Sports-Related Injuries of the Biceps and Triceps

Functional evaluation after cortical button fixation for distal biceps ruptures - Is there any difference between manual or non-manual workers?

BACKGROUND

This study aims to compare clinical and functional results after distal biceps tendon repair in manual workers vs. non-manual workers.

METHODS

This is a retrospective comparative study which refers to 57 cases with distal biceps tendon rupture, divided in manual workers (24 elbows) and non-manual workers (33), that were treated by a single incision with cortical button and interference screw fixation. Included cases have a minimum of 3 months follow-up, post-operative X-ray and signed informed consent for the investigation.

RESULTS

Supination and flexion strength was higher in manual workers vs. non-manual workers (p-value=0.192 and 0.878, respectively). Nine patients showed loss of range of motion, concerning supination and pronation, and this was correlated to worse functional scores. Functional scores tend to be superior in non-manual workers. Ten patients had heterotopic ossification and 20 patients reported lateral antebrachial cutaneous nerve neuropraxia; one had both. Most of them had a full recovery.

CONCLUSION

According to clinical evaluation and post-operative scores, the performed surgical procedure provides good to excellent mid-term functional results. Nevertheless, there were not any differences between manual or non-manual workers.

Distal Triceps Tendon Repair in Strength Athletes Leads to Satisfactory Return to Sports: A Retrospective Analysis of 22 Cases

Background: Distal triceps brachii tendon rupture (DTTR) is a relatively rare injury that is common in bodybuilding and high-intensity contact sports and can lead to significant functional impairment of the elbow joint. This study was conducted to evaluate clinical outcomes and the rate of return to sports among competitive bodybuilders and high-demand strength athletes after surgical repair of DTTR. Methods: This retrospective case series was performed in an institutional setting in tertiary health care. Return to sports of 22 competing or high-demand strength athletes (meaning three or more exercises per week) were analyzed pre- and postoperatively after surgical repair of DTTR using a hybrid technique of transosseous sutures and anchor fixation. Descriptive statistics were used to analyze demographic variables, and independent and paired t-tests were used to assess clinical outcomes. Results: The follow-up showed that from pre- to postoperatively, there was no deterioration in the number of sports disciplines (2.4 and 2.5 sporting activities per person, respectively; p = 0.540) or in the frequency of weekly training (4.1 and 4.1 times per person, respectively; p = 0.329). The postoperative visual analog scale for pain (from 6.0 to 1.6, p < 0.001), level of fitness (from 5.1 to 2.6, p = 0.002), and ability to train (from 5.2 to 1.3, p < 0.001) improved significantly. The time of return to sports was 1.5-3 months and 4-6 months after the surgery for ten patients each. The overall rate of return to sports was 95%, whereas 86% returned to the preinjury level of sporting activity. Conclusions: Repair of DTTR leads to high rates of return to sports in competitive athletes.

Surgically treated acute distal biceps tendon injuries: What results do they have in comparison with the contralateral healthy arm? A systematic review and meta-analysis

BACKGROUND

Surgical repair of distal biceps tendon injury restores flexion and supination strength, resulting in good functional outcome. There are few studies that consider clinical results of the operated arm compared to the healthy contralateral arm, whereas there are many articles examining the results of different surgical techniques. We carried out a systematic review with meta-analysis of the studies that consider this comparison. The aim was to evaluate if there are significative differences in terms of functional results between the operated arm and the non-injured contralateral arm. In fact, we believe that this comparison is useful for assessing patient true satisfaction.

PATIENTS AND METHODS

In accordance with the PRISMA and QUORUM statements, a comprehensive search on PubMed, Scopus, Embase, Cochrane, Google Scholar and Web of Science databases was conducted to identify studies reporting comparative functional results of the operated arm with healthy contralateral arm from January 1985 until November 2022. Criteria for inclusion were acute complete injury of the distal biceps' tendon operated within 30days; range of motion (ROM), isokinetic and isometric strength measurements; minimum patients follow-up of 24months; studies written in English language. Then a DerSimonian and Laird meta-analysis was conducted to compare the functional outcomes of the operated arm to the non-injured arm.

