- Email: [email protected]
Bilateral ruptures of the distal biceps brachii tendon
J Shoulder Elbow Surg (2009) 18, 804-807
www.elsevier.com/locate/ymse
Bilateral ruptures of the distal biceps brachii tendon Adam Schneider, MDa, J. Michael Bennett, MDb,*, Daniel P. O’Connor, PhDc, Thomas Mehlhoff, MDb, James B. Bennett, MDd,e a
Fellow in Hand and Microvascular Surgery, Baylor College of Medicine, Houston, TX Texas Orthopedic Hospital, Fondren Orthopedic Group, Houston, TX c Laboratory of Integrated Physiology, University of Houston, Houston, TX d Division Plastic Surgery, Baylor College and Medicine, and University of Texas, Houston, TX e Department of Orthopedic Surgery; Houston Health Science Center, Chief of Staff, Texas Orthopedic Hospital, Houston, TX b
Background: The purpose of this study was to identify characteristics associated with bilateral ruptures of the distal biceps tendons. Methods: We present a retrospective case series of 25 patients who sustained non-simultaneous bilateral distal biceps brachii tendon ruptures that were repaired surgically, with follow-up available on 10 patients. The average age of the patients was 50 years (range 28-76). All patients were male. The mean time from the first tendon rupture to the contralateral tendon rupture was 2.7 years (range 0.5 6.3). Follow-up averaged 45 months (range 24-85). Results: Patients with bilateral ruptures tended to be middle-aged men, who commonly participated in weight lifting, manual labor, or sports, and who had higher rates of nicotine (50%) and anabolic steroid use (20%) than the general population. After surgical repair of 9 of 10 patients, patients with bilateral distal biceps tendon ruptures had good to excellent outcomes. With the numbers available, outcomes were not statistically associated with manual labor, past medical history, prescription medications, prior tendon injury, body mass index, current activity in sports, use of nutritional supplements, or anabolic steroid use, although worker’s compensation claims approached statistical significance (p ¼ 0.059). Conclusions: Patients who sustained bilateral distal biceps tendon ruptures tended to be middle-aged men with higher rates of nicotine and anabolic steroid use than the general population. Level of Evidence: Level IV, Case Series, Treatment Study. Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. keywords: Biceps brachii; biceps tendon; distal biceps rupture; bilateral injury; surgical repair; anabolic steroids; nicotine
Several risk factors have been reported in the literature for acute and chronic unilateral ruptures of the distal biceps brachii tendon; however, none have been reported for bilateral tendon ruptures. Losing the ability to use both upper extremities at separate time intervals is a more cumulatively debilitating condition than a unilateral rupture. Most reports *Reprint requests: J. Michael Bennett, M.D. Texas Orthopedic Hospital, Fondren Orthopedic Group, 7401 South Main Street, Houston, TX 77030 E-mail address: [email protected] (J.M. Bennett).
of causative factors for bilateral biceps brachii tendon ruptures have, to date, been anecdotal. The purpose of this study was to identify characteristics associated with bilateral rupture of the distal biceps brachii tendon.
Materials and methods The patients in this study had bilateral distal biceps tendon ruptures that were referred to this institution for evaluation between July
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2009.01.029
Bilateral ruptures of the distal biceps brachii tendon 1997 and November 2006. The subjects were identified from a practice database maintained by 3 of the investigators. A detailed chart review was performed for each patient. Data recorded included gender, age, ethnicity, hand dominance, injured extremity, mechanism and date of injury, presentation, and surgery; medical and surgical history; social history; occupation; medication history; family history, and height and weight. The patients were all contacted by telephone by the same investigator (AMS). An internally composed questionnaire consisting of pertinent questions pertaining to the circumstances of the injuries was administered over the telephone after obtaining verbal consent of the patient. These questions included asking about history of weight lifting, sports participation, smoking, personal and family history of tendon problems, and whether they had ever used anabolic steroids. The Disabilities of Arm, Shoulder, and Hand (DASH) assessment tool was then administered and the data recorded. The effects of the demographic and historical factors on DASH scores were analyzed using analyses of variance and correlation coefficients, with statistical significance set at P .05.
