Case Study by Chris Peach
- 38 year old male
- Company Director
- Regularly attends the gym - some cardiovascular work but predominantly weight training
Key Learning Points
- Partial thickness tear of the distal biceps is a differential diagnosis of anterior elbow pain
- Consider early imaging in cases with suspected partial thickness tear
- Small partial thickness tears respond well to minimally invasive endoscopic debridement of the tendon insertion - with a full return to sporting activity.
Presented with 1 year symptoms of anterior elbow pain. Remembers a twinge in the arm when performing biceps curls but the pain eased after a few days and he returned to his sporting activities. Although he continued to work out in the gym, the pain increased in severity over time.
He did not respond to rest and physiotherapy. He had pain deep in the antecubital fossa on the radial side. It was worse on lifting, turning door handles or keys in locks (i.e. resisted supination) . Worst action to undertake at the gym was dumbbell work, however deadlifts, squats and bench pressing were relatively asymptomatic.
Referred with lateral elbow pain, there were no features of extensor tendinopathy; the hook test was negative -confirming that he had not ruptured his distal biceps tendon - however on ‘active hook testing’ of the tendon origin, this caused pain.
The hook test just confirms whether the examiner is able to hook his or her index finger under the intact biceps tendon from the lateral side, which indicates whether there is a full rupture of the tendon. The 'active hook test', in flexion and active supination, puts further tension on the tendon with the hooking finger thus stressing the insertion and reproduces the patient’s symptoms at the tendon insertion in a positive test.
An MRI scan of the elbow with FABS views was obtained which suggested a partial thickness tear at the distal biceps tendon origin.
What treatment did you recommend / undertake
- He underwent a distal biceps endoscopy with assessment on the degree of partial thickness tearing.
At surgery it was evident that less than 25% of the tendon insertion was torn and so the remaining tendon footprint and synovitis was debrided.
- If he had torn more than 50% of the insertion then it would have been appropriate for his tendon partial detachment to be completed and for the tendon to be reconstructed using an endobutton into a bone tunnel in the radial tuberosity.
What post operation rehab was required?
- He rested in a padded bandage for 2 days post operatively then, after reducing his bulky dressings, he started regaining range of motion performing active, biceps sparing, range of motion.
Progressing onto strengthening at 6 weeks post operatively.
He made a full recovery with return to full weight training at 3 months and has regained strength equivalent to the contralateral side with no recurrence of his painful symptoms.
What were the challenges and how was this case unique?
Anterior elbow pain can be due to partial rupture of the distal biceps tendon, even with a chronic history. Although many cases settle with non surgical treatment (with either physiotherapy and/ or platelet rich plasma treatment) partial thickness tears of the distal biceps insertion, require surgical intervention to either debride or repair the tear - with good outcomes.