RESULTS

Of the 588 initial studies, 18 studies met the inclusion criteria; methodological quality was assessed using the Newcastle-Ottawa scale. A total of 272 surgically treated distal biceps ruptures were included in the study. The mean follow-up time was of 39.6months (24 to 72months). ROM flexion, pronation, and supination of the operated elbows were significantly decreased, with mean differences of -1.24̊ (p=0.004), -7.95̊ (p=0.003), and -9.27̊ (p=0.004) respectively, compared to the non-injured healthy elbows. The difference of ROM extension was not-statistically significant (+0.21̊; p=0.66). The Isokinetic data showed a statistically significant reduction in the flexion strength (-4.56Nm; p=0.0004) and a statistical significative reduction in the supination strength (-1.18 Nm; p=0.02) of the injured operated arm compared with the healthy one. The forest-plot table of the isometric data was not elaborated due to the small number of studies eligible for the meta-analysis.

DISCUSSION

This study represents the first systematic review and meta-analysis to compare functional and clinical outcomes following operative treatment of distal biceps tendon ruptures with the contralateral healthy arm. Significant differences in ROM flexion, supination, and pronation and in isokinetic and isometric data were found between the operated and non-operated unaffected arm, demonstrating that, as expected, the unaffected arm performed better than the operated one. However, the functional differences between the data of the operated and healthy arm were slight and lead us to overall consider surgery as good functional result.

LEVELS OF EVIDENCE

III.

Return to sports following distal biceps tendon repair: A current concepts review

Distal biceps tendon ruptures are relatively rare injuries but tend to occur in active and athletic populations, especially in weightlifting and contact sports. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow, thus an injury to this ligament can be invalidating for athletes. The aim of this review was to determine the ability and the time to return to sports following distal biceps tendon repair in athletes and the level of performance. The literature is scarce about the return to sports among athletes. Most studies include athletes are National Football League (NFL) players, others are weightlifters and a few recreational athletes. The return to play rate after distal biceps tendon repair is high. The performances of the returned players were similar to matched players and most players returned to the same level. Most players-depending on the sport-were not able to return to competition within the same season. In order to manage expectations, it should be discussed preoperatively with the athlete (and their coach) that the return to sports rate is high, but the return will probably be the following season.

Brachial artery trauma as a complication of bicep muscle injury

We describe a rare case of injury to a branch of the brachial artery in a 48-year-old man with a bicep musculotendinous injury. His presenting symptoms included severe pain, swelling, and paresthesias in the right upper extremity. Examination revealed significant soft tissue swelling with ecchymoses in the right upper arm with diminished palpable pulses. Imaging revealed a biceps muscle injury along with active arterial extravasation of a branch of the deep brachial artery. Interventional radiology successfully performed coil embolization. Bicep musculotendinous injury is typically characterized by pain, swelling, and decreased strength. Rarely, complications such as compartment syndrome have been reported. Brachial arterial injury has not been implicated in the setting of this entity, especially in the absence of blunt or penetrating trauma, until our current patient's presentation.

Distal biceps tendon repairs and reconstructions-an analysis of demographics, prodromal symptoms and complications

INTRODUCTION

The purpose of this study was to evaluate the demographics, complications and prodromal symptoms (any pain or unpleasant sensation in the area distal biceps tendon preceding the injury) of distal biceps tendon tears (DBTTs) of patients treated with primary repair or Achilles allograft reconstruction.

MATERIALS AND METHODS

228 consecutive DBTTs in 226 patients from a single centre were evaluated. The demographic data, prodromal symptoms and postoperative adverse events were documented.

RESULTS

There were 225 males and 1 female patient. The age distribution showed a bimodal pattern in the whole cohort, but once the 48 (20%) elite athletes were excluded, the age was normally distributed, peaking in the 5^th decade. Direct repairs were performed in 184 cases and reconstruction with Achilles tendon allograft in 45 cases. An adverse event was observed in 34 (19%) patients who underwent direct repair and in 3 (7%) cases with graft reconstruction, corresponding to RR of 0.32 (95% CI 0.1-0.96, p = 0.04). Adjusting with the potential confounders (age, occupation and smoking), the OR was 0.35; 95% CI 0.09-1.3, p = 0.11). Adverse events included 28 (12.3% of all adverse events) lateral antebrachial cutaneous nerve (LABCN) neurapraxias, 5 (2.1%) other neurapraxias, 6 (2.6%) heterotopic ossifications and 1 (0.4%) re-rupture. Twenty-three (10%) patients reported prodromal symptoms before the tear.

CONCLUSIONS

DBTT is a condition that affects men predominantly. The observed bimodal incidence distribution was related to elite athletes, but in the normal population the peak occurs at the age typical to tendinopathies. LABCN neurapraxia was the most common adverse event, and graft use does not seem to predispose to adverse events.

