Distal Biceps Research Articles

Poster 132: Long Term Outcomes of Distal Biceps Injuries: A Comparative Study of Surgical and Non-operative Management at a Mean Follow Up of 13 years

Objectives:Distal biceps tendon tears, although rare, significantly impair patient’s elbow mobility and function. There is a paucity of contemporary literature reporting long term outcomes of distal biceps (DB) injuries. Therefore, the authors sought to identify magnetic resonance imaging (MRI) confirmed distal bicep tears and report on (1) patient demographics and injury characteristics of all patients with distal bicep pathology, (2) outcomes of all patients with non-operatively managed DB pathology, and (3) outcomes of all patients with operatively managed DB pathology.Methods:Patients with an MRI-confirmed distal biceps rupture from 1996 to 2016 were identified through an institutional image database. Patients from the initial search were then cross-referenced with the [REDACTED]1 to ensure record availability. Patients were included if they had complete medical records and ≥5 years of clinical follow-up. Patients with inflammatory arthritis and enthesitis, polytrauma, or incidental findings without clinical assessment were excluded. Medical records were reviewed to confirm the diagnosis of distal biceps tears and obtain further subject details.Results:A total of 158 patients (22 female, 136 male) with a mean age 51.5 years (44.8-61.2) were identified and included. Baseline patient demographics including BMI, smoking status, dominant-handedness, laborer occupation, and gender were gathered (Table 1). Patients had a mean clinical follow-up of almost 14 years (Table 1, range 8.4 -17.8). Outcomes of the 52 non-operative and 106 operatively managed patients, included severe complications, functional outcomes, and health-related productivity loss are reported in Table 2. There were 7 re-operations (4%), 5 re-ruptures (3%), and overall 35% of the operatively treated cohort experienced a complication.Conclusions:Patients with distal bicep pathology tended to be a male laborer in their 50s without clinically significantly associated risk factors. The majority of patients regained full ROM, and 83% were able to return to work without modifications, irregardless of operative or non-operative management. At long term follow up, patients treated operatively were more likely to report missing time from work and averaged more days missed than their non-operatively treated counterparts. Additionally, operative patients had no statistically significant gains functional outcomes, and were subject to potential post-operative complications. Surgeon bias may play a role in deciding treatment for distal biceps tears. As such, careful patient selection for surgical intervention for distal biceps pathology should be employed; surgeons should consider restricting surgical intervention to patients who have significant clinical symptoms or fail non-operative management.Table 1.Patient Demographics and Clinical CharacteristicsTable 2.Outcomes for Operative and Non-Operative Patients.

A Prospective Assessment of Opioid Utilization Post-Operatively in Orthopaedic Sports Medicine Surgeries.

The healthcare system is plagued finding the balance between opioid use and abuse. Orthopaedic surgeons are expected to curtail the number of opioids prescribed in order to lower opioid abuse. We sought to prospectively evaluate opioid consumption following a wide range of sports orthopaedic surgical procedures to determine utilization patterns. All patients receiving procedures within a one-year period were consented and then called daily for one week followed by weekly for up to two months or until the patients no longer were taking their opioid medication. We studied the number of opioids patient's took postoperatively and also collected information in regards to the patient and the surgical procedure. Included were 223 patients with a mean age of 32.9 years (range, 11 to 82). Surgeons prescribed a mean total of 59.5 pills, and patients reported consuming a mean total of 20.9 pills, resulting in a utilization rate of 40%. 94.4% of patients received no education on how to properly dispose of unused opioids. The mean SANE score was 53.9. The mean Pain Catastrophizing Scale score was 15.1. The mean Opioid Risk Tool was 3.3. The procedures were broken down into: 47.5% ligamentous knee repair, 18.4% shoulder arthroscopy/other shoulder, 7.6% meniscus, 7.6% shoulder arthroplasty, 5.4% distal biceps, 4.0% lower leg (ankle/foot/tibia) and 4.0% shoulder ORIF. Over-prescribing opioids after sports orthopaedic surgeries is widespread. In this study, we found that patients are being prescribed 2.48 times greater opioid medications than needed following sports orthopaedic surgical procedures. We recommend surgeons take care when prescribing postoperative pain control and consider customizing their opioid prescriptions on the basis of prior opioid usage, anatomic location and procedure type. We also recommend educating the patients on proper disposal of excess opioids and consider involving pain management for patients likely to require prolonged opioid usage.

Biceps, Brachialis, and Triceps.

Tendon injuries at the elbow affect mostly the distal biceps and can progressively degenerate over time or rupture in an acute event. The degree of retraction may depend on the integrity of the lacertus fibrosus, a fibrous expansion that merges with the forearm flexor fascia. Biceps disorders are frequently associated with fluid or synovitis of the adjacent bicipital bursa; primary bursal disorders (primary inflammatory synovitis) can also be observed. Distal triceps is less frequently injured than the distal biceps, and tears usually manifest as distal ruptures with avulsion of a small flake of bone from the tip of the olecranon. Brachialis injuries are uncommon and the consequence of sudden muscle stretching during forced elbow hyperextension, as in posterior elbow luxation.

Common tendinopathies around the elbow; what does current evidence say?

Tendinopathies are common causes of pain around the elbow resulting in significant functional impairment in athletes or the working-age population. Patients complain of a gradual onset pain with or without any specific trauma. Tissue histology shows chronic fibroblast and vascular proliferation, with a disorganized collagen pattern and absence of inflammatory mediators. Currently, numerous treatment options are described, but many of these are only supported by a heterogenous evidence base. Thus, management guidelines are difficult to define. Surgery is mostly indicated in selected cases that have failed non-operative management. This article reviews the pathophysiology and natural history of lateral and medial elbow tendinopathies, as well as distal biceps and triceps tendinopathies, and their current treatment options.

338 Biceps Metastasis Presenting as A Presumed Abscess in Patient with An Undiagnosed Non-Small Cell Lung Cancer - An Unusual Presentation

Abstract Lung cancer is the most common cancer worldwide and has highest cancer mortality. Around 50% of cases present with metastasis, however skeletal muscle metastasis is rarely reported. In this case we describe a fifty-nine-year-old male patient who presented complaining of fever and a mass on the distal biceps and proximal forearm over a five-month period, with no reported improvement despite debridement and antibiotics spanning three presentations to the emergency department. Subsequent biopsy at various anatomical sites showed adenocarcinoma, later identified as metastatic from a primary non squamous-cell lung cancer (NSCLC). Metastases from lung cancer are more commonly limited to liver and adrenal glands. Presentation of such a mass in skeletal muscle would raise suspicion for the more-commonly seen soft-tissue sarcoma or hemangiomas. This case illustrates a rare example of lung cancer metastatic to skeletal muscle, more specifically, the biceps. Presentation of the mass was also unique in its morphology of an abscess with purulent discharge, raising the importance of cytology and suspicion for malignancy in an abscess unresponsive to antibiotics. Non-small cell lung cancer can present with skeletal metastasis. A work-up of a mass or abscess of the muscle should include the possibility of soft tissue metastasis.

Ultrasound-Guided Procedures in Common Tendinopathies at the Elbow: From Image to Needle

Elbow pain is a prevalent condition in musculoskeletal physicians’ settings. The majority of cases present with periarticular pathologies (varying from tendinopathy to nerve entrapment syndrome). Nevertheless, in some cases, the underlying cause can be intra-articular, e.g., loose bodies or rheumatic disease. Progress in ultrasound (US) technology has yielded high-resolution assessment of the elbow and, importantly, allows real-time, radiation-free guidance for interventions. Particularly in ambiguous cases, US imaging is necessary to arrive at the correct diagnosis. The following four clinical conditions are covered: tennis elbow, golfer’s elbow, distal biceps, and distal triceps tendinopathy. The present review illustrates cadaveric elbow anatomy, corresponding US images, and exemplary pathologies. Additionally, the authors also discuss the existing evidence on ultrasound-guided procedures in the conditions mentioned above.

RESIDENTS CASE REPORT: MUSCULOCUTANEOUS NERVE INJURY IN A COLLEGIATE BASEBALL PITCHER.

Literature regarding musculocutaneous nerve injuries among the athletic population is scarce, with only several reported clinical cases among baseball and softball pitchers. To present a unique case of a musculocutaneous nerve injury to aid in clinician awareness and propose innovative rehabilitation practices that may facilitate improved patient outcomes during recovery. A 23-year-old Division 1 NCAA collegiate baseball pitcher presented with vague anterior arm pain following a pre-season game. The athlete described the pain as an "intense stretch" of his right arm that occurred during his last pitch. The initial evaluation identified tenderness over the right distal bicep. All shoulder and elbow orthopedic tests to assess shoulder impingement, labral pathologies, and glenohumeral instability were unremarkable. Increased neural tension was also noted with upper limb neurodynamic testing of the median and ulnar nerves on the right arm compared bilaterally. Electromyography (EMG) testing confirmed a right upper and mid-brachial plexus stretch injury with the primary involvement of the musculocutaneous nerve. Rehabilitation focused on restoring strength deficits and diminishing neural tension. Blood flow restriction (BFR) was introduced on the uninvolved limb to reduce deficits in bicep musculature strength. Once the athlete regained bicep strength and forearm sensation, he was progressed from flat-ground throwing activities to throwing off the mound. A reduction in neural tension during neurodynamic testing of the right arm, improvement of bicep brachii deficits seen between the right and left limbs, and restoration of sensation in the right lateral forearm enabled a progressive return to sport. Due to vague reports and inconclusive findings, the initial presentation of musculocutaneous nerve injuries may be mistaken for other conditions such as a biceps brachii strain. Further -documentation of this injury and rehabilitation procedures are needed to enhance patient outcomes.

There is a role for allografts in reconstructive surgery of the elbow and forearm.

Allografts play an important role in tendon, ligament, and bone reconstruction surgery, particularly when suitable available autologous tissue is limited. Enthusiasm for the use of allografts in reconstructive orthopedic surgery has increased over the past decade, with an increase in allograft use in a variety of procedures. The purpose of this review is to provide an overview of the various applications and indications for the use of allografts in reconstructive surgical procedures of the elbow and forearm. MEDLINE/PubMed was searched from 1990 through October 2018 for studies on tendon and bony allografts in elbow and forearm reconstructive surgery. The Achilles tendon allograft is the most frequently used tendinous allograft, predominantly used in distal biceps and triceps reconstruction. Although reconstruction of the ulnar collateral ligament of the elbow is generally performed using autografts, it has been shown that semitendinosus and gracilis allografts may be equally effective. Extensor hallucis longus allografts are recommended for reconstruction of the lateral collateral ligaments in patients with posterolateral rotatory instability, and there may be a role for osteochondral allograft transplantation in capitellar osteochondral defects. In addition, the use of allografts in reconstruction of the interosseous membrane and various bone pathologies (fractures, bone tumors, forearm nonunions) has been described in current literature. There is a large variety of pathology and procedures involving the use of various types of allografts in orthopedic reconstructive surgery of the elbow and forearm.

Elbow US: Anatomy, Variants, and Scanning Technique

As with other musculoskeletal joints, elbow ultrasonography (US) depends on the examination technique. Deep knowledge of the relevant anatomy, such as the bone surface anatomy, tendon orientation, nerves, and vessels, is crucial for diagnosis. It is important to be aware of the primary imaging pitfalls related to US technique (anisotropy) in the evaluation of deep tendons such as the distal biceps and peripheral nerves. In this article, US scanning technique for the elbow as well as the related anatomy, primary variants, and scanning pitfalls are described. In addition, an online video tutorial of elbow US describes a possible approach to elbow evaluation. Online supplemental material is available for this article.

Distal biceps and triceps injuries in athletes.

Biceps and triceps ruptures are rare, but can cause significant disability. They typically result from a forceful eccentric contraction, resulting in weakness and pain. Biceps and triceps tendon injuries represent the most and least common tendinous injuries about the elbow, respectively. Nonoperative management of these injuries is generally reserved for partial ruptures or patients unfit for surgery. Surgical repair has become the preferred method of treatment for acute, complete ruptures. Anatomy, epidemiology, clinical evaluation, and treatment of these injuries are described in this review.

Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies.

In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.

Evaluation and Management of Elbow Tendinopathy

Context:Elbow tendinopathy is a common cause of pain and disability among patients presenting to orthopaedic surgeons, primary care physicians, physical therapists, and athletic trainers. Prompt and accurate diagnosis of these conditions facilitates a directed treatment regimen. A thorough understanding of the natural history of these injuries and treatment outcomes will enable the appropriate management of patients and their expectations.Evidence Acquisitions:The PubMed database was searched in December 2011 for English-language articles pertaining to elbow tendinopathy.Results:Epidemiologic data as well as multiple subjective and objective outcome measures were investigated to elucidate the incidence of medial epicondylitis, lateral epicondylitis, distal biceps and triceps ruptures, and the efficacy of various treatments.Conclusions:Medial and lateral epicondylitis are overuse injuries that respond well to nonoperative management. Their etiology is degenerative and related to repetitive overuse and underlying tendinopathy. Nonsteroidal anti-inflammatory drugs and localized corticosteroid injections yield moderate symptomatic relief in short term but do not demonstrate benefit on long-term follow-up. Platelet-rich plasma injections may be advantageous in cases of chronic lateral epicondylitis. If 6 to 12 months of nonoperative treatment fails, then surgical intervention can be undertaken. Distal biceps and triceps tendon ruptures, in contrast, have an acute traumatic etiology that may be superimposed on underlying tendinopathy. Prompt diagnosis and treatment improve outcomes. While partial ruptures confirmed with magnetic resonance imaging can be treated nonoperatively with immobilization, complete ruptures should be addressed with primary repair within 3 to 4 weeks of injury.

Elbow injuries.

The elbow is a commonly injured joint, yet physicians may be less comfortable treating injuries to the elbow compared with knee and shoulder injuries. Common injuries involving the elbow are tendinosis, instability, tendon ruptures, osteochondritis dissecans, and fractures. Tendinosis is a common overuse injury and may occur on the lateral, medial, or infrequently, the posterior side of the elbow. Injury to the medial or lateral ulnar collateral ligaments may result in instability. Repetitive trauma from overuse is the most common etiologic factor in athletes. Distal biceps and triceps tendon injuries may result in elbow disability in active individuals. Partial tears are more difficult to diagnose than complete ruptures. Osteochondritis dissecans of capitellum affects adolescents involved in overhead throwing athletics. Fractures about the elbow most commonly involve the radial head in adults, and the distal humerus in children. Athletes are prone to elbow injuries resulting from both overuse and acute trauma. Our purpose is to describe the diagnosis and treatment of these common elbow injuries in athletes of all ages.

The Effects of Creatine Supplementation on Exercise-Induced Muscle Damage

This investigation evaluated the effects of oral creatine (Cr) supplementation on markers of exercise-induced muscle damage following high-force eccentric exercise in subjects randomly administered Cr or placebo (P) in a double-blind fashion. When injected, exogenous phosphocreatine has been shown to stabilize the muscle membrane in cardiac tissue and enhance recovery of strength and power following injury. Twenty-three men aged 18–36 years ingested either 20 g of Cr or P for 5 days. Criterion measures were maximal isometric force of the elbow flexors (MIF), range of motion (ROM) about the elbow, mid and distal arm circumference (CIR; to assess swelling), soreness with movement and palpation (SOR), and blood levels of creatine kinase (CK) and lactate dehydrogenase (LDH). Following the supplementation period, subjects performed 50 maximal eccentric contractions of the elbow flexors. Criterion measures were assessed pre-exercise, immediately postexercise, and for 5 days after exercise. Both groups experienced a significant loss of MIF and ROM (time effect, p < 0.05). There was a significant increase in CIR of the mid and distal biceps, SOR with movement and palpation, CK, and LDH (time effect, p < 0.05), indicating that there was significant muscle damage. However, there were no significant differences in any of the criterion measures between groups (group χ time interaction term, p > 0.05). The pattern of change over the 6 days, in response to the eccentric exercise, was nearly identical between groups. These data suggest that 5 days of Cr supplementation does not reduce indirect markers of muscle damage or enhance recovery from high-force eccentric exercise.

The Effects of Creatine Supplementation on Exercise-