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Complete rupture of the distal biceps brachii tendon in female patients: A report of 2 cases
CASE REPORTS Complete rupture of the distal biceps brachii tendon in female patients: A report of 2 cases Henry M. Toczylowski, MD, Christopher R. Balint, DO, Mark E. Steiner, MD, Matt Boardman, BS, and Arnold D. Scheller, Jr, MD, Boston, Mass
C omplete rupture of the distal biceps tendon is an
uncommon injury, accounting for only 3% of all biceps brachii avulsions. The distal biceps typically ruptures in the dominant extremity of men between 40 and 60 years of age following an excessive eccentric contraction. Although this injury continues to be reported in the literature with increased frequency, complete rupture of the distal biceps in female patients is yet to be reported. We present 2 case reports of complete distal biceps tendon rupture in female patients. Both women, aged 58 and 72 years, were athletically active and sustained their injuries during sporting activities. Both surgical and nonoperative treatment were used in their care. Both patients subjectively considered their results excellent and returned unencumbered to their prior level of sporting activity by 16 weeks. We review these 2 cases of complete distal biceps rupture in female patients and consider the etiology of male dominance in this injury. We speculate that the increased level of activity and greater sports involvement of women at all ages will lead to an increased incidence in distal biceps tendon ruptures in female patients.
CASE 1 A 58-year-old, right-hand– dominant competitive ice dancer had an immediate onset of pain about the right elbow while being lowered to the ice in a normal manner during a practice routine. She described a snapping sensation with immediate onset of pain and weakness in her elbow. She reported no prior trauma or pain of the elbow region preceding her injury. She was evaluated 10 days after the injury, complaining of a deformity of the upper From the Sports Medicine Section, New England Baptist Hospital, Boston, Mass. Reprint requests: Henry M. Toczylowski, MD, 830 Boylston St, Chestnut Hill, MA 02467. J Shoulder Elbow Surg 2002;11:516 –18. Copyright © 2002 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2002/$35.00 ⫹ 0 32/4/126617 doi:10.1067/mse.2002.126617
516
arm, as well as continued pain, weakness, and ecchymosis about the elbow. Physical examination revealed a full arc of active flexion and extension with pain elicited at the terminal ends of motion. A significant deficit in supination strength and elbow flexion power was noted in comparison to the contralateral side. There was an obvious deformity of the distal biceps that was accentuated with active flexion of the elbow. Further examination revealed tenderness, swelling, extensive ecchymosis, and a soft-tissue defect just proximal to the antecubital fossa of the right upper extremity. Radiograph results were normal. Surgical exploration confirmed a complete avulsion of the distal biceps from the radial tuberosity. A standard 2-incision modified BoydAnderson technique was used to reattach the avulsed tendon to the radial tuberosity. Postoperatively, the patient’s arm was placed in a posterior splint for 9 days, then a hinged orthosis was used for an additional 2 weeks. By 3 months, she had regained full active flexion/extension and pronation/supination of the forearm symmetric to the opposite extremity. Manual muscle strength testing was 5/5 in elbow flexion and forearm supination. She subsequently returned to competitive ice dancing 4 months after injury.
CASE 2 A healthy 72-year-old, right-hand– dominant woman experienced a popping sensation about her right elbow while serving during recreational tennis. Pain, ecchymosis, and decreased range of motion immediately ensued. She denied any prior trauma or symptomatology of her right elbow before the injury. She was seen at our clinic 4 days after injury. Physical examination disclosed swelling and ecchymosis about the antecubital fossa. A palpable defect of the distal biceps in the anterior elbow region was present. Marked weakness in supination and elbow flexion compared with the contralateral upper extremity was noted. Magnetic resonance imaging of the affected elbow region confirmed a complete avulsion of the distal biceps tendon (Figures 1 and 2). The patient elected to pursue conservative treatment. Her arm was placed in an sling for comfort with gentle active-assisted range of motion exercises initiated at 2 weeks. After formal physical therapy, functional assessment of the distal biceps tendon revealed elbow flexion and forearm supination range of motion that was symmetric to the opposite extremity. There was no tender-
J Shoulder Elbow Surg Volume 11, Number 5
Figure 1 T1 weighted axial magnetic resonance image of the distal biceps tendon rupture at the level of the radial neck (RN). The brachialis tendon (BrT) is well seen as a low-signal structure superior to the ulna; there is no biceps tendon identified throughout its course to the radial tuberosity (Absent BiT).
