The Biceps muscle is possibly the most commonly known muscle of the body. It is found in the front of the upper arm, originating from the shoulder and attaching just below the elbow joint. It often starts to pain once you lifted an excessively heavy object. Playing an instrument for an extended amount of time (for example violin) can also strain your biceps muscle. We take the function off this muscle for granted. However once injured, we realize how much we actually use the muscle. Unfortunately a bicep muscle tear can cause havoc along the rest of your arm, so be sure you take good care of it.
Where is the bicep muscle located?
Normally the bicep muscle has two parts that come from slightly different locations at the shoulder joint. There are some people that have three parts or more but that is very rare. The muscle makes a big belly over the upper arm, that can be clearly felt when you bring your wrist to your shoulder. The biceps then runs down the arm and has a strong tendon that connects it to the forearm. It is one of the seven two-joint muscles in the body, which means that it does not only move one joint but your elbow and your shoulder joint. This makes the bicep muscle more susceptible for injuries.
What does the Bicep muscle do?
The Bicep muscle is responsible to bend the elbow, bring the hand to the shoulder. It also assists to turn the forearm inwards. This means that it has to be strong while you lift boxes or hold them, pick up a child, assist in arm wrestling.
The biceps can lengthen and still contract, when it needs to control the elbow when your arm straightens. This happens during throwing (as in darts) or in overhead sports such as tennis, cricket or netball.
How does a bicep muscle tear happen?
A bicep muscle tears when you lift too heavy. The bicep muscle cannot create enough force and so it starts to tear some muscle fibers. If you are into weight lifting you will surely have seen at least one you-tube video of someone tearing a bicep muscle as they attempted to break their personal best.
A sudden strong resistance can also cause the same damage because the muscle did not contract and was too slow to activate. The force tears the fibers. A typical example of this is when you are moving and your husband hands you a heavy box jokingly saying “Oh honey catch this feather-light box ;)” and while you do not see that he is struggling to carry it, the weight drops onto your arms and SNAP, you feel that muscle talking to you.
Another option of the biceps muscle tearing is through throwing so hard that the muscle could not control the elbow straightening and it stretched over its normal length. This happens in a serve of a tennis player or with swimming. “You really wanted to end of that match with an ace”, was going through your mind as you feel the already fatigued muscle trying to control the high load, after which the pain sets in.
In bowling or in a rugby match you can injure your bicep muscle. When the shoulder joint is locked down and someone falls onto your forearm, forcing it straight, your bicep muscle will tear. Most commonly the muscle tears at the musculotendinous junction, where the muscle joins the tendon.
If it is a severe tear, an audible snap can be heard and the muscle might have torn a lot of fibres. Along the muscles, from the shoulder to the elbow it can be painful and blue and swelling would start to appear around.
You will notice an increase in temperature around the bicep tear. Bluish discoloration comes from bleeding of the small arteries around the torn fibers of the biceps muscle. The bleeding can also shift to a different location in the arm, for example into the chest or elbow. The bruising will shift depending on how you sleep at night and follow the pull of gravity. So you’ll notice the area of bruising will move more to the back if you sleep on your back, more on the side if you side-sleep, or in the front if you’re a stomach sleeper.
Causes of the bicep muscle strain
Bicep muscle strains happen because of various reasons.
practicing violin, which is a repetitive low load movement and can lead to multiple small bicep muscle strains. Especially if the body is overwhelmed because of too long hours of practicing. This high volume of repetitions combined with fatigue are a dangerous combination. The risk increases exponentially with every 10 minutes longer practice as fatigue might have set in already.
The severe stiffness that you feel after a long practicing session comes from micro-trauma, where a small amount of tears are in the muscle. Now every 10 minutes longer will increase that amount of tearing and the micro-trauma will turn into macro-trauma. This we call a muscle strain or tear.
doing cross-fit with too heavy weights without being used to the extreme increase in load, can tear your bicep muscle. This could also be from lifting heavy furniture or appliances.
The upper arm will feel painful to touch and certain localized points may be more tender. Those trigger points can also refer into the shoulder region or down into the elbow or lower arm. A very sensitive spot is right on the knob in the front of the shoulder where the shorter part of the bicep muscle attaches.
lifting an object anticipating it to be a lot lighter but with a sudden drop you feel a discomfort in your biceps muscle. This is a frustrating way to attain an injury because your muscle can bear that weight, it just was not ready for the weight and the fibres did not react fast enough.
You will be able to tell the exact moment your pain started and the exact area where you felt it. Mostly it is a constant discomfort for a couple of days that should resolve within a view days. At the gym it may also happen when using heavy free weights, doing quick movements and especially on eccentric training (i.e. negatives).
having gymned very hard and feeling sore and stiff when training again you straighten the elbow fast or with load, without having warmed up properly, the muscle fibres will tear where they were still recovering from the previous work-out. One forceful elbow straightening can also be the reason for an over-stretch where the triceps (the muscles at the back of your arm) were contracting stronger than your biceps could control and the elbow straightens more than it should. This sort of pain feels like a constant niggle if neglected in Rehab.
a direct blow to the biceps muscle where the elbow is forcefully hyper-extended.
