Understanding Distal Biceps Tears in Workers Comp: Diagnosis and Treatment Options

Written by Anand Panchal, DO

Distal biceps tears are a significant concern, especially among workers engaged in physically demanding jobs. Such injuries can lead to considerable functional impairment and necessitate comprehensive management strategies. This article reviews the diagnosis and treatment options for distal biceps tears, particularly in the context of workers' compensation injuries.

Anatomy and Mechanism of Injury

The biceps brachii muscle, located in the upper arm, has two tendons at its distal end that attach to the radial tuberosity in the forearm. These tendons allow the biceps muscle to flex the elbow and supinate (rotate the hand into the palm up position) the forearm. A distal biceps tear involves the rupture of these tendons, often occurring when there is a sudden, forceful contraction of the muscle against a heavy load. (example is lifting a heavy tire or metal door with the arm slightly extended)

Diagnosis of Distal Biceps Tears

Accurate and timely diagnosis is crucial for optimal recovery, especially for workers whose livelihoods depend on their physical capabilities. The diagnostic process involves several steps:

Clinical Evaluation:

• History: Patients typically report a sudden, sharp pain in the front of the elbow, often accompanied by a "pop" sound. Swelling, bruising, and weakness in elbow flexion and forearm supination are common.

Physical Examination: Key tests include:

• Hook Test: The examiner attempts to hook a finger under the biceps tendon from the lateral side of the elbow. A positive test, where the tendon cannot be palpated, indicates a tear.

• Biceps Squeeze Test: The examiner squeezes the biceps muscle belly while the forearm is supinated. A lack of forearm supination indicates a possible tear.

Imaging Studies:

• X-rays: While not definitive for diagnosing tendon tears, X-rays can rule out fractures and other bony abnormalities.

• Ultrasound: An effective, non-invasive tool that can visualize the torn tendon and assess its retraction.

• Magnetic Resonance Imaging (MRI): The gold standard for confirming distal biceps tears, MRI provides detailed images of the soft tissues, showing the extent of the tear and retraction. This can extremely helpful in surgical planning.

Treatment Options for Distal Biceps Tears

Treatment strategies for distal biceps tears depend on the severity of the tear, the patient's age, activity level, and occupational demands. For workers' compensation cases, the goal is to restore function quickly and safely to facilitate a return to work.

Non-Surgical Treatment:

• Non-surgical management may be considered for partial tears or in patients with low functional demands.

• Rest and Immobilization: Initial immobilization in a sling or brace helps reduce pain and swelling.

• Physical Therapy: Once the acute pain subsides, physical therapy focuses on gentle range-of-motion exercises, followed by strengthening exercises to restore function.

• Limitations: Non-surgical treatment often results in decreased strength and endurance in elbow flexion and forearm supination, which can be problematic for physically demanding jobs.

Surgical Treatment:

• Surgical repair is the standard of care for complete distal biceps tears, especially for workers who require full arm strength and function.

Techniques:

• Single-Incision Technique: This approach involves a single anterior incision to access and reattach the tendon to the radial tuberosity. It minimizes the risk of nerve injury and provides excellent cosmetic results.

• Two-Incision Technique: This method involves an additional posterior incision to help secure the tendon. It may reduce the risk of heterotopic ossification but carries a higher risk of nerve damage.

Postoperative Rehabilitation:

• Immobilization: The arm is typically immobilized in a brace for several weeks to protect the repair.

• Physical Therapy: Gradual rehabilitation begins with passive and active range-of-motion exercises, progressing to strengthening exercises. The goal is to restore full function within 4-6 months.

Workers' Compensation Considerations

For workers' compensation cases, several factors need to be addressed to ensure a successful outcome:

Timely Diagnosis and Treatment:

• Early recognition and intervention are critical to prevent long-term disability. Prompt surgical repair offers the best chance for a full functional recovery.

• Typically time from injury to surgery should be less than 2 weeks to maximize ability to perform a repair of the tendon.

Return-to-Work Programs:

• Modified Duties: Initially, workers may need to perform modified duties that avoid heavy lifting or strenuous activities.

  • Gradual Return: A phased return-to-work program helps workers gradually resume their full duties, minimizing the risk of re-injury.

Communication with Stakeholders:

• Employer Collaboration: Open communication with employers about the worker's progress and capabilities ensures appropriate job modifications and accommodations.

Insurance and Legal Considerations: Documentation of the injury, treatment, and rehabilitation progress is crucial for workers' compensation claims.

Psychosocial Support:

• Workers may experience stress and anxiety related to their injury and job security. Providing psychological support and counseling can aid in the overall recovery process.

Prognosis and Long-Term Outcomes

The prognosis for distal biceps tears is generally favorable with appropriate treatment. Surgical repair offers excellent outcomes, with most patients regaining near-normal strength and function. However, some patients may experience residual weakness or discomfort.

Long-term outcomes are influenced by several factors:

• Severity of the Tear: Complete tears with significant retraction may require more complex repairs and have longer recovery times.

• Timing of Surgery: Early surgical intervention generally leads to better outcomes.

• Rehabilitation Compliance: Adherence to physical therapy and rehabilitation protocols is crucial for optimal recovery.

Distal biceps tears are significant injuries that require a comprehensive approach to diagnosis and treatment, particularly in the context of workers' compensation. Timely intervention, appropriate surgical techniques, and structured rehabilitation programs are essential for restoring function and facilitating a successful return to work. By addressing both the physical and psychosocial aspects of recovery, healthcare providers can support injured workers in achieving the best possible outcomes and maintaining their occupational capabilities.