Effectiveness of Magnetic Resonance Imaging in Detecting Partial and Complete Distal Biceps Tendon Rupture

Abstract

The data published by Festa and colleagues provide an important opportunity to better understand enthesopathy of the distal biceps tendon insertion.1Festa A. Mulieri P.J. Newman J.S. Spitz D.J. Leslie B.M. Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture.J Hand Surg. 2010; 35A: 77-83Google Scholar As pointed out by Hobbs and colleagues in a recent evidence-based medicine review,2Hobbs M.C. Koch J. Bamberger H.B. Distal biceps tendinosis: evidence-based review.J Hand Surg. 2009; 34A: 1124-1126Google Scholar the concepts of acute and chronic, partial and complete, and tendinopathy versus partial rupture have been used in imprecise and confusing ways when addressing so-called “tears” of the distal biceps tendon. My understanding of the best available evidence in the context of my experience treating patients is that normal tendons do not rupture, that acute tears (ecchymosis, swelling, and pain) are always complete, and that the so-called “partial tear” is just distal biceps tendinopathy without acute rupture. I had trouble clarifying my knowledge about distal biceps pathology because Festa and colleagues defined an acute tear based on symptom onset. This is problematic because chronic problems are variably symptomatic and are often misperceived as new at the time of symptom onset. Furthermore, patients with true acute traumatic ruptures might not present for months or years—presumably that explains the 5 complete ruptures in the chronic cohort. A better definition of acute would involve the classic eccentric load, audible pop, antecubital ecchymosis and swelling, and notable loss of supination strength that is characteristic of an acute traumatic rupture of the distal biceps insertion. The word tear is often misused in orthopedic surgery. Tear implies damage. Damage implies the need for repair. Aren't so-called “partial tears” just deteriorations or defects that are part of the pathophysiology/enthesopathy? Enthesopathies are diseases of middle age that are typically benign and self-limiting (eg, tennis elbow and plantar fasciitis) for which etiological theories regarding overuse are prevalent but poorly supported by scientific evidence. We do not know how many people have enthesopathy of the distal biceps tendon and never present to a doctor. We do not know what would happen to the patients who request surgery for distal biceps enthesopathy if they declined surgical treatment. I would ask the authors to clarify their data and the interpretation of the data in light of my critique of the terms and definitions that are often used to describe enthesopathy of the distal biceps tendon insertion on the radius. Effectiveness of Magnetic Resonance Imaging in Detecting Partial and Complete Distal Biceps Tendon RuptureJournal of Hand SurgeryVol. 35Issue 1PreviewA magnetic resonance imaging (MRI) scan of the elbow is often obtained to confirm the clinical suspicion of a distal biceps tendon rupture. The goal of this study was to evaluate the effectiveness of MRI in diagnosing partial and complete distal biceps tendon ruptures as determined at the time of surgery. Full-Text PDF In ReplyJournal of Hand SurgeryVol. 35Issue 5PreviewOur understanding of distal biceps injuries is biased by our experience with complete distal biceps tendon ruptures. Patients with complete ruptures almost always present with a history of a sudden eccentric load associated with a popping, tearing, or ripping sensation and the usual clinical findings of ecchymosis, proximal muscle migration, and weakness. Any clinician who has seen enough complete distal biceps tendon ruptures will eventually begin to recognize patients who have pain in the antecubital fossa but lack the findings of a complete rupture. Full-Text PDF