Diagnosis and Rehabilitation of Distal Biceps Tendon Partial Tear and Bursitis Complicated With Cervical Nerve Root Impingement

by | Nov 10, 2023 | Blog

Diagnosis and Rehabilitation of Distal Biceps Tendon Partial Tear and Bursitis Complicated With Cervical Nerve Root Impingement: A Case Report with Diagnostic Ultrasound and MRI Validation.

John L. Pape, PT, ScD1, Jean-Michel Brismée, PT, ScD2,3

1Department of Physiotherapy, University Hospital of North Tees, Stockton on Tees, United Kingdom; 2International Academy of Orthopedic Medicine-US, Anchorage, AK; 3Texas Tech University Health Sciences Center, Center for Rehabilitation Research, Lubbock, TX, USA.

The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article.

Address correspondence to John Pape, 1Department of Physiotherapy, University Hospital of North Tees, Stockton on Tees, United Kingdom. Email: john.pape@nhs.net

ABSTRACT

Case Description: A 60-year-old male with antecubital pain radiating into the forearm, neck pain, and upper limb paraesthesia was evaluated using clinical examination, musculoskeletal ultrasound (MUS), Magnetic Resonance Imaging (MRI) and received conservative treatment weekly for six weeks. Treatment targeted local structures with biceps stretching and eccentric exercises, and treatments for the cervical and thoracic spine, behavioural modification.

Outcome and Follow-up: The patient’s elbow pain decreased from 7/10 to 3/10 at four months and 1/10 at one year follow-up. The upper extremity functional index -15 (UEFI 15) improved from 59.4 to 72.9 at four months and 82.3 at one year.

Discussion: Diagnosis of distal biceps partial tendon injuries and bicipital bursitis can be difficult. These structures can be visualised on MUS from a posterior aspect. Conservative management for distal biceps injuries can be beneficial.

KEYWORDS: distal biceps partial tear, Bicipital Bursitis, Radial Tuberosity, Elbow, Rehabilitation.

BACKGROUND: Distal biceps tendon ruptures at the radial tuberosity insertion are infrequent, comprising only 3% of all biceps tendon ruptures. They are less common than proximal long head of biceps tears1. They typically occur in the dominant arm of middle-aged males after an eccentric extension load is applied2. Detection of complete distal biceps rupture is relatively clear cut with the presence of deformity, a positive hook3, and biceps squeeze4 tests. However, with more subtle objective findings, diagnosis of partial tears can be more difficult and is frequently delayed5. The true incidence of partial thickness tears of the distal biceps is unknown as many cases are not formally evaluated5, especially when findings are clouded with contributions from other musculoskeletal conditions such as peripheral nerve and cervical nerve root impingement.

 CASE PRESENTATION

The patient is a 60 y/o right hand dominant physiotherapist and certified fly-casting instructor and guide complaining of neck pain radiating to the right shoulder and scapula, right anterior elbow pain, with burning pain in the dorsal forearm, and paraesthesia in the dorsal hand, 1st second and 3rd digits.

The patient had a longstanding occasional neck ache. Six months previously, the patient felt and heard a pop in the anterior cubital area while performing a manual muscle test on a patient with a bodybuilding background. There was instant discomfort in the anterior cubital area that subsequently worsened, with radiation to the forearm, intermittent paraesthesia in the dorsal hand, and radial three digits. These symptoms were aggravated by activities that required resisted elbow flexion and supination. Right-sided neck and trapezius pain developed some days later. He could not continue his training and eventually stopped fly fishing altogether.

The patient had attempted self-treatment with acupuncture, stretching, self-friction massage, and neural mobilization. However, there were multiple exacerbations of symptoms following resisted elbow flexion activities at work, with a severe exacerbation on assisting an elderly patient with Parkinson’s disease down four flights of stairs. Subsequently, arm activities involving elbow flexion led to increased symptoms throughout the upper extremity, especially in the forearm and hand. Sleep was disturbed every night with pain and paraesthesia. The patient sought a review from a physiotherapist colleague. Pain was verbally reported as 9/10, upper extremity functional index -15 (UEFI-15)6 score = 53.0. On examination, there was some reduced muscle mass in the right forearm. Painfully reduced extension and right rotation of the neck. Right elbow resisted flexion, and supination was painfully reduced. Spurling’s test and tests for adverse mechanical tension in the nervous system were mildly positive for pain and paraesthesia in the right upper extremity. Although squeeze and hook tests were negative, suggesting an intact biceps tendon3,4, the examiner’s index finger was able to penetrate to a much greater depth behind the right biceps tendon, and the tendon appeared to be thinner in its anterior-posterior diameter, suggesting a partial rupture. A TILT sign for the distal biceps tendon partial rupture was positive7. A cervical nerve root impingement and partial biceps tendon rupture was diagnosed. Treatment comprised of continuation of his previous self-treatment program and a trial of dorso-ventral mobilisations applied to C7 on C6, which gave relief to neck and trapezius pain without change of elbow/ distal arm/ hand symptoms.