Return to Play After Distal Biceps Tendon Repair

PURPOSE OF REVIEW

Distal biceps tendon ruptures (DBTR) are uncommon injuries in 40- to 50-year-old men but occur at a younger age in the athlete population. The distal biceps tendon is an important supinator of the forearm and flexor of the elbow. A complete injury results in limiting function in the upper extremity. The current review evaluates the different options in management and the current literature on return to play in athletes.

RECENT FINDINGS

The distal biceps tendon inserts on the posterior aspect of the radial tuberosity as two independent heads. The long head footprint is more proximal and posterior giving it a better lever arm for supination. The short head footprint is more distal and anterior giving it a better lever arm for flexion. Surgical anatomic repair is highly recommended among the athlete population, to restore proper function of the upper extremity. There is scarce literature on return to play among athletes. The most recent studies on high-performance athletes are on National Football League (NFL) players. These studies showed that 84-94% of NFL players returned to play at least one game after distal biceps repair. Compared to matched control groups, there was no difference in the player's performance after surgery. Anatomic repair of DBTR results in excellent outcomes, high return to work, and high rate of return to play among athletes. When compared to matched control groups, NFL players have the performance score and play the same number of games after surgery.

Distal biceps ruptures in National Football League players: return to play and performance analysis

BACKGROUND

Distal biceps ruptures are rare injuries that tend to occur at a younger age in high-level athletic populations. Data analyzing athletes' ability to return to play, as well as performance, after surgery for a distal biceps rupture are lacking.

METHODS

All National Football League (NFL) players from the 2000-2016 seasons who were found to have a surgically treated distal biceps rupture were included. Analysis of performance and career length was conducted with a control group matched for position, age, experience, and performance statistics. Data for the cohort vs. control group, as well as before vs. after injury, were analyzed with the paired-samples Student t test, with P < .05 deemed statistically significant.

RESULTS

We identified 35 NFL players for the study; 33 (94%) were able to return to sport at an average of 351.4 ± 123.9 days. Offensive linemen undergoing surgery played fewer games per season compared with the control group (P = .04). However, the average number of seasons after surgery and after the index date was not found to be significant (P > .05). Mean career length, as well as number of games per season, did not differ in the postsurgical group vs. control group (P > .05) for all other positions. Performance scores within skill players did not prove to be significant between the postoperative and control groups (P > .05).

CONCLUSIONS

Distal biceps ruptures treated surgically in NFL players allow for return to play at a high rate. The level of performance after surgery is similar to that of the player before injury. On average, NFL career length does not appear to be affected after distal biceps surgery.

The Flexion Initiation Test and an Evidence-Based Diagnostic Algorithm for Distal Biceps Tendon Tears

Purpose

The purpose of this study was (1) to assess the flexion initiation test’s (FIT) ability to detect distal biceps tendon tears (DBTT) in a cohort of consecutive patients presenting with elbow pain and (2) to generate a reliable evidence-based diagnostic algorithm using a combination of both the FIT and hook tests.

Methods

We performed a retrospective review of 125 consecutive patients who presented with elbow pain, all of which had the FIT and hook test performed prior to imaging/further intervention. The integrity of the tendon was determined during surgery or by magnetic resonance imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for the FIT and hook test.

Results

Our evidence-based diagnostic algorithm showed that when both test results are in agreement, there is a 100% diagnostic accuracy for detecting what prior authors have termed surgically indicated tears (complete ruptures and high-grade partial tears) and biceps pathology that can be treated with nonoperative management. The FIT demonstrated 100% sensitivity for surgically indicated tears. The hook test demonstrated 100% sensitivity for complete ruptures, but 18% sensitivity for diagnosing partial tears.

Conclusions

The FIT, which is aimed at improving diagnostic acuity of high-grade partial thickness tears, demonstrated a 93% sensitivity and 96% specificity overall and a 100% sensitivity for complete ruptures and high-grade partial tears. The evidence-based diagnostic algorithm using the combination of the FIT and hook test demonstrates high accuracy for the diagnosis of both complete and high-grade partial DBTTs. The methodology may help to prevent diagnosis delays, improve patient education, and preserve the option for timely primary surgical repair in the treatment of DBTTs.

Level of Evidence

Level IV, diagnostic.

Minimal Damage to the Supinator Muscle After the Double-Incision Technique for Distal Biceps Tendon Repair

Background

The effect of the double-incision technique on the supinator muscle is unclear.