Fractures: The chances of having your biceps muscle torn, after an elbow or shoulder fracture is very likely. Some times the attention to the fracture overshadows the bicep muscle tear, but when the fracture is healed, you are left with the aftermath of an unhealed tear.
Symptoms of a bicep tear
- place your hand flat against the wall, at the height of your shoulder
- fingers should be pointing down
- straighten your elbow so that hand, elbow and shoulder are in 1 straight line
Minimal pain, sharp pain or not possible at all , respectively, will give you the indication on how bad you hurt your bicep muscle. If it has been longer than 4 weeks and the swelling and inflammation have subsided, the pain might have improved and even some strength in bending the elbow may return, yet the rotation of the forearm will still be very difficult.
How bad is your bicep torn?
Grade 1 tear:
- very view fibres are torn, up to 20% only
- you can still pull a heavy table or lift up the full kettle but pain can be felt during the use of the muscle
- recovery time: 4-5 days for healing to take place that all the fibres should reconnect and heal
Grade 2 tear:
- a moderate to significant percentage of the fibres are torn that can vary from 20-80% of the fibres
- some pins and needles might be felt down the arm and it is not possible lift a heavy box up; a palpable gap can be felt in the muscle once the swelling has decreased
- recovery time: 2-4 weeks according to the percentage of fibres that are torn; full recovery and return to sport will take longer though and should not be confused with the healing time. Return to sport can depend on the sport but will only be after 4-6 weeks.
Grade 3 tear:
- the whole muscle is torn off
- also referred to as the Popeye muscle when the muscle bulk moved down because the bicep muscle tore at the shoulder. When bending the elbow a very visible “Popeye” bicep belly will display.
- recovery time: 2-3 months non-operatively. Different healing times apply with operations. 4 months can be an indication if only one part of the bicep is completely torn off. It takes 6-7 months before returning to play if the muscle tore at the elbow joint.
Diagnosis of a torn bicep
Clinical tests will be able to provide you with an accurate diagnosis. The diagnosis can be confirmed with sonar or an MRI. The MRI comes with a great cost and will most likely show a shift of the bicep muscle out of its grove where it should be located near the shoulder. If concomitant injuries are suspected in the Rotator Cuff Muscles of the shoulder an MRI can also be helpful, although Rotator Cuff Muscle injuries are also diagnosed with clinical tests.
X-rays are sometimes advised in the elderly patients due to the presentation of an upper arm bone fracture being similar to that of a bicep muscle tear. Normally you would not need X-rays though because they only show bones and not the muscles. Therefore they will not help in the diagnosis of your bicep muscle tear.
How we test it?
A comprehensive set of clinical tests will give us the best indication what structures have been injured. The following structures should be included:
- elbow and wrist
- cervical neck
- 3 main nerve branches
- surrounding muscles
Within these joints are different structures that have to be tested for their integrity, the range of movement and strength as well as length of the muscles.
The following tests are used to determine if the bicep muscle is strained:
- Speeds test (bicep muscles resistance capability)
- Yergason’s test (ligament integrity- bicep muscle still in the groove?)
- Ludington’s test (long head of biceps muscle torn?)
These tests provide information about different structures that could also be involved, such as the labrum which holds the shoulder in the shoulder joint and the ligaments that hold the bicep muscle in the groove.
Physio treatment for a bicep muscle tear
- Physiotherapy treatment focuses on pain management and accelerating the healing process by using Ultrasound and Laser
- Strapping and Taping to support and protect from further injury
- Acupuncture or Dry Needling of the Bicep muscle and surrounding compensating muscles
- Massage and Soft tissue mobilization
- Myofascial release of the upper arm muscles to guide the scar tissue formation
- Eccentric loading exercises to condition the muscle fibers
- Compression bandaging like compression gloves can promote blood flow through the site of injury and prevent the blood from pooling
- A sling to immobilize the bicep muscle for the first few days
- We will gradually progress your rehabilitation exercises to regain full function of the whole arm
Acute injury management: PRICE
|P||Protect||Do not continue using the muscle when there is pain. Apply some soft padding to minimize impact with touch or other objects. The main concern is to prevent the muscle from tearing even further.|
|R||Rest||A sling can be worn in severe cases to off-load the muscle and give it the rest it deserves.|
|I||Ice||Ice cubes in a bag or an ice pack wrapped in a towel, tied around the upper arm reduces pain & inflammation and speeds up the healing process. For at least the first 3 days or until the swelling goes down, apply ice for 15 minutes every two hours. Always keep a towel between the ice and your skin (to prevent a cold burn). An ice bath is also a good option.|
|C||Compress||Use strapping (Leukotape S) or elastic compression bandage to keep the muscle supported and to control swelling.|
|E||Elevate||As long as the arm is above the level of the heart then the blood does not pool in the arm.|
Perform passive and active-assisted elbow and shoulder joint activities immediately, so that the fibres can be laid down in the correct line and format. Resting it in one position without any passive movement will cause the fibres to form a mash instead of an aligned network. The mash will have to be broken up later on which causes more pain in the rehabilitation phase and can also lead to other complications, such as myositis ossificans. Bone starts to form inside the muscle or other surrounding tissue. The cause of the complication is also credited to returning back to sports too soon or having too severe hard treatment too soon after the injury.