As the condition had been ongoing for some months with recurrent exacerbations and signs of both cervical nerve root and distal biceps tendon partial rupture, a Magnetic Resonance Imaging (MRI) scan of the cervical spine and Musculoskeletal Ultrasound (MUS) scan of the right elbow were requested. MUS of the right elbow from the anterior aspect reported the distal biceps brachii tendon appeared normal and intact, no obvious fluid collection, no radial nerve pathology. However, on viewing the images, there appeared to be signs of tendinopathy and fluid with possible bursitis (Figure 1). MRI of the cervical spine demonstrated multilevel degeneration with broad-based disc/ osteophytic bars just extending into the spinal canal, ligamentous buckling/ osteophytes posteriorly, minimally narrowing the spinal canal.

Symptoms continued for some weeks, and the patient was seen in the clinic for a second opinion.

There was a kyphotic, forward shoulder posture. Cervical extension, right rotation, and right and left lateral flexion were provocative of the forearm burning paraesthesia. Spurling’s on the right was mildly provocative of the forearm and radial hand paraesthesia. The right first rib was elevated, hypomobile, and mildly provocative of forearm symptoms. Elbow PROM was full and pain-free.

Resisted elbow flexion was painfully reduced in neutral, supination, and pronation, with the greatest pain in pronation. Muscle power in wrist extension and finger extensors was reduced. Reflexes and light touch sensation were intact. There was tenderness over the distal biceps tendon, from the anterior aspect, radial and deep to the bicipital aponeurosis, between the brachioradialis and pronator teres muscles and posteriorly in pronation at the biceps tendon insertion at the radial tuberosity. There was also tenderness over the radial tunnel. Pain was reported as 7/10, UEFI-15=59.4. The clinical impression was of biceps bursitis with a double crush involving cervical nerve root impingement, thoracic outlet syndrome, and radial nerve impingement/ supinator syndrome. With the significant pain on resisted elbow flexion in all 3 positions and the mechanism of injury partial rupture of distal biceps tendon could not be ruled out. Bicipital bursitis is an indication for corticosteroid injection therapy8,9. However, with the continued suspicion of a partial rupture, MUS of the right distal biceps was carried out in our clinic. Images from the posterior aspect of the upper forearm in pronation showed signs of distal biceps bursitis and a partial tear of the biceps tendon (Figure 2). Subsequent MRI of the right elbow reports marked abnormality in the distal biceps leading up to and including the attachment at the radial tuberosity with extensive oedema and thickening. The extent and intensity of the oedema suggest a partial tear of the distal biceps tendon. Fluid around the distal biceps is suggestive of coexisting bicipital bursitis. OA changes of mild severity were noted in the radiocapitellar joint (Figure 3).

As the bicipital bursa surrounds the distal biceps tendon, the bursal wall is indistinguishable from the tendon paratenon, with implications for tendinosis of the distal biceps tendon. Biceps tendon degeneration due to bursitis on its own may be an indication for surgery10. With the possibility of a partial rupture, ongoing symptoms, and concerns for further degeneration, the possibility of a tendon repair was discussed with an upper limb orthopaedic consultant. Tendon repair would involve a tendon graft, frequently complete separation, then reattachment of the tendon to the radial tuberosity10, and extensive rehab. In this instance, the patient elected for continued self-management.

REHABILITATION TREATMENT

Management for this patient involved multiple components, including postural elements with switching from using varifocals to office glasses for computer work, work station modification, including the provision of a sit-to-stand desk—local cervical extension with a Deni roll. Thoracic extension stretches and extensor strengthening. Behavioural modification with learning to fly cast with the left hand. Proximal treatments with neural flossing for both thoracic outlet and radial nerve and local treatment with soft tissue mobilisation, biceps stretching, and progression through isometric, concentric to eccentric loading exercises for the biceps.

 OUTCOMES

At four months, the patient was managing light resistance activities for his biceps. Pain and paraesthesia were reduced and no longer disturbing his sleep. He had returned to fly fishing using light equipment and alternating hands. Pain was reported as 3/10, UEFI-15=72.9.

