I was going to name this article “Quads vs. Biceps, who will win? Hint: there can only be one!” in honor of how I got my injury, but decided for a less cheesy approach. I still found it clever (even though it was very scary at the time), so I decided to have it in my opener. Given my personal connection to this blog, I’m first going to give you my story before diving into the anatomy/rehabilitation of muscle tears in the arm.
My story of how I injured all 3 muscles is as follows: while holding the pads and bracing for a low kick, I decided not to rest my arms on my leg (a mistake) and brace for impact, but instead hold my arms out in the air like I was bumping a volleyball. I’m strong enough for it, I thought. It took only a few kicks before the final one broke the camel’s back. The last kick was very intense, I didn't hear a pop in my elbow (as it was pretty loud in the gym) but had intense burning pain, saw my outer biceps muscles spasm and twitch repeatedly. I immediately placed my arm on my chest, bracing with the other one, and called it. I used my shirt as a sling while I walked home, contemplating if I should go to the hospital for imaging so they can rule out a complete Gr3 tear. Being a Physio, I of course palpated and felt through both my upper and lower arm to see if there were any muscle balls or loose tendons (indicating a Gr3 tear which in most likelihood would require surgery). Luckily, I didn’t, but fear set in knowing that an injury like this can take months to heal, even when non-surgical, and if in fact I was correct it is not a Gr 3. I decided to give it a night, PRICE it when I got home (Protect, Rest, Compress, Ice and Elevate), sleep with the sling (yes, used a t-shirt) while being very careful not to extend the elbow. I wanted to see how it looked in the morning, and if there were going to be any bruising, swelling, craters in the muscle bellies, or tendon retractions before I decide on my next step (i.e. going to the hospital).
Hindsight is always 20/20, blaming myself for the injury as I, out of all people (being a Physio), should know better. I knew it would definitely get in the way of my training and work – awful feeling, lots of worry and anxiety and even though being a Physio, with the knowledge/training that I have + means to rehabilitate it, I still felt unsure and almost convinced myself of a worst-case scenario. In hindsight, even though I should have done better to prevent it, I don’t regret going through this. It is a humbling experience, as I treat clients with similar injuries, reminding me of how it is being so worried, fearful and anxious when an injury like this occurs that can, at times, turn one’s world upside down. If I felt all these things, while having the knowledge and training to know what it is and how to make it better, then how do my clients feel with similar injuries who don’t have all this and count on me and my team to make them whole again. The psychology behind one’s injury is real and intense, and not to be overlooked in the treatment room with clients. I have always been mindful of this; however, now more than ever as I’ve never experienced such an injury like this before – really eye opening.
In summary, it ended up being a Gr2 tear (still waiting on imaging, suspecting it’s all 3 elbow flexors), will take some time to rehabilitate but making progress. After almost 3 weeks since I injured it, I’m able to curl 3lbs dumbbells (10 reps x 2 sets) with minimal to no pain, giving me hope. Note, I used to be able to curl 50lbs, so I have a long way to go but I’m sure in a few months, I’ll be back close to it. I’m not going to rush it or try to be the hero I once thought I was, and given I’m 38, I’ve accepted the fact that I won’t bounce back as if I was 28. I’m myself seeing Tim Fung at VanCity Physio, and even though being a Physio myself, it really helped having him help me rehabilitate my arm – I highly recommend him.
So that’s my story guys – hope you enjoyed it and hopefully it gave you some direction as to what to do in certain situations. Now, for the fun stuff and as promised, below is more info about what muscle/tendon tears are, what they look like and what can be done about it.
BICEPS TENDON TEAR AT THE ELBOW
The biceps muscle is located in the front of your upper arm. It is attached to the bones of the shoulder and elbow by tendons — strong cords of fibrous tissue that attach muscles to bones.
Gr 3 (complete) tears of the biceps tendon at the elbow are uncommon, occurring in only 3 to 5 people per 100,000 each year, and rarely in women. These tears are most often caused by a sudden injury and tend to result in greater arm weakness than injuries to the biceps tendon at the shoulder. Once torn off, the biceps tendon at the elbow will not grow back to the bone and heal. Other arm muscles make it possible to bend the elbow fairly well without the biceps tendon. However, they cannot fulfill all the functions of the elbow, especially the motion of rotating the forearm from palm down to palm up. This motion is called supination and is important for power gripping activities. To return arm strength to near normal levels, your surgeon may offer surgery to repair the torn tendon. However, nonsurgical treatment is a reasonable option for patients who may not require full arm function, or who cannot make time for the rehabilitation required after surgery.
Gr 2 (partial) tears of the biceps tendon at the elbow are more common, and take anywhere between 6-8 weeks to heal with adequate rest and Physio rehabilitation.
The biceps muscle has two tendons that attach the muscle to the shoulder and one tendon that attaches at the elbow. The tendon at the elbow is called the distal biceps tendon. It attaches to a part of the radius bone called the radial tuberosity, a small bump on the bone near your elbow joint. The biceps muscle helps you bend and rotate your arm. It attaches at the elbow to a small bump on the radius bone called the radial tuberosity.