Results Twenty-five patients with unilateral distal biceps brachii tendon ruptures that later went on to develop a contralateral distal biceps brachii tendon ruptures and underwent treatment between July 1997 and November 2006 were identified. At the time of the investigation, 1 of the patients was deceased. Fourteen of the patients were unreachable or declined to participate in the study. The study group of the current investigation, therefore, consisted of 10 patients with bilateral distal biceps tendon ruptures. Between July 1997 and November 2006, all patients were treated at the same institution by 3 of the authors. All surgeries were performed at least 1 year prior to the investigation. This study was approved by our facility’s Institutional Review Board. The 10 patients with bilateral distal biceps ruptures had an average age of 49.5 years (range, 27.7-76.2) at initial injury. All patients were right-handed male Caucasians. Only 1 patient had simultaneous bilateral ruptures. The average time from the initial to contralateral distal biceps tendon rupture was 2.7 years (range, 6 months to 6.3 years) (Table I). Nine of the 10 patients underwent surgical repair or reconstruction of at least 1 distal biceps tendon. One patient elected nonoperative treatment for both ruptures. Three patients had only 1 of their distal biceps tendons repaired or reconstructed. Of the 15 total surgeries, 8 were performed using single incision techniques and 6 were performed using 2 incision techniques. Two patients (20%) reported using anabolic steroids at the time of their injuries. Five patients (50%) reported a history of using tobacco products (ie, cigarettes, cigars, or snuff) at the time of injury. Seven patients (70%) reported taking prescription medications at the time of injury. As might be expected among a male population in this age range, the medications consisted primarily of statins, proton pump inhibitors, antihypertensives, and various cardiac
805 Table I Demographics of patients with bilateral distal biceps tendon rupture Height in cm Weight in kg Age at left rupture Age at right rupture Time (years) between ruptures DASH score
Range
Mean
SD
167.6-190.5 79.5-127.3 34-77.4 27.7-76.2 0.50-6.33 0-0.16
179.2 99.8 50.1 49.5 2.67 0.03
8.5 16.3 12.0 13.0 2.0 0.1
DASH, Disabilities of Arm, Shoulder, and Hand; SD, standard deviation.
medicines. One patient reported taking levofloxacin prior to injury. Six patients (60%) reported using nutritional supplements consisting of multivitamins and omega 3 oils (‘‘fish oil’’). None of the patients reported using any type of ergogenic or performance supplement (eg, creatine). Five patients (40%) reported performing regular weight lifting at the time of injury. Three patients (30%) had occupations involving heavy manual labor at the time of injury. Seven patients (70%) reported being active in sports at the time of injury. The sports reported were volleyball, baseball, softball, swimming, golf, bicycling, soccer, and bow hunting. Two of these patients had sustained their biceps rupture while playing volleyball. The other patients were injured while lifting or pulling a heavy object, or as the result of a fall. Four patients (40%) reported having tendon injuries or problems prior to rupture of the biceps tendon. One patient had lateral epicondylitis, 1 had rotator cuff problems, 1 had plantar fasciitis, and 1 patient had sustained a previous rupture of the biceps tendon proximally. At an average follow-up of 45.3 months (range, 24-85) for the left arm and 74.4 months (range, 9-180) for the right arm, the average postoperative DASH score was 3.5% (range, 0-16.3%), indicating a relatively low level of disability related to upper extremity function. With the numbers available, DASH scores were not significantly related to age at initial injury (P ¼ .452); number of surgical incisions (P ¼ .452); having only 1 of the biceps tendons repaired (P ¼ .634); working in manual labor (P ¼ .158); having a history of prior tendon injuries (P ¼ .158); taking prescription medications at the time of injury (P ¼ .364); using tobacco (P ¼ .660); filing worker’s compensation (P ¼ .059); using nutritional supplements at the time of injury (P ¼ .145), or using anabolic steroids at the time of injury (P ¼ .830).