Figure 2 Magnetic resonance image of the distal biceps tendon rupture at the level of radial tuberosity (RT) fails to demonstrate any biceps tendon (BiT). The brachialis tendon (BrT) continues to be a well-visualized low-signal structure.
ness about the biceps with palpation and no pain with normal muscle testing. Although the patient declined isokinetic strength assessment, she was able to return unencumbered to her prior level of recreational tennis activity at 16 weeks after injury.
DISCUSSION Complete rupture of the distal biceps tendon is a relatively rare injury, accounting for only 3% of all biceps brachii avulsions.2,10 Although partial ruptures of the distal biceps tendon have been described in both men and women previously in the literature, we could find no previous reports of complete rupture of the distal biceps tendon in women.4,28,31 Complete rupture is typically seen in the dominant extremity of male patients after an excessive eccentric contraction.1,8,12, 20 This injury occurs primarily during the fifth to seventh decades of life. The mean age at the time of reported rupture is 50 years, ranging from 18 to 72 years.* The 2 cases of complete distal biceps rupture presented involved women aged 58 and 72 years. Subjec* References 1,3,8,11,13,15,18,20-23,29,32.
Toczylowski et al
517
tively, they reported that a pop was felt in the affected extremity at the time of injury and both noted immediate deformity and weakness about the elbow. The injuries were sustained by their dominant extremity during vigorous athletic activities and in both cases followed an excessive eccentric contraction. Current literature supports early anatomic repair for complete distal biceps tendon rupture in young, active individuals, with conservative therapy reserved for the older individual and sedentary lifestyle.1,2,8,13,15,22,26,29,30 Although surgical repair has been shown to restore optimal function of the biceps, some studies have suggested that there is a minimal functional deficit associated with nonoperative treatment.7 This implies that some patients’ loss of strength and endurance provided by the biceps will not significantly affect their daily activity. Studies have shown that conservative management of distal biceps injuries can lead to significant strength deficits in flexion and supination. Morrey et al26 reported losses of up to 40% occurring in supination and 30% in flexion strength with conservative treatment. Baker and Bierwagen2 reported an even greater deficit for elbow flexion and supination endurance, with objective deficiencies estimated at 21% and 47%, respectively, with nonoperative management. Because no complete distal biceps tendon ruptures have previously been reported in female patients, it is interesting to note that ruptures of other major tendons are not exclusive to male patients. Caborn and Boyd5 reported an overall male-to-female ratio of 6:1 for quadriceps ruptures. Achilles tendon ruptures have been reported as a primarily male-dominant injury. Myerson27 reported that male patients outnumber female patients 30:1, somewhat higher than the ratio previously reported by Carden et al,6 ranging between 2:1 and 19:1 for Achilles ruptures. However, multiple authors have reported no statistically significant difference between gender and the prevalence of full or partial rotator cuff tears.19,24,33 In the future, the increased athletic pursuits of women early, as well as in the later years of life, may influence the reported incidence of major tendon injuries. There is generally a poor understanding of the pathogenesis of distal biceps ruptures. Predisposing factors that have been implicated in this injury include mechanical impingement, degenerative changes of the radial tuberosity, and hypovascularity of the tendon near its insertion.30 It is unknown whether these theoretical factors display a gender bias and whether they contribute to the prior unreported injury in female patients. One possible explanation for the male predominance of this injury may be based on the cross-sectional area of biceps brachii area in female patients