Long Head Biceps Tendon Rupture

History: sudden audible or palpable snap during a trivial lifting or reaching task, with transient sharp anterior shoulder pain. Often a preceding history of chronic anterior shoulder pain or known cuff disease. Pain commonly improves after the rupture; bruising may track distally down the arm over 24-72 hours.

Examination:

• •Standard Popeye deformity: distal bulge of the biceps muscle belly in the mid-upper arm. Accentuated by resisted elbow flexion with active supination. Contrast with the reverse Popeye of distal biceps rupture, where the muscle retracts proximally
• •The deformity may be delayed or absent with autotenodesis - absence does not exclude rupture

• •Ecchymosis in the arm or antecubital region
• •Ludington's test: the patient interlocks fingers and rests both hands on top of the head, then alternately contracts and relaxes the biceps while the examiner palpates the bicipital groove. An absent cord-like tendon confirms rupture
• •Elbow flexion strength is usually normal or only mildly reduced (short head and brachialis compensate)
• •Supination strength is largely preserved (distal biceps intact)
• •Provocative biceps tests (Speed's, Yergason's) are often negative because the tendon is no longer under tension
• •Always assess the cuff: Jobe's, lift-off and belly-press, resisted external rotation

Features suggesting additional pathology: marked weakness of abduction or external rotation (significant cuff involvement); positive lift-off or belly-press (subscapularis tear, often with antecedent biceps subluxation); inability to actively flex the elbow (consider distal biceps involvement or a neurological cause); sensory changes or radicular arm pain (consider cervical radiculopathy or brachial plexus pathology).

Differentials: distal biceps rupture (reverse Popeye, marked supination weakness, antecubital bruising); LHBT medial subluxation or dislocation (empty groove on ultrasound without a Popeye); rotator cuff tear (frequently coexists); SLAP lesion; subacromial impingement.

Clinical diagnosis usually suffices when the Popeye deformity is obvious. Imaging is selective, directed at coexisting pathology, equivocal cases (suspected autotenodesis), or surgical planning.

Plain radiographs: first-line when bony injury is suspected (greater tuberosity fracture, proximal humeral fracture, rare supraglenoid tubercle avulsion). Usually normal in isolated LHBT rupture.

MRI: preferred when cuff, subscapularis, labral, or biceps-labral complex characterisation will change management - particularly in younger active patients being considered for surgery.

Ultrasound: an empty bicipital groove is a specific finding. With a Popeye deformity it supports rupture; without a Popeye deformity it suggests medial dislocation, typically with an underlying subscapularis or biceps pulley tear. Dynamic assessment of subluxation is a particular strength. Operator-dependent but a strong first-line option where MSK ultrasound expertise is available.

Non-operative management is the default for the majority: older or low-demand patients, non-dominant arm, those content to accept the Popeye deformity, and those unfit for or declining surgery. Most experience reduced pain after rupture because the degenerate tendon was the pain source.

• •Sling for comfort 1-2 weeks; simple analgesia
• •Early pain-free range of movement from day 1-3
• •Physiotherapy focused on scapular control, rotator cuff function, and overhead positioning
• •Counsel that the Popeye deformity is permanent without surgery but is usually painless and functionally mild; modest endurance loss on sustained lifting or repetitive supination is more noticeable than peak strength loss

Operative management is selective: younger patients (typically under 60), high-demand manual workers or athletes, significant cosmetic concern after a period of rehabilitation, or coexisting surgical shoulder pathology (e.g. repairable cuff tear in a younger patient).

Tenotomy vs tenodesis - the core surgical decision. Functional outcomes overlap substantially; demographic and cosmetic factors drive the choice.

