) +/- NSAIDs Proliferation Phase (Week 2) Gradual increase to full shoulder PROM and AAROM Promote healing of tissue Regain and improve muscular strength Do not over stress healing tissue

4 Week 2 Therapy Soft tissue: begin preferred soft tissue interventions when initial phase of inflammation has subdued ROM: continue all ROM exercises Initiate UBE Initiate elbow flexion isometrics Initiate tubing ER/IR, Extension Initiate non-weighted isotonics (i.e. prone row, prone extension, prone horizontal abduction) Initiate weighted isotonics (side-lying ER, side-lying abd) Modalities: Continue as needed Sub-acute Maturation Phase (Week 3) Increase strength, power, endurance Gradual increase applied stress Full elbow ROM Minimal to no swelling or inflammation Improve dynamic stability Week 3 Therapy ROM: Continue all pertinent ROM exercises Continue isotonic exercises Initiate isolated biceps exercises Shoulder isotonics (flexion, scaption, and abduction) Initiate shoulder pressing exercises Advanced strengthening (4 week >) Criteria for starting Full shoulder and elbow ROM No pain or tenderness Satisfactory muscle strength Satisfactory clinical exam Increase strength, power and endurance Gradually initiate sporting activities Progressively increase activities to prepare for full return Week 4 Therapy Continue all exercises Initiate hand plyometrics (i.e. chest-pass, soccer throw and X-pattern) Progress to single hand plyometrics (i.e. wall dribble, 90/90 and rainbow) Begin interval sports programs Problems with Conservative Treatment Complaints of cramping and aching of the biceps muscle Concerns about maximum strength - loss of 8-29% of elbow flexion strength - loss of 10-21% of supination strength Dislike of the cosmetic appearance

5 Beware Concomitant injuries/ddx Rotator cuff tears/impingement Instability SLAP 25 5