versus male patients. Miller et al25 assessed biceps brachii muscle strength, cross-sectional area, and muscle type in men and women. They reported a significant correlation between strength and muscle crosssectional area. Specifically, women had a 45% smaller muscle cross-sectional area for the biceps brachii. This resulted in the women having only 52% of the strength of their male counterparts in elbow flexion. In addition, men had a significantly larger percentage of type I, fast-twitch fibers comprising their biceps brachii. The fact that men generally have a larger proportion of lean tissue distributed in their upper bodies may account for this gender difference in upper body strength. Davies et al9 studied gender differ-
518
Toczylowski et al
ences in handgrip strength. The female patients demonstrated strength that was only 60% of that in males, and they possessed only 61% of the males’ forearm muscle mass. Greater muscle force generated by the increased crosssectional area of muscle may be one consideration for the predominance of male patients with this injury. One of our two female patients was at the upper age limit of what is generally reported in male patients for this injury. Aging produces an array of degenerative changes affecting the structural integrity of a tendon. Specifically, greater cross-linking of the collagen fibers with further maturation produces a less compliant and stiffer tendon.17 Although the collagen content increases, there is speculation that diminished elasticity resulting from a relative decrease of the elastin and proteoglycan matrix predisposes to biceps injury. In addition to the reduction in glycosaminoglycan concentration, the total water content of collagen decreases nearly 50% throughout life.14,16 Collectively, these factors decrease a tendon’s effective resistance to a tensile load. In a study by Kannus and Jozsa,17 all biopsy specimens from 891 spontaneously ruptured tendons, including 302 biceps brachii tendon ruptures, had detectable pathological changes. The mean patient age for all tendon ruptures in this study was 49 ⫾ 9 years and that for biceps brachii ruptures was 63 ⫾ 8 years. The degenerative lesions included degenerative tendinopathy, mucoid degeneration, tendolipomatosis, and calcifying tendinopathy. Kannus and Jozsa reported degenerative tendinopathy as the most consistent finding in spontaneously ruptured tendons. Degeneration of the tendon can remain asymptomatic until the time of rupture. Although there was no prior trauma or prodrome of pain in the 2 active female patients presented, we are unable to exclude microscopic degenerative changes at the tendon insertion site that may have compromised tendon integrity. With a general increase in the level of activity and increased participation by females in athletic competition, we anticipate an increased frequency of distal biceps tendon ruptures in women in future years. Certainly, individual circumstances of age and anticipated activity level should be considered in the management of these patients. REFERENCES
1. Agins HJ, Chess JL, Hoekstra DV, et al. Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop 1988;234: 34-8. 2. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii: operative versus nonoperative treatment. J Bone Joint Surg Am 1985;67:414-7. 3. Boucher PR, Morton KS. Rupture of the distal biceps brachii tendon. J Trauma 1967;7:626-32. 4. Bourne MH, Morrey BF. Partial rupture of the distal biceps tendon. Clin Orthop 1991;271:143-8. 5. Caborn D, Boyd DW. Tendon ruptures. In: Fu FH, Harner CD, Vince KG, editors. Knee surgery. Baltimore: Williams and Wilkins; 1994. p. 911–925. 6. Carden DG, Noble J, Chalmers J, Lunn P, Ellis J. Rupture of the calcaneal tendon: the early and late management. J Bone Joint Surg Br 1987;69:416-20. 7. Carroll RE, Hamilton LR. Rupture of biceps brachii: a conservative method of treatment. J Bone Joint Surg Am 1967;49:1016. 8. D’Alessandro DF, Shields CL Jr, Tibone JE, et al. Repair of the
J Shoulder Elbow Surg September/October 2002
9.
10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33.