Biceps tendon tears can be either partial (Gr 2) or complete (Gr 3).
- Partial tears. These tears damage the soft tissue but do not completely sever the tendon. In most cases, superficial muscle fibers are torn but do grow back as healing takes place.
- Complete tears. A complete tear will detach the tendon completely from its attachment point at the bone. This means that the entire muscle is detached from the bone and pulled toward the shoulder, resulting in a ball being formed mid arm. Other arm muscles can compensate for the injured tendon, usually resulting in full motion and reasonable function. Left without surgical repair, however, the injured arm will have a 30 to 40% decrease in strength, mainly in twisting the forearm (supination).
The main cause of a distal biceps tendon tear is a sudden injury, especially eccentric loading (i.e. muscle resistance against lengthening). These tears are rarely associated with other medical conditions.
Injuries to the biceps tendon at the elbow usually occur when the elbow is forced straight against resistance. It is less common to injure this tendon when the elbow is forcibly bent against a heavy load.
Preventing a heavy box from falling is a good example. Perhaps you brace for it without realizing how much it weighs. You strain your biceps muscles and tendons trying to keep your arms bent, but the weight is too much and forces your arms straight suddenly. As you struggle, the stress on your biceps increases and the tendon tears away from the bone.
- Men aged 30 years or older, are most likely to tear the distal biceps tendon.
- Additional risk factors for distal biceps tendon tear include:
- Smoking. Nicotine use can affect tendon strength and quality.
- Corticosteroid and anabolic steroid medications. These drugs have been linked to muscle and tendon weakness.
- Over training, not giving body enough time to heal between training session
A distal biceps tendon tear (Gr3) can cause the muscle to ball up near the shoulder. Bruising at the elbow is also common.
There is often a pop at the elbow when the tendon ruptures. Pain is severe at first, but may subside after a week or two. Other symptoms include:
- Swelling in the front of the elbow
- Visible bruising in the elbow and forearm
- Weakness in bending of the elbow
- Weakness in twisting the forearm (supination)
- A bulge in the upper part of the arm created by the recoiled, shortened biceps muscle
- A gap in the front of the elbow created by the absence of the tendon
After discussing your symptoms and how the injury occurred, your doctor or physiotherapist will examine your elbow. During the physical examination, your doctor or physiotherapist will:
- Feel the front of your elbow, looking for a gap in the tendon.
- Test the supination strength of your forearm by asking you to rotate your forearm against resistance.
- Compare the supination strength to the strength of your opposite, uninjured forearm.
In addition to the examination, your doctor or physiotherapist that refers you to see a doctor, may recommend imaging tests to help confirm a diagnosis.
- X-rays. Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause elbow pain.
- Ultrasound. This imaging technique can show the free end of the biceps tendon that has recoiled up in the arm.
- Magnetic resonance imaging (MRI). MRI scans create better images of soft tissues than X-rays. They can show both partial and complete tears of the biceps tendon.
When the diagnosis of a distal biceps tendon tear is obvious on examination, your doctor may not order an ultrasound or MRI scan.
Treatment for Gr 1-2 (partial) tear of biceps
- VANCITY PHYSIO + Rehabilitation (in most cases, no surgery is needed and recovery is pretty good within 2-3 months.
Treatment for Gr 3 (complete) tear of biceps.
- Orthopedic Intervention + VANCITY PHYSIO + Rehabilitation
- Surgery may or may not be needed/decided for.
Nonsurgical treatment may be considered:
- If you are older and less active
- If the injury occurred in your non-dominant arm and you can tolerate not having full arm function
- If you have medical problems that put you at higher risk for complications during surgery
- If you cannot make time for the rehabilitation required after surgery
Nonsurgical treatment focuses on relieving pain and maintaining as much arm function as possible. Treatment recommendations may include:
- Rest. Avoid heavy lifting and overhead activities to relieve pain and limit swelling. Your doctor may recommend using a sling for a brief time.
- Anti-inflammatory drugs like ibuprofen and naproxen reduce pain and swelling.
- Physical therapy. After the pain decreases, your doctor may recommend rehabilitation exercises to strengthen surrounding muscles and help restore as much movement and function as possible.
Surgery to repair the tendon should be performed during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten, and it may not be possible to restore arm function with surgery. While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.
Procedure. There are several different procedures to reattach the distal biceps tendon to the forearm bone. Some doctors prefer to use one incision at the front (inside) of the elbow, while others use small incisions at both the front and back (outside) of the elbow.
One method for reattaching the tendon is through a single incision at the front (inside) of the elbow.
A common surgical option is to attach the tendon with stitches through holes drilled in the radius bone. Another method is to attach the tendon to the bone using small metal implants (called suture anchors or buttons).
There are pros and cons to each approach.
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