Rupture of the biceps Rupture of the biceps can occur at the proximal biceps tendon, the distal biceps tendon, or the muscle belly. Intrasubstance biceps rupture is uncommon, and it most typically occurs in young males in their late teens to early 20s. Research demonstrates this injury is most common among military parachutists due to the impact from the ripcord line when jumping out of the aircraft. Forced eccentric loading is one possible mechanism for this injury. Additionally, it can be seen in those who participate in water sports, from eccentric loading from a tow rope (Selley et al., 2019). The distal biceps tendon inserts onto the ulnar aspect of the radial tuberosity. Predisposition to this injury is the presence of a zone of hypovascularity and reduced distance between the radius and ulna during pronation (Vishwanathan & Soni, 2021). Most people with a distal biceps tendon rupture describe a painful “pop” sensation at the time of injury. Other symptoms include anterior elbow pain, swelling, and weakness with elbow flexion and forearm supination. Signs of a torn distal biceps tendon include anterior elbow ecchymosis and swelling as well as a prominent bulge in the anterior mid-arm (Popeye sign). Tenderness with palpation is expected, as is a defect in the anterior aspect of the cubital fossa (Vishwanathan & Soni, 2021). The hook test is a special test that can be used to determine if a tear of the distal biceps tendon is present. For the modified version of this test, the client positions their shoulder in 90 degrees of abduction and 90 degrees of elbow flexion with the forearm Elbow dislocation/instability Elbow dislocation is the second most common joint dislocation (after shoulder dislocation). Posterior dislocations are most common and appear to be initiated by rupture of the lateral ulnar collateral ligament. This leads to posterolateral rotatory instability, causing the forearm to displace into external rotation with circumferential tearing of the capsuloligamentous structures from lateral to medial (Hackl et al., 2015). A fall from standing height is the cause of approximately 60% of elbow dislocations. (Jones & Jordan, 2017). Individuals who frequently work on ladders to access elevated surfaces, such as painters, construction workers, and housekeepers, are more at risk than others. A combination of valgus, axial, and posterolateral rotatory forces applied to the extended elbow are necessary for dislocation to occur. Approximately 20% of elbow dislocations are associated with a fracture (Jones & Jordan, 2017). The terrible triad of the elbow occurs when dislocation is accompanied by radial head/neck fracture and coronoid fracture. Clinical Presentation Symptoms of elbow dislocation include pain, clicking, and locking with the elbow in extension. Physical exam will possibly show varus and valgus instability (Battista & Cohen, 2023).
in full supination. The examiner palpates the distal biceps (hooking the lateral aspect of the tendon) while the client resists forearm pronation. The test is positive if the examiner is unable to hook the biceps tendon, which means it is ruptured (Vishwanathan & Soni, 2021). According to Lalehzalian et al. (2022), a tear of the proximal long head of the biceps tendon will result in pain that will decrease over time with preserved biceps function. Risk factors for proximal biceps tendon rupture include falling on an outstretched arm, lifting heavy objects, excess overhead use of the shoulder, aging, smoking, and corticosteroid medications. Signs and symptoms of proximal biceps tendon tear include (Athwal, 2022a): ● A sudden sharp pain at the tendon site with an audible snap or pop. ● Cramping of the biceps with strenuous arm activity. ● Bruising in the upper arm down to the elbow. ● Pain and tenderness at the shoulder and elbow. ● Weakness with elbow flexion and forearm supination. ● A muscle bulge in the upper arm. Physical examination should include inspection of the arm for bruising, swelling, and muscle bulge as well as palpation of the biceps muscle and proximal tendon for deformity and pain. Elbow flexion and forearm supination strength testing should be performed as well. A partial tear will be less obvious than a complete tear, as a muscle bulge will not be as visible. Several tests can be used to assess elbow stability including: ● Valgus stress test : The valgus stress test assesses the stability of the medial aspect of the elbow. For this test, the patient’s elbow is placed in 20 to 30 degrees of flexion with the forearm supinated. The examiner applies medial stress to the elbow. The test is positive if there is no firm end feel, if there is gapping of the medial joint, and/or there is reproduction of the patient’s pain. This test has a sensitivity of 66% and a specificity of 60% (Karbach & Elfar, 2017). ● Milking maneuver : The milking maneuver is used to specifically test the anterior bundle of the ulnar (medial) collateral ligament. For this test, the patient’s arm is externally rotated, and the elbow is flexed beyond 90 degrees. A valgus force is applied by pulling the patient’s thumb, while the other hand stabilizes the elbow and palpates the medial joint line. The test is considered positive if there is pain, apprehension, or instability (Karbach & Elfar, 2017). ● Moving valgus test : The moving valgus test is completed by placing the patient’s shoulder in 90 degrees of abduction and maximal external rotation with the elbow in maximal flexion. The examiner applies a constant valgus force to the elbow as the elbow is extended to 30 degrees of flexion. The test is positive if pain is reproduced over the ulnar collateral ligament between 70 and 120 degrees of flexion. To confirm a positive finding, the examiner may reverse the movement and flex the elbow while applying valgus force, with reproduction of pain expected in the same range of flexion. This test has been shown to be 100% sensitive and 75% specific for ulnar collateral injuries (Karbach & Elfar, 2017).
Posterolateral rotary instability The most common recurrent instability of the elbow is posterolateral rotatory instability, which occurs secondary to trauma to the lateral collateral ligament. Lateral elbow pain is present and occurs because of recurrent posterior
radial head dislocation. The symptoms occur when a load is applied to the elbow while it is flexed and the forearm is supinated (Karbach & Elfar, 2017).
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