Discussion In this study, we present the largest series of bilateral distal biceps tendon ruptures to date.6,7,10,21,27,28,39 Our results are consistent with the findings of previous authors.7,11,21,22,24,28,31 Most of the patients were middleaged men, with higher body mass indices than average and
806 a higher representation of nicotine users than the general population. This reinforced the demographic most commonly reported for the injury; distal biceps tendon ruptures are very rare in females.3,34 These injuries have been reported to occur in men who are between 40-50 years of age1,3,21,28,34,40; our patients were all males who had an average age of 50 years at the time of injury. Several risk factors have been reported in the literature for unilateral ruptures of the distal biceps brachii tendon21,24 however, to our knowledge, there has been no significant series that has reported the risk factors specific for bilateral rupture. Of Safran et al’s case series of 13 unilateral distal biceps brachii tendon ruptures, 21% of the injuries were work related,28 similar to the rate of 20% observed in the current investigation. Previous studies6,8,12,13,17,18,32,36,37 have suggested an association between various medical comorbidities and biceps brachii tendon rupture. Conditions suggested to have causative effects include obesity, cancer, inflammatory spondyloarthropathies, gout, renal failure, and hyperparathyroidism.12 Nine of the 10 subjects in both of the study groups had chronic systemic comorbidities, although only 1 of the aforementioned diseases (gout) was reported in 2 of our patients. The other reported chronic medical conditions reported in our patients (eg, hypertension, hypercholesterolemia, cardiac disease) can be expected to have a high incidence in a cohort of this age and were likely unrelated to the tendon injuries. Nicotine’s vasoconstrictive and deoxygenating effects on tissue have been implicated in the degeneration of the distal biceps tendon.28,31,33 In a cadaveric study, Seiler et al31 found that pre-existing degenerative changes may exacerbate impingement of the tendon insertion during pronation and supination at a zone of relative hypovascularity just proximal to the radial tuberosity. The prevalence of nicotine use (eg, smoking or using smokeless tobacco) in our study (50%) is similar to that in Safran et al’s series. This prevalence is considerably higher than the prevalence of nicotine use in the general population, which has been estimated to be approximately 10%.28 Anabolic steroid use has also been implicated due to induced collagen dysplasia and, therefore, lower threshold for tendon injury with exercise.14,18,23,37,39 Two of the 10 patients (20%) in our study reported a history of anabolic steroid use, which is considerably higher than estimated lifetime prevalence of 2% among American males.20 The subjects who admitted to androgenic steroid use also reported that they used various nutritional supplements. Though not previously reported for the distal biceps tendon, previous injection of depository steroid leading to rupture of the injected tendon has been described.9 None of the subjects in this study reported having had a depository steroid injection into or about the biceps tendon. Overall, the patients with bilateral ruptures did well after surgical repair, with a postoperative DASH score that averaged 3%. We found no correlation between outcome
A. Schneider et al. following surgical treatment and manual labor, worker’s compensation claims, past medical history, prescription medications, prior tendon injury, body mass index, current activity in sports, use of nutritional supplements, or androgenic steroid use. The strength of our study is that we present the largest case series of bilateral distal biceps brachii tendon ruptures reported to date. The main weakness of this study is the reliance on self-report and chart data, although there is no other reasonable way to evaluate many of the factors (eg, history of anabolic steroid use). These data may be useful in identifying potential risk factors related to bilateral rupture of the distal biceps brachii tendon.
Conclusion We found that patients with bilateral distal biceps tendon ruptures have a similar profile as that reported for unilateral distal biceps tendon ruptures. Specifically, these patients are primarily middle-aged males who participate in regular weight lifting, manual labor, or sports, and are more likely than the general population to have used tobacco products or anabolic steroids. Surgical repair of the distal biceps tendons results in good functional outcomes at 2 to 7 years following surgery.
References 1. Agins HJ, Chess JL, Hoekstra DV, Teitge RA. Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop Rel Res 1988;234: 34-8. 2. Anzel SH, Covey KW, Weiner AD, Lipscomb PR. Disruption of muscles and tendons e an analysis of 1,014 cases. Surgery 1959;45: 406-14. 3. Bauman JT, Sotereanos DG, Weiser RW. Complete rupture of the distal biceps tendon in a woman: case report. J Hand Surg 2006;31A: 798-800. 4. Bayat A, Neumann L, Wallace WA. Late repair of simultaneous bilateral distal biceps brachii tendon avulsion with fascia lata graft. Br J Sports Med 1999;33:281-3. 5. Bernstein AD, Breslow MJ, Jazrawi LM. Distal biceps tendon ruptures: a historical perspective and current concepts. Am J Orthop 2001;30:193-200. 6. Davis WM, Yassine Z. An etiological factor in the tear of the distal tendon of the biceps brachii e report of two cases. J Bone Joint Surg [Am] 1956;38A:1365-8. 7. Dobbie RP. Avulsion of the lower biceps brachii tendon e analysis of fifty-one previously unreported cases. Am J Surg 1941;51:662-82. 8. Eksioglu E, Eksioglu F, Aydogdu F. Bilateral spontaneous rupture of the long head of the biceps brachii tendon in rheumatoid arthritis. Rheumatol Int 2004;24:368-9. 9. Ford LT, DeBender J. Tendon rupture after local steroid injection. South Med J 1979;72:827-30. 10. Hargrove R, Griffiths DE, Clasper J. Ruptured distal biceps in military personnel. J R Army Med Corps 2006;152:26-9. 11. Holmes GB Jr, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Ankle 1992;13:70-9.