distal biceps tendon ruptures in athletes. Am J Sports Med 1993; 21:114-9. Davies BN, Greenwood EJ, Jones SR. Gender difference in the relationship of performance in the handgrip strength and standing long jump tests to lean limb volume in young adults. Eur J Appl Physiol 1993;66:254-62. DiChristina DG, Lustig KA. Rupture through the short head of the biceps muscle belly: a case report. Clin Orthop 1992;277:13941. Dobbie RP. Avulsion of the lower biceps brachii tendon: analysis of fifty-one previously unreported cases. Am J Surg 1941;51: 662-83. Foxworthy M, Kinninmonth AWG. Median nerve compression in the proximal forearm as a complication of partial rupture of the distal biceps brachii tendon. J Hand Surg [Br] 1992;17:515-7. Friedmann E. Rupture of the distal biceps brachii tendon: report on 13 cases. JAMA 1963;184:60-3. Hess GP, Cappiello WL, Poole RM, et al. Prevention and treatment of overuse tendon injuries. Sports Med 1989;8:371-84. Hovelius L, Jesefsson G. Rupture of the distal biceps tendon: report of five cases. Acta Orthop Scand 1977;48:280-2. Jozsa L, Lehto M, Kvist M, et al. Alterations in dry mass content of collagen fibers in degenerative tendinopathy and tendon-rupture. Matrix 1989;9:140-6. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg Am 1991;73:1507-25. Lee HG. Traumatic avulsion of tendon of insertion of biceps brachii. Am J Surg 1951;82:290-2. Lehman C, Cuomo F, Kummer FJ, et al. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Joint Dis 1995;54:30-1. Leighton MM, Bush-Joseph CA, Bach BR. Distal biceps brachii repair: results in dominant and nondominant extremities. Clin Orthop 1995;317:114-21. Lintner S, Fischer T. Repair of the distal biceps tendon using suture anchors and an anterior approach. Clin Orthop 1996;322: 116-9. Louis DS, Hankin FM, Eckenrode JF, et al. Distal biceps brachii tendon avulsion: a simplified method of operative repair. Am J Sports Med 1986;14:234-6. Meherin JM, Kilgore ES Jr. The treatment of ruptures of the distal biceps brachii tendon. Am J Surg 1960;99:636-40. Milgrom C, Schaffler M, Gilbert S, et al. Rotator cuff changes in asymptomatic adults: the effect of age, hand dominance and gender. J Bone Joint Surg Br 1995;77:296-8. Miller AE, Macdougall JD, Tarnopolsky MA, et al. Gender differences in strength and muscle fiber characteristics. Eur J Appl Physiol 1993;66:254-62. Morrey BF, Askew LJ, An KN, et al. Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg Am 1985;67:418-21. Myerson MS. Achilles tendon ruptures. Instr Course Lect 1999; 48:219-30. Nielsen K. Partial rupture of the distal biceps brachii tendon: a case report. Acta Orthop Scand 1987;58:287-8. Norman WH. Repair of avulsion of insertion of biceps brachii tendon. Clin Orthop 1985;193:189-94. Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg 1999;7:199-207. Rokito AS, McLaughlin JA, Gallagher MA, et al. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg 1996;5:73-5. Strauch RJ. Biceps and triceps injuries of the elbow. Orthop Clin North Am 1999;30:95-107. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-9.
C omplete rupture of the distal biceps tendon is an
uncommon injury, accounting for only 3% of all biceps brachii avulsions. The distal biceps typically ruptures in the dominant extremity of men between 40 and 60 years of age following an excessive eccentric contraction. Although this injury continues to be reported in the literature with increased frequency, complete rupture of the distal biceps in female patients is yet to be reported. We present 2 case reports of complete distal biceps tendon rupture in female patients. Both women, aged 58 and 72 years, were athletically active and sustained their injuries during sporting activities. Both surgical and nonoperative treatment were used in their care. Both patients subjectively considered their results excellent and returned unencumbered to their prior level of sporting activity by 16 weeks. We review these 2 cases of complete distal biceps rupture in female patients and consider the etiology of male dominance in this injury. We speculate that the increased level of activity and greater sports involvement of women at all ages will lead to an increased incidence in distal biceps tendon ruptures in female patients.
CASE 1 A 58-year-old, right-hand– dominant competitive ice dancer had an immediate onset of pain about the right elbow while being lowered to the ice in a normal manner during a practice routine. She described a snapping sensation with immediate onset of pain and weakness in her elbow. She reported no prior trauma or pain of the elbow region preceding her injury. She was evaluated 10 days after the injury, complaining of a deformity of the upper From the Sports Medicine Section, New England Baptist Hospital, Boston, Mass. Reprint requests: Henry M. Toczylowski, MD, 830 Boylston St, Chestnut Hill, MA 02467. J Shoulder Elbow Surg 2002;11:516 –18. Copyright © 2002 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2002/$35.00 ⫹ 0 32/4/126617 doi:10.1067/mse.2002.126617
516
arm, as well as continued pain, weakness, and ecchymosis about the elbow. Physical examination revealed a full arc of active flexion and extension with pain elicited at the terminal ends of motion. A significant deficit in supination strength and elbow flexion power was noted in comparison to the contralateral side. There was an obvious deformity of the distal biceps that was accentuated with active flexion of the elbow. Further examination revealed tenderness, swelling, extensive ecchymosis, and a soft-tissue defect just proximal to the antecubital fossa of the right upper extremity. Radiograph results were normal. Surgical exploration confirmed a complete avulsion of the distal biceps from the radial tuberosity. A standard 2-incision modified BoydAnderson technique was used to reattach the avulsed tendon to the radial tuberosity. Postoperatively, the patient’s arm was placed in a posterior splint for 9 days, then a hinged orthosis was used for an additional 2 weeks. By 3 months, she had regained full active flexion/extension and pronation/supination of the forearm symmetric to the opposite extremity. Manual muscle strength testing was 5/5 in elbow flexion and forearm supination. She subsequently returned to competitive ice dancing 4 months after injury.