When the bicep muscle is torn at the elbow joint a trail of non-operative treatment is always advocated, especially for elderly or lazy people. There can be complications with the radial or median nerve, that they become entrapped or injured. Nerve complications have to be addressed as soon a possible to minimize loss of sensation and pain.
2nd Phase: Regain Full Range of Movement
The most important component of rehabilitation is to regain full range of movement of the elbow and shoulder joint. The scar tissue that forms inside the site of the tear must be lengthened and orientated to allow the bicep muscle to contract without any restrictions. We use massage, stretches and neurodynamic mobilizations to achieve full range of movement. This will also prevent future recurrence.
3rd Phase: Eccentric Muscle Strength
A muscle contraction works in two directions: One where the muscle is contracted and it shortens as when bending the elbow (concentric), and the other controlling the elbow straightening (eccentric). This loads the muscle fibers while being lengthened. This type of exercises is vital at conditioning the muscle fibers to absorb a force.
4th Phase: Concentric Muscle Strength
Shortening of the muscle during a contraction involves strength and power exercises that will be progressed gradually as healing takes place. This will be tested frequently to determine if you can progress from non-weighted activities of daily living to being able to carry more weight again. The physiotherapist will guide and monitor the muscles reaction to normal forces like pulling, picking up objects and driving.
5th Phase: High Speed, Power, Proprioception
The bicep muscle needs to be able to carry heavy load again and also to be effective when doing fast upper body movements with precision. Proprioception improves very fast with the correct stimulation of the exercises. To build up power and regain high speed training a gradual program has to b followed to optimally progress and to avoid any regression in the rehabilitation process. This phase requires close monitoring to get back to sport specific training as soon as possible. It can not be rushed and the bicep muscle will have to be given enough time to rebuild fibres and to increase in muscle mass to be able to not only tolerate but to fall back into the movement patterns that the body knows well from the sport.
6th Phase: Sport Specific Training
Depending on your sport, the physiotherapist will tailor specific exercises that will maximize the elbow and shoulder stability and strength that the known movement patterns will not feel restricted to return because the functionality of the muscle will have returned. It is of utmost importance that you have confidence in the previously injured muscle (which at this stage is NOT injured anymore!!) and can rely on it fully when returning to the sport. If this is not the case, compensatory patterns will kick in and other muscles will take over and your normal timing and previous patterns of movement will become distorted.
This will in turn predispose you to other injuries in the future.
SO: rather ensure optimal return to play than struggle in the future with other muscles and joints that get injured.
After the initial 48 hours have past anti-inflammatories might be prescribed if the inflammatory process seems to be overactive. Inflammation is the bodies way of healing so limiting the inflammation for too long is also not useful because the body does not get to heal the bicep muscle optimally.
Pain medication can also be prescribed, either purely for pain or in combination with anti-Inflammatory components. If the pain is more than a 6/10 these can be used. Try to use them sparingly since pain is actually your body trying to communicate with you. Get to know your body by being able to interpret your bodies language more effectively as you learn to differentiate different types of pain, the duration of pain as well as the intensity.
Corticosteroid injections or PRP injections are also an option to help in the recovery process. The use is controversial but may improve healing times.
If the long head of the bicep tendon is torn, no operation is necessary although the arm might look a bit different to the other arm. Minimal loss of elbow flexion and turning of the forearm has to be anticipated, but it is only very slight. For high performance athletes that will be a deficit but for non high-performance athletes and the general public it will not be a very noticeable loss.
Surgery may be indicated if you were not compliant with the exercises that the physiotherapist gave you, conservative management was not effective (which can also be caused because of smoking or a high alcohol consumption, which delays healing) or because of poor rehab or a nerve complication.
There are different surgical techniques with which a complete bicep tear can be operated on. General outcome after operation is a recovery up to 90% of strength of the bicep muscle. Outcomes after chronic repairs of a tear closer to the elbow joint are less satisfactory and have a higher incidence of complications. Complications include compartment syndrome, entrapment or injury of the nerve or permanent loss of range of movement.