Bilateral ruptures of the distal biceps brachii tendon 12. Jones N, Kjellstrand CM. Spontaneous tendon ruptures in patients on chronic dialysis. Am J Kidney Dis 1996;28:861-6. 13. Jo´zsa L, Kannus P. Histopathological findings in spontaneous tendon ruptures. Scand J Med Sci Sports 1997;7:113-8. 14. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon e a controlled study of 891 patients. J Bone Joint Surg [Am] 1991;73A:1507-25. 15. Kelly EW, O’Driscoll SW. Exploration and repair of partial distal biceps tendon ruptures through a single posterior incision. Tech Shoulder Elbow Surg 2002;3:68-72. 16. Kristensen PW. Distal avulsion of the biceps brachii tendon. Injury 1991;22:151-2. 17. Kron SD, Satinsky VP. Avulsion of the distal biceps brachii tendon. Am J Surg 1954;88:657-9. 18. Lauzon C, Carette S, Mathon G. Multiple tendon rupture at unusual sites in rheumatoid arthritis. J Rheumatol 1987;14:369-71. 19. Le Huec JC, Moinard M, Liquois F, Zipoli B, Chauveaux, Le Rebeller A. Distal rupture of the tendon of biceps brachii: evaluation by MRI and the results of repair. J Bone Joint Surg [Br] 1996;78B:767-70. 20. McCabe SE, Brower KJ, West BT, Nelson TF, Wechsler H. Trends in non-medical use of anabolic steroids by U.S. college students: results from four national surveys. Drug Alcohol Depend 2007;90:243-51. 21. McReynolds IS. Avulsion of the insertion of the biceps brachii tendon and its surgical treatment. J Bone Joint Surg [Am] 1963;45A:1780. 22. Manjunath S, Trash DB. Spontaneous bilateral rupture of biceps tendons. Postgrad Med J 1999;75:470. 23. Michna H. Tendon injuries induced by exercise and anabolic steroids in experimental mice. Int Orthop 1987;11:157-62. 24. Morrey BF. Biceps tendon injury. Instr Course Lect 1999;48:405-10. 25. Ncube BA, Singhal K. Rupture of the distal end of the biceps brachii tendon: an unusual occurrence in a horse rider. Injury 1991;22:150-1. 26. Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg 1999;7:199-207. 27. Rantanen J, Orava S. Rupture of the distal biceps tendon e a report of 19 patients treated with anatomic reinsertion, and a meta-analysis of 147 cases found in the literature. Am J Sports Med 1999;27:128-32.