CASE 2 A healthy 72-year-old, right-hand– dominant woman experienced a popping sensation about her right elbow while serving during recreational tennis. Pain, ecchymosis, and decreased range of motion immediately ensued. She denied any prior trauma or symptomatology of her right elbow before the injury. She was seen at our clinic 4 days after injury. Physical examination disclosed swelling and ecchymosis about the antecubital fossa. A palpable defect of the distal biceps in the anterior elbow region was present. Marked weakness in supination and elbow flexion compared with the contralateral upper extremity was noted. Magnetic resonance imaging of the affected elbow region confirmed a complete avulsion of the distal biceps tendon (Figures 1 and 2). The patient elected to pursue conservative treatment. Her arm was placed in an sling for comfort with gentle active-assisted range of motion exercises initiated at 2 weeks. After formal physical therapy, functional assessment of the distal biceps tendon revealed elbow flexion and forearm supination range of motion that was symmetric to the opposite extremity. There was no tender-
J Shoulder Elbow Surg Volume 11, Number 5
Figure 1 T1 weighted axial magnetic resonance image of the distal biceps tendon rupture at the level of the radial neck (RN). The brachialis tendon (BrT) is well seen as a low-signal structure superior to the ulna; there is no biceps tendon identified throughout its course to the radial tuberosity (Absent BiT).
Figure 2 Magnetic resonance image of the distal biceps tendon rupture at the level of radial tuberosity (RT) fails to demonstrate any biceps tendon (BiT). The brachialis tendon (BrT) continues to be a well-visualized low-signal structure.
ness about the biceps with palpation and no pain with normal muscle testing. Although the patient declined isokinetic strength assessment, she was able to return unencumbered to her prior level of recreational tennis activity at 16 weeks after injury.
DISCUSSION Complete rupture of the distal biceps tendon is a relatively rare injury, accounting for only 3% of all biceps brachii avulsions.2,10 Although partial ruptures of the distal biceps tendon have been described in both men and women previously in the literature, we could find no previous reports of complete rupture of the distal biceps tendon in women.4,28,31 Complete rupture is typically seen in the dominant extremity of male patients after an excessive eccentric contraction.1,8,12, 20 This injury occurs primarily during the fifth to seventh decades of life. The mean age at the time of reported rupture is 50 years, ranging from 18 to 72 years.* The 2 cases of complete distal biceps rupture presented involved women aged 58 and 72 years. Subjec* References 1,3,8,11,13,15,18,20-23,29,32.