Purpose

The aim of this study was to quantify fatty atrophy of the supinator muscle and map the area of muscle damage.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 19 male patients (median age, 43 years) who underwent distal biceps tendon repair were included in the analysis. Patients with a minimum of 12 months of follow-up were included. The following variables were analyzed: range of motion; shortened version of Disabilities of the Arm, Shoulder and Hand (QuickDASH) score; Summary Outcome Determination (SOD) score; and isokinetic peak force and endurance in supination. Quantitative analysis and mapping of fatty infiltration of the supinator muscle were based on the calculation of proton density fat fraction on magnetic resonance imaging scans of both elbows using the IDEAL (Iterative Decomposition of Echoes of Asymmetrical Length) sequence.

Results

At an average follow-up of 24 months (range, 12-64 months), the median SOD score was 9.0 (95% CI, 7.8-9.4), and the mean QuickDASH score was 6.7 (95% CI, 0.0-14.1). A difference of 17% in peak torque was measured between repaired and nonrepaired elbows (repaired elbow: 9.7 N·m; nonrepaired elbow: 11.7 N·m; P = .11). Endurance was better in the repaired elbow than the nonrepaired elbow (8.4% vs 14.9% work fatigue, respectively; P = .02). The average fat fraction of the supinator muscle was 19% (95% CI, 16%-21%) in repaired elbows and 14% (95% CI, 13%-16%) in contralateral elbows (P = .04). The increase in fat fraction was located in a limited area between the radius and ulna at the level of the bicipital tuberosity.

Conclusion

The assessment of the supinator muscle showed a limited increase in fat fraction between the radius and ulna at the level of the bicipital tuberosity. No significant effect on supination strength was highlighted.

Acute distal biceps tendon ruptures: anatomy, pathology and management - state of the art

All patients with acute complete distal biceps tendon ruptures who are not low demand or medically unfit to proceed with surgery are offered operative repair. This restores arm shape, supination strength and function, and decreases their cramping symptoms. Surgical repair technique varies significantly depending on location and training centre. Nuances in technique and appropriate implant selection need to be noted in order to achieve a strong repair allowing early active range of motion. Intimate knowledge of distal biceps tendon anatomy is key to avoid complications associated with the different approaches. The cumulative body of evidence on complications, coupled with knowledge of the different biomechanical construct strengths of the alternative methods of fixation, points to the use of the cortical button technique without the addition of an interference screw. Subtle variations in drill hole positioning on the bicipital tuberosity secures either an anatomic or non-anatomic repair. Anatomic repair results in greater supination peak torque and fatigue strength, and in greater flexion fatigue strength. It is advisable to perform an anatomic repair in elite athletes or those patients who significantly rely on supination strength and endurance for their livelihood. A universal postoperative protocol is suggested for all repairs.

Rupture of the Short Head of the Biceps Brachii Muscle Belly Caused by a Rock-Climbing Accident

The case of a 42-y-old rock climber who sustained a complete, isolated rupture of the short head of the biceps brachii muscle after falling onto his upper arm while bouldering is presented. This is the first description of this rare injury after a climbing accident. Moreover, there is no definitive consensus on whether and when surgical intervention is necessary in such a case. We performed a direct end-to-end suture of the muscle belly through an open surgical approach. Postoperatively, we performed a detailed follow-up, including clinical examinations and sonography and magnetic resonance imaging to check the integrity of the suture. After 6 mo, our patient had regained a full range of motion without functional complaints or pain. Concerning the sports-specific outcome, we only found a slight decrease in rock-climbing abilities (Union Internationale des Associations d'Alpinisme Scale of Difficulty grade VII+ postsurgery compared to VIII preinjury). In conclusion, we suggest that early surgical reapproximation of the muscle belly might be the best treatment option for this severe but rare injury in athletes.

Surgical Reconstruction Options in Chronic Distal Biceps Tendon Ruptures - Case Report and Literature Review

INTRODUCTION

Chronic distal biceps tendon ruptures are rare and conservative or operative treatment options are suitable. There is a consensus in the literature in case of acute traumatic ruptures the operative refixation should be preferred. Disagreement exists in the best way of care of old ruptures (> 4 weeks) of distal biceps tendon. Several kinds of refixation possibilities up to tendon grafts are described. Aim of this publication is showing an overview of the literature of the approved methods in reconstruction of the distal biceps tendon using autogenous and allogenic grafts, comparing the outcomes and transferring them on an own case.

MATERIAL AND METHODS

A literature research was carried out using the online medical database "PubMed" with the following keywords "chronic rupture distal biceps tendon, surgical techniques". 59 citations were found concerning the topic, 37 publications were relevant for this work.