• •Tenotomy: arthroscopic release at the origin. Quick, technically simple, reliable pain relief. Accepts the Popeye deformity. Favoured for older or lower-demand patients and as an adjunct to other arthroscopic procedures or irreparable cuff repair where pain is the dominant complaint. Specific risk: fatigue cramping on resisted supination (the screwdriver problem)
• •Tenodesis: reattachment of the distal LHBT to the humerus (suprapectoral or subpectoral; cortical button, interference screw, or anchor fixation). Preserves length-tension and contour. Favoured for younger active patients, cosmetic priorities, and combined surgery alongside cuff repair. Specific risks: failure of fixation, humeral fracture at the tenodesis site (rare, more common with subpectoral interference screws), persistent bicipital groove pain

Fatigue cramping is a specific consent point favouring tenodesis in younger active patients who use sustained or resisted supination at work.

Referral: routine specialist review when conservative management fails in an active patient; urgent shoulder specialist review when a significant associated rotator cuff tear is suspected in a younger patient with surgery being considered. Most older patients with isolated LHBT rupture are followed in primary care with physiotherapy.

Progression varies with pain, function, coexisting pathology, and any operative technique. Local protocols and surgeon or physiotherapist advice take precedence.

Non-operative:

• •Sling for comfort 1-2 weeks only; early active pain-free range of movement from day 1-3
• •Scapular control, rotator cuff rehabilitation, and overhead positioning
• •Progressive strengthening as symptoms permit
• •Return to light manual activity within a few weeks; heavier manual work and overhead sport depend largely on coexisting pathology

Post-operative (tenotomy):

• •Minimal restrictions; sling for comfort only
• •Early range of movement and progressive strengthening as comfort allows
• •Return to activity typically within 6-8 weeks

Post-operative (tenodesis):

• •Sling or immobiliser for 4-6 weeks to protect the fixation
• •Avoid active elbow flexion and resisted supination against gravity in the early phase
• •Progressive strengthening from around 6 weeks; return to heavier resistance or overhead sport usually from 3-4 months, guided by the operating surgeon

Modifiable factors: smoking slows tendon healing - signpost NHS Stop Smoking services. Address repetitive overhead occupational load and graded return-to-work planning. Do not drive while wearing a sling; return to driving only when safe to control the vehicle and perform an emergency stop.

• •BESS shoulder care pathways - LHBT rupture in middle-aged and older patients is typically managed non-operatively; surgery is reserved for selected younger or high-demand cases with cosmetic or functional concerns.
• •Tenotomy vs tenodesis - Systematic reviews show comparable functional outcomes; the choice is driven by age, demand, and cosmetic priority. Fatigue cramping and Popeye deformity favour tenodesis in younger active patients.
• •NICE CKS Shoulder pain - The primary-care framework for acute LHBT rupture and shoulder differentials; emphasises cuff assessment and selective imaging.
• •Autotenodesis recognition - A chronically scarred tendon can hold position in the bicipital groove after rupture, masking the Popeye deformity. Absence of bulge does not exclude rupture.
• •Empty bicipital groove on ultrasound - With a Popeye it supports rupture; without a Popeye it suggests medial dislocation associated with a subscapularis or biceps pulley tear. Two distinct findings with different management implications.

• •Standard Popeye deformity (distal bulge) in a middle-aged patient after a snap during trivial lifting = LHBT rupture. Reverse Popeye (proximal retraction) plus marked supination weakness = distal biceps rupture.
• •Autotenodesis: a chronically scarred tendon can stay wedged in the bicipital groove after rupture, masking the deformity. Absence of a Popeye does not exclude rupture.
• •The LHBT is intra-articular but extra-synovial within the glenohumeral joint - a classic anatomy distractor.
• •Empty bicipital groove on ultrasound WITHOUT a Popeye = medial dislocation associated with a subscapularis or biceps pulley tear, not frank rupture.
• •Outcomes of tenotomy and tenodesis are comparable - demographic and cosmetic priorities (not function) drive the surgical choice.
• •Fatigue cramping on resisted supination (the screwdriver problem) is the specific consent point favouring tenodesis over tenotomy in younger active patients.