Toczylowski et al
517
tively, they reported that a pop was felt in the affected extremity at the time of injury and both noted immediate deformity and weakness about the elbow. The injuries were sustained by their dominant extremity during vigorous athletic activities and in both cases followed an excessive eccentric contraction. Current literature supports early anatomic repair for complete distal biceps tendon rupture in young, active individuals, with conservative therapy reserved for the older individual and sedentary lifestyle.1,2,8,13,15,22,26,29,30 Although surgical repair has been shown to restore optimal function of the biceps, some studies have suggested that there is a minimal functional deficit associated with nonoperative treatment.7 This implies that some patients’ loss of strength and endurance provided by the biceps will not significantly affect their daily activity. Studies have shown that conservative management of distal biceps injuries can lead to significant strength deficits in flexion and supination. Morrey et al26 reported losses of up to 40% occurring in supination and 30% in flexion strength with conservative treatment. Baker and Bierwagen2 reported an even greater deficit for elbow flexion and supination endurance, with objective deficiencies estimated at 21% and 47%, respectively, with nonoperative management. Because no complete distal biceps tendon ruptures have previously been reported in female patients, it is interesting to note that ruptures of other major tendons are not exclusive to male patients. Caborn and Boyd5 reported an overall male-to-female ratio of 6:1 for quadriceps ruptures. Achilles tendon ruptures have been reported as a primarily male-dominant injury. Myerson27 reported that male patients outnumber female patients 30:1, somewhat higher than the ratio previously reported by Carden et al,6 ranging between 2:1 and 19:1 for Achilles ruptures. However, multiple authors have reported no statistically significant difference between gender and the prevalence of full or partial rotator cuff tears.19,24,33 In the future, the increased athletic pursuits of women early, as well as in the later years of life, may influence the reported incidence of major tendon injuries. There is generally a poor understanding of the pathogenesis of distal biceps ruptures. Predisposing factors that have been implicated in this injury include mechanical impingement, degenerative changes of the radial tuberosity, and hypovascularity of the tendon near its insertion.30 It is unknown whether these theoretical factors display a gender bias and whether they contribute to the prior unreported injury in female patients. One possible explanation for the male predominance of this injury may be based on the cross-sectional area of biceps brachii area in female patients versus male patients. Miller et al25 assessed biceps brachii muscle strength, cross-sectional area, and muscle type in men and women. They reported a significant correlation between strength and muscle crosssectional area. Specifically, women had a 45% smaller muscle cross-sectional area for the biceps brachii. This resulted in the women having only 52% of the strength of their male counterparts in elbow flexion. In addition, men had a significantly larger percentage of type I, fast-twitch fibers comprising their biceps brachii. The fact that men generally have a larger proportion of lean tissue distributed in their upper bodies may account for this gender difference in upper body strength. Davies et al9 studied gender differ-
518
Toczylowski et al
ences in handgrip strength. The female patients demonstrated strength that was only 60% of that in males, and they possessed only 61% of the males’ forearm muscle mass. Greater muscle force generated by the increased crosssectional area of muscle may be one consideration for the predominance of male patients with this injury. One of our two female patients was at the upper age limit of what is generally reported in male patients for this injury. Aging produces an array of degenerative changes affecting the structural integrity of a tendon. Specifically, greater cross-linking of the collagen fibers with further maturation produces a less compliant and stiffer tendon.17 Although the collagen content increases, there is speculation that diminished elasticity resulting from a relative decrease of the elastin and proteoglycan matrix predisposes to biceps injury. In addition to the reduction in glycosaminoglycan concentration, the total water content of collagen decreases nearly 50% throughout life.14,16 Collectively, these factors decrease a tendon’s effective resistance to a tensile load. In a study by Kannus and Jozsa,17 all biopsy specimens from 891 spontaneously ruptured tendons, including 302 biceps brachii tendon ruptures, had detectable pathological changes. The mean patient age for all tendon ruptures in this study was 49 ⫾ 9 years and that for biceps brachii ruptures was 63 ⫾ 8 years. The degenerative lesions included degenerative tendinopathy, mucoid degeneration, tendolipomatosis, and calcifying tendinopathy. Kannus and Jozsa reported degenerative tendinopathy as the most consistent finding in spontaneously ruptured tendons. Degeneration of the tendon can remain asymptomatic until the time of rupture. Although there was no prior trauma or prodrome of pain in the 2 active female patients presented, we are unable to exclude microscopic degenerative changes at the tendon insertion site that may have compromised tendon integrity. With a general increase in the level of activity and increased participation by females in athletic competition, we anticipate an increased frequency of distal biceps tendon ruptures in women in future years. Certainly, individual circumstances of age and anticipated activity level should be considered in the management of these patients. REFERENCES
1. Agins HJ, Chess JL, Hoekstra DV, et al. Rupture of the distal insertion of the biceps brachii tendon. Clin Orthop 1988;234: 34-8. 2. Baker BE, Bierwagen D. Rupture of the distal tendon of the biceps brachii: operative versus nonoperative treatment. J Bone Joint Surg Am 1985;67:414-7. 3. Boucher PR, Morton KS. Rupture of the distal biceps brachii tendon. J Trauma 1967;7:626-32. 4. Bourne MH, Morrey BF. Partial rupture of the distal biceps tendon. Clin Orthop 1991;271:143-8. 5. Caborn D, Boyd DW. Tendon ruptures. In: Fu FH, Harner CD, Vince KG, editors. Knee surgery. Baltimore: Williams and Wilkins; 1994. p. 911–925. 6. Carden DG, Noble J, Chalmers J, Lunn P, Ellis J. Rupture of the calcaneal tendon: the early and late management. J Bone Joint Surg Br 1987;69:416-20. 7. Carroll RE, Hamilton LR. Rupture of biceps brachii: a conservative method of treatment. J Bone Joint Surg Am 1967;49:1016. 8. D’Alessandro DF, Shields CL Jr, Tibone JE, et al. Repair of the
J Shoulder Elbow Surg September/October 2002
9.