807 28. Safran MR, Graham SM. Distal biceps tendon ruptures. Clin Orthop Rel Res 2002;404:275-83. 29. Sassmannhausen G, Mair SD, Blazar PE. Rupture of a bifurcated distal biceps tendon e a case report. J Bone Joint Surg [Am] 2004; 86A:2737-40. 30. Scho¨ffl VR, Harrer J, Ku¨pper T. Biceps tendon ruptures in rock climbers. Clin J Sport Med 2006;16:426-7. 31. Seiler JG, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA. The distal biceps tendon e two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg 1995;4:149-56. 32. Shah MK. Simultaneous bilateral rupture of quadriceps tendons: analysis of risk factors and associations. South Med J 2002;95:860-6. 33. Strauch RJ. Biceps and triceps injuries of the elbow. Orthop Clin North Am 1999;30:95-107. 34. Toczylowski HM, Balint CR, Steiner ME, Boardman M, Scheller AD. Complete rupture of the distal biceps brachii tendon in female patients: A report of 2 cases. J Shoulder Elbow Surg 2002;11:516-8. 35. Tomaino MM, Towers JD. Clinical presentation and radiographic findings of distal biceps tendon degeneration: a potentially forgotten cause of proximal radial forearm pain. Am J Orthop 2004;33:31-4. 36. van der Linden PD, Nad HW, Simonian S, Stricker BH, Leufkens HG, Herings RM. Fluoroquinolone use and the change in incidence of tendon ruptures in the Netherlands. Pharm World Sci 2001;23:89-92. 37. van der Linden P, Sturkenboom MC, Hering RM, Leufkens HM, Rowlands S, Stricker BH. Increased risk of achilles tendon rupture with quinolone antibacterial use, especially in elderly patients taking oral corticosteroids. Arch Intern Med 2003;163:1801-7. 38. Vidal A, Allen A. Biceps tendon and triceps tendon injuries. Sports Med Arthrosc Rev 2003;11:47-56. 39. Visuri T, Lindholm H. Bilateral distal biceps tendon avulsions with use of anabolic steroids. Med Sci Sports Exerc 1994;26:941-4. 40. White DW, Wenke JC, Mosely DS, Mountcastle SB, Basamania CJ. Incidence of major tendon ruptures and anterior cruciate ligament tears in US Army soldiers. Am J Sports Med 2007;35:1308-14.
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Bilateral ruptures of the distal biceps brachii tendon Adam Schneider, MDa, J. Michael Bennett, MDb,*, Daniel P. O’Connor, PhDc, Thomas Mehlhoff, MDb, James B. Bennett, MDd,e a
Fellow in Hand and Microvascular Surgery, Baylor College of Medicine, Houston, TX Texas Orthopedic Hospital, Fondren Orthopedic Group, Houston, TX c Laboratory of Integrated Physiology, University of Houston, Houston, TX d Division Plastic Surgery, Baylor College and Medicine, and University of Texas, Houston, TX e Department of Orthopedic Surgery; Houston Health Science Center, Chief of Staff, Texas Orthopedic Hospital, Houston, TX b
Background: The purpose of this study was to identify characteristics associated with bilateral ruptures of the distal biceps tendons. Methods: We present a retrospective case series of 25 patients who sustained non-simultaneous bilateral distal biceps brachii tendon ruptures that were repaired surgically, with follow-up available on 10 patients. The average age of the patients was 50 years (range 28-76). All patients were male. The mean time from the first tendon rupture to the contralateral tendon rupture was 2.7 years (range 0.5 6.3). Follow-up averaged 45 months (range 24-85). Results: Patients with bilateral ruptures tended to be middle-aged men, who commonly participated in weight lifting, manual labor, or sports, and who had higher rates of nicotine (50%) and anabolic steroid use (20%) than the general population. After surgical repair of 9 of 10 patients, patients with bilateral distal biceps tendon ruptures had good to excellent outcomes. With the numbers available, outcomes were not statistically associated with manual labor, past medical history, prescription medications, prior tendon injury, body mass index, current activity in sports, use of nutritional supplements, or anabolic steroid use, although worker’s compensation claims approached statistical significance (p ¼ 0.059). Conclusions: Patients who sustained bilateral distal biceps tendon ruptures tended to be middle-aged men with higher rates of nicotine and anabolic steroid use than the general population. Level of Evidence: Level IV, Case Series, Treatment Study. Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. keywords: Biceps brachii; biceps tendon; distal biceps rupture; bilateral injury; surgical repair; anabolic steroids; nicotine
Several risk factors have been reported in the literature for acute and chronic unilateral ruptures of the distal biceps brachii tendon; however, none have been reported for bilateral tendon ruptures. Losing the ability to use both upper extremities at separate time intervals is a more cumulatively debilitating condition than a unilateral rupture. Most reports *Reprint requests: J. Michael Bennett, M.D. Texas Orthopedic Hospital, Fondren Orthopedic Group, 7401 South Main Street, Houston, TX 77030 E-mail address: [email protected] (J.M. Bennett).
of causative factors for bilateral biceps brachii tendon ruptures have, to date, been anecdotal. The purpose of this study was to identify characteristics associated with bilateral rupture of the distal biceps brachii tendon.