RESULTS

There is consensus that even in chronic ruptures the operative management of the distal biceps tendon generates the best results. Consistently the experiences and results of only little patient collectives are reported. Numerous techniques of surgery are described without predominance of one method. Reinsertions of the tendon butts are reported in different techniques: with achilles, palmaris longus, fascia lata, triceps, quadriceps and semitendinosus tendon grafts. All together they showed postoperative satisfactory results.

CONCLUSION

With surgical treatment of chronic ruptured distal biceps tendons comparable outcomes can be achieved by primary refixation and graft augmentations. In case of graft augmentations several tissue options are available which showed in all cases satisfactory functional results in the end.

MRI overestimates the full-thickness tear of distal triceps tendon rupture

PURPOSE

Injury to the distal triceps brachii tendon is rare. Imaging radiographs are used to confirm the findings of physical examination, classify the extent of injury, and guide treatment. Magnetic resonance imaging (MRI) is considered the gold standard of diagnostic imaging. However, no previous study has reported on the accuracy of differentiation between partial- and full-thickness triceps tendon tears. Our study's aim was to define the accuracy of MRI in differentiating partial- from full-thickness tear of the distal triceps tendon. We hypothesized that MRI has low accuracy in differentiating partial- from full-thickness tears.

METHODS

A total of eight patients with nine triceps tendon tears underwent surgical repair from 2011 to 2015. MRI of the elbows were retrospectively reviewed for the presence and type of tear, tendon involvement, and location of the tear, and later correlated with surgical findings.

RESULTS

Of the three surgically confirmed complete tears, MRI correctly reported a complete tear in all patients. Of the six partial tears confirmed at surgery, MRI correctly identified four tears. In two cases, MRI described a complete tear, but only a partial tear was noted at surgery.

CONCLUSION

False-positive MRI assessment of distal triceps injury is not rare. Surgeons should rely on clinical examination in assessing distal triceps tendon injury, with imaging studies providing an adjunctive role in the diagnosis and decision-making.

Distal Biceps and Triceps Injuries

Background:

Rupture of the distal biceps and triceps tendons are relatively uncommon injuries typically occurring in middle-aged males as a result of eccentric loading of the tendon.

Methods:

A literature search was performed and the authors’ personal experiences reported.

Results:

This review discusses the diagnosis, indications and guidelines for management of these injuries and provides a description of the authors’ preferred operative techniques.

Conclusion:

Whilst non-operative treatment may be appropriate for patients with low functional demands, surgical management is the preferred option for the majority of patients. We have described a cortical button technique and osseous tunnel technique utilised at our institution for distal biceps and triceps tendon fixation respectively. For biceps or triceps tendon injuries, those receiving an early diagnosis and undergoing surgical intervention, an excellent functional outcome can be expected.

Distal biceps and triceps injuries in athletes

Biceps and triceps ruptures are rare, but can cause significant disability. They typically result from a forceful eccentric contraction, resulting in weakness and pain. Biceps and triceps tendon injuries represent the most and least common tendinous injuries about the elbow, respectively. Nonoperative management of these injuries is generally reserved for partial ruptures or patients unfit for surgery. Surgical repair has become the preferred method of treatment for acute, complete ruptures. Anatomy, epidemiology, clinical evaluation, and treatment of these injuries are described in this review.

MR imaging of the elbow in the injured athlete

This article summarizes key MR imaging findings in common athletic elbow injuries including little leaguer's elbow, Panner disease, osteochondritis dissecans, olecranon stress fracture, occult fracture, degenerative osteophyte formation, flexor-pronator strain, ulnar collateral ligament tear, lateral ulnar collateral ligament and radial collateral ligament tear, lateral epicondylitis, medial epicondylitis, biceps tear, bicipitoradial bursitis, triceps tear, olecranon bursitis, ulnar neuropathy, posterior interosseous nerve syndrome, and radial tunnel syndrome. The article also summarizes important technical considerations in elbow MR imaging that enhance image quality and contribute to the radiologist's success.

Closed proximal muscle rupture of the biceps brachii in wakeboarders

Closed proximal muscle rupture of the biceps brachii is a rare injury. In this report, two cases of closed proximal muscle rupture of the biceps brachii after wakeboard traumas are described. Both patients presented with a swollen arm, weakness during flexion, and a mass in the affected forearm. Magnetic resonance imaging showed displacement of the biceps brachii into the forearm. The rupture was successfully treated with muscle removal in one case and muscle repair in the other. In patients with a wakeboard trauma and similar presentations, closed proximal muscle rupture of the biceps brachii should be suspected.