10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33.
distal biceps tendon ruptures in athletes. Am J Sports Med 1993; 21:114-9. Davies BN, Greenwood EJ, Jones SR. Gender difference in the relationship of performance in the handgrip strength and standing long jump tests to lean limb volume in young adults. Eur J Appl Physiol 1993;66:254-62. DiChristina DG, Lustig KA. Rupture through the short head of the biceps muscle belly: a case report. Clin Orthop 1992;277:13941. Dobbie RP. Avulsion of the lower biceps brachii tendon: analysis of fifty-one previously unreported cases. Am J Surg 1941;51: 662-83. Foxworthy M, Kinninmonth AWG. Median nerve compression in the proximal forearm as a complication of partial rupture of the distal biceps brachii tendon. J Hand Surg [Br] 1992;17:515-7. Friedmann E. Rupture of the distal biceps brachii tendon: report on 13 cases. JAMA 1963;184:60-3. Hess GP, Cappiello WL, Poole RM, et al. Prevention and treatment of overuse tendon injuries. Sports Med 1989;8:371-84. Hovelius L, Jesefsson G. Rupture of the distal biceps tendon: report of five cases. Acta Orthop Scand 1977;48:280-2. Jozsa L, Lehto M, Kvist M, et al. Alterations in dry mass content of collagen fibers in degenerative tendinopathy and tendon-rupture. Matrix 1989;9:140-6. Kannus P, Jozsa L. Histopathological changes preceding spontaneous rupture of a tendon: a controlled study of 891 patients. J Bone Joint Surg Am 1991;73:1507-25. Lee HG. Traumatic avulsion of tendon of insertion of biceps brachii. Am J Surg 1951;82:290-2. Lehman C, Cuomo F, Kummer FJ, et al. The incidence of full thickness rotator cuff tears in a large cadaveric population. Bull Hosp Joint Dis 1995;54:30-1. Leighton MM, Bush-Joseph CA, Bach BR. Distal biceps brachii repair: results in dominant and nondominant extremities. Clin Orthop 1995;317:114-21. Lintner S, Fischer T. Repair of the distal biceps tendon using suture anchors and an anterior approach. Clin Orthop 1996;322: 116-9. Louis DS, Hankin FM, Eckenrode JF, et al. Distal biceps brachii tendon avulsion: a simplified method of operative repair. Am J Sports Med 1986;14:234-6. Meherin JM, Kilgore ES Jr. The treatment of ruptures of the distal biceps brachii tendon. Am J Surg 1960;99:636-40. Milgrom C, Schaffler M, Gilbert S, et al. Rotator cuff changes in asymptomatic adults: the effect of age, hand dominance and gender. J Bone Joint Surg Br 1995;77:296-8. Miller AE, Macdougall JD, Tarnopolsky MA, et al. Gender differences in strength and muscle fiber characteristics. Eur J Appl Physiol 1993;66:254-62. Morrey BF, Askew LJ, An KN, et al. Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg Am 1985;67:418-21. Myerson MS. Achilles tendon ruptures. Instr Course Lect 1999; 48:219-30. Nielsen K. Partial rupture of the distal biceps brachii tendon: a case report. Acta Orthop Scand 1987;58:287-8. Norman WH. Repair of avulsion of insertion of biceps brachii tendon. Clin Orthop 1985;193:189-94. Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg 1999;7:199-207. Rokito AS, McLaughlin JA, Gallagher MA, et al. Partial rupture of the distal biceps tendon. J Shoulder Elbow Surg 1996;5:73-5. Strauch RJ. Biceps and triceps injuries of the elbow. Orthop Clin North Am 1999;30:95-107. Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 1999;8:296-9.