At one year, he had returned to distance fly casting with his right hand using a slight modification of his casting stroke and was considering a return to training for competition distance casting. There was some overall loss of muscle power on resisted flexion and supination. He was working normally except for guarding his right biceps in resisted activities, with only occasional right anterior elbow aching following repeated resisted biceps loading activities. Pain was reported as 1/10, UEFI-15=82.3

 DISCUSSION

Distal biceps tendon ruptures at the radial tuberosity insert are infrequent, comprising only 3% of all biceps tendon ruptures1. Typically involves a tearing from its attachment at the radial tuberosity, occurring in middle aged males after an eccentric extension load is applied. Patients usually complain of a sudden, sharp popping, and painful tearing sensation in the antecubital region. In comparison to complete ruptures given the subtle symptoms and clinical findings, the diagnosis of partial rupture of the distal biceps tendon is difficult to make2 and frequently delayed or missed altogether5,11. As the bursa surrounds the distal biceps tendon, the wall of the bursa can be indistinguishable from the tendon paratenon and bicipital bursitis, tendinosis and partial tendon rupture can coexist and be impossible to distinguish clinically10,12. It is difficult to establish a cause-and-effect relationship10. Although Shim and Strauch claim the TILT sign is 100% sensitive for diagnosing partial distal biceps ruptures. The authors do admit that other sources of inflammation in the region of the radial tuberosity such as biceps tendinosis or bicipital bursitis could also give a positive TILT sign7. Thus limiting its specificity for partial rupture, especially as several authors have previously stated tenderness over the radial tuberosity palpated in pronation can be attributed to bicipital bursitis8,9. The bicipital bursa is compressed against the radius in pronation13.   Thus, bicipital bursitis would be expected to be more provocative on resisted elbow flexion in pronation than supination9. However, a sensitivity and specificity of 100% for distal biceps tendon pathology with increased pain on resisted elbow flex in pronation compared to resisted elbow flexion in supination has also been reported14. This was attributed to the abraded portion of the tendon being compressed against the radial tuberosity11,14. In this patient, significant pain on both resisted supination and pronation was felt to be suggestive of a partial tendon tear as well as bursitis.

MRI is frequently obtained for suspected partial tears of the distal biceps tendon. Although 100% specificity for partial rupture detection has been described, sensitivity has been shown to be only 59.1%, suggesting a risk of missed diagnoses15. For MUS viewing the bicipital bursa and distal biceps insertion into the radial tuberosity from the posterior aspect appeared to provide more information than from the anterior aspect. This would suggest a sensible alternative method of viewing these lesions especially when bony land mark guided injections for bicipital bursitis are carried out from the posterior aspect8,9.

There is a dearth of data on Outcomes for conservative therapy for partial tears of the distal biceps tendon5. Many authors recommend rest/avoidance of provocative activities post-injury 5,14. With this patient’s delay in seeking a review for his condition and in many other cases of delayed diagnosis, what may be the important early stage of protection from further injury and promotion of healing was missed, allowing the condition to become chronic. However, only 5% of patients with partial ruptures of the distal biceps tendon initially treated conservatively progressed to complete ruptures, the majority occurring within 3 months following diagnosis5. However, a large number of patients with partial tears initially treated conservatively will go on to have a surgical repair within 1 year of the injury5. The major indicator for surgical repair was weakness in supination, other indicators being a popping sensation at the time of injury, young age, tenderness over the biceps tendon, and a manual occupation. The patient did have several of these indicators for surgery and may have considered a surgical option early on in his condition. However, opting for conservative therapy, he had a satisfactory outcome. Some of this may, in part, be attributable to the treatment of components arising from his cervical spine and peripheral nerves as well as the treatment targeted at his biceps.

PATIENT PERSPECTIVE

The final impression of the patient was one of satisfaction with the conservative care he received and his outcome. However, he regretted trying to work through his injury and not taking some time off work to allow healing to occur and also not seeking an assessment and imaging at an earlier stage. His concern was the residual weakness and that the biceps tendon may progress to a full tear in the future. A non-conservative intervention may have been considered if he was aware of the full nature of his injury at an early stage.

LEARNING POINTS

  • Distal bicipital tendon tears are difficult to diagnose and differentiate from bicipital bursitis
  • With only a 59.1% sensitivity for a partial tear detection on MRI, a suspicion of a partial tear should be maintained even in the presence of negative imaging.
  • MUS scanning from the posterior aspect of the upper forearm may be an alternative method for viewing distal bicipital tendon tears and bicipital bursitis.
  • Early recognition is necessary for optimal outcomes.
  • Conservative care can lead to satisfactory outcomes in distal biceps tendon partial tears.

REFERENCES

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  7. Shim SS, Strauch RJ. A novel clinical test for partial tears of the distal biceps brachii tendon: The TILT sign. 2018; 31: 301-303.
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Figures

Figure 1: MUS Right distal bicipital tendon from anterior approach, forearm in supination – reported as showing normal appearance and intact with no obvious fluid collection, however on viewing there are some appearances of tendinopathy ( green arrows ) and fluid collection ( yellow arrows ).

Figure 2: US of Right distal bicipital tendon from the posterior approach showing bicipital tendon (BT) its attachment to the Radial Tuberosity (RT) and underlying bicipital bursa that appears enlarged with apparent disruption of the bicipital tendon (yellow arrow).

Figure 3: Right Elbow MRI, T2 sagittal view showing radial tuberosity (RT) and underlying bicipital bursa (yellow arrow).