Materials and methods The patients in this study had bilateral distal biceps tendon ruptures that were referred to this institution for evaluation between July
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2009.01.029
Bilateral ruptures of the distal biceps brachii tendon 1997 and November 2006. The subjects were identified from a practice database maintained by 3 of the investigators. A detailed chart review was performed for each patient. Data recorded included gender, age, ethnicity, hand dominance, injured extremity, mechanism and date of injury, presentation, and surgery; medical and surgical history; social history; occupation; medication history; family history, and height and weight. The patients were all contacted by telephone by the same investigator (AMS). An internally composed questionnaire consisting of pertinent questions pertaining to the circumstances of the injuries was administered over the telephone after obtaining verbal consent of the patient. These questions included asking about history of weight lifting, sports participation, smoking, personal and family history of tendon problems, and whether they had ever used anabolic steroids. The Disabilities of Arm, Shoulder, and Hand (DASH) assessment tool was then administered and the data recorded. The effects of the demographic and historical factors on DASH scores were analyzed using analyses of variance and correlation coefficients, with statistical significance set at P .05.
Results Twenty-five patients with unilateral distal biceps brachii tendon ruptures that later went on to develop a contralateral distal biceps brachii tendon ruptures and underwent treatment between July 1997 and November 2006 were identified. At the time of the investigation, 1 of the patients was deceased. Fourteen of the patients were unreachable or declined to participate in the study. The study group of the current investigation, therefore, consisted of 10 patients with bilateral distal biceps tendon ruptures. Between July 1997 and November 2006, all patients were treated at the same institution by 3 of the authors. All surgeries were performed at least 1 year prior to the investigation. This study was approved by our facility’s Institutional Review Board. The 10 patients with bilateral distal biceps ruptures had an average age of 49.5 years (range, 27.7-76.2) at initial injury. All patients were right-handed male Caucasians. Only 1 patient had simultaneous bilateral ruptures. The average time from the initial to contralateral distal biceps tendon rupture was 2.7 years (range, 6 months to 6.3 years) (Table I). Nine of the 10 patients underwent surgical repair or reconstruction of at least 1 distal biceps tendon. One patient elected nonoperative treatment for both ruptures. Three patients had only 1 of their distal biceps tendons repaired or reconstructed. Of the 15 total surgeries, 8 were performed using single incision techniques and 6 were performed using 2 incision techniques. Two patients (20%) reported using anabolic steroids at the time of their injuries. Five patients (50%) reported a history of using tobacco products (ie, cigarettes, cigars, or snuff) at the time of injury. Seven patients (70%) reported taking prescription medications at the time of injury. As might be expected among a male population in this age range, the medications consisted primarily of statins, proton pump inhibitors, antihypertensives, and various cardiac
805 Table I Demographics of patients with bilateral distal biceps tendon rupture Height in cm Weight in kg Age at left rupture Age at right rupture Time (years) between ruptures DASH score
Range
Mean
SD
167.6-190.5 79.5-127.3 34-77.4 27.7-76.2 0.50-6.33 0-0.16
179.2 99.8 50.1 49.5 2.67 0.03
8.5 16.3 12.0 13.0 2.0 0.1
DASH, Disabilities of Arm, Shoulder, and Hand; SD, standard deviation.
medicines. One patient reported taking levofloxacin prior to injury. Six patients (60%) reported using nutritional supplements consisting of multivitamins and omega 3 oils (‘‘fish oil’’). None of the patients reported using any type of ergogenic or performance supplement (eg, creatine). Five patients (40%) reported performing regular weight lifting at the time of injury. Three patients (30%) had occupations involving heavy manual labor at the time of injury. Seven patients (70%) reported being active in sports at the time of injury. The sports reported were volleyball, baseball, softball, swimming, golf, bicycling, soccer, and bow hunting. Two of these patients had sustained their biceps rupture while playing volleyball. The other patients were injured while lifting or pulling a heavy object, or as the result of a fall. Four patients (40%) reported having tendon injuries or problems prior to rupture of the biceps tendon. One patient had lateral epicondylitis, 1 had rotator cuff problems, 1 had plantar fasciitis, and 1 patient had sustained a previous rupture of the biceps tendon proximally. At an average follow-up of 45.3 months (range, 24-85) for the left arm and 74.4 months (range, 9-180) for the right arm, the average postoperative DASH score was 3.5% (range, 0-16.3%), indicating a relatively low level of disability related to upper extremity function. With the numbers available, DASH scores were not significantly related to age at initial injury (P ¼ .452); number of surgical incisions (P ¼ .452); having only 1 of the biceps tendons repaired (P ¼ .634); working in manual labor (P ¼ .158); having a history of prior tendon injuries (P ¼ .158); taking prescription medications at the time of injury (P ¼ .364); using tobacco (P ¼ .660); filing worker’s compensation (P ¼ .059); using nutritional supplements at the time of injury (P ¼ .145), or using anabolic steroids at the time of injury (P ¼ .830).
Discussion In this study, we present the largest series of bilateral distal biceps tendon ruptures to date.6,7,10,21,27,28,39 Our results are consistent with the findings of previous authors.7,11,21,22,24,28,31 Most of the patients were middleaged men, with higher body mass indices than average and
806 a higher representation of nicotine users than the general population. This reinforced the demographic most commonly reported for the injury; distal biceps tendon ruptures are very rare in females.3,34 These injuries have been reported to occur in men who are between 40-50 years of age1,3,21,28,34,40; our patients were all males who had an average age of 50 years at the time of injury. Several risk factors have been reported in the literature for unilateral ruptures of the distal biceps brachii tendon21,24 however, to our knowledge, there has been no significant series that has reported the risk factors specific for bilateral rupture. Of Safran et al’s case series of 13 unilateral distal biceps brachii tendon ruptures, 21% of the injuries were work related,28 similar to the rate of 20% observed in the current investigation. Previous studies6,8,12,13,17,18,32,36,37 have suggested an association between various medical comorbidities and biceps brachii tendon rupture. Conditions suggested to have causative effects include obesity, cancer, inflammatory spondyloarthropathies, gout, renal failure, and hyperparathyroidism.12 Nine of the 10 subjects in both of the study groups had chronic systemic comorbidities, although only 1 of the aforementioned diseases (gout) was reported in 2 of our patients. The other reported chronic medical conditions reported in our patients (eg, hypertension, hypercholesterolemia, cardiac disease) can be expected to have a high incidence in a cohort of this age and were likely unrelated to the tendon injuries. Nicotine’s vasoconstrictive and deoxygenating effects on tissue have been implicated in the degeneration of the distal biceps tendon.28,31,33 In a cadaveric study, Seiler et al31 found that pre-existing degenerative changes may exacerbate impingement of the tendon insertion during pronation and supination at a zone of relative hypovascularity just proximal to the radial tuberosity. The prevalence of nicotine use (eg, smoking or using smokeless tobacco) in our study (50%) is similar to that in Safran et al’s series. This prevalence is considerably higher than the prevalence of nicotine use in the general population, which has been estimated to be approximately 10%.28 Anabolic steroid use has also been implicated due to induced collagen dysplasia and, therefore, lower threshold for tendon injury with exercise.14,18,23,37,39 Two of the 10 patients (20%) in our study reported a history of anabolic steroid use, which is considerably higher than estimated lifetime prevalence of 2% among American males.20 The subjects who admitted to androgenic steroid use also reported that they used various nutritional supplements. Though not previously reported for the distal biceps tendon, previous injection of depository steroid leading to rupture of the injected tendon has been described.9 None of the subjects in this study reported having had a depository steroid injection into or about the biceps tendon. Overall, the patients with bilateral ruptures did well after surgical repair, with a postoperative DASH score that averaged 3%. We found no correlation between outcome
A. Schneider et al. following surgical treatment and manual labor, worker’s compensation claims, past medical history, prescription medications, prior tendon injury, body mass index, current activity in sports, use of nutritional supplements, or androgenic steroid use. The strength of our study is that we present the largest case series of bilateral distal biceps brachii tendon ruptures reported to date. The main weakness of this study is the reliance on self-report and chart data, although there is no other reasonable way to evaluate many of the factors (eg, history of anabolic steroid use). These data may be useful in identifying potential risk factors related to bilateral rupture of the distal biceps brachii tendon.
Conclusion We found that patients with bilateral distal biceps tendon ruptures have a similar profile as that reported for unilateral distal biceps tendon ruptures. Specifically, these patients are primarily middle-aged males who participate in regular weight lifting, manual labor, or sports, and are more likely than the general population to have used tobacco products or anabolic steroids. Surgical repair of the distal biceps tendons results in good functional outcomes at 2 to 7 years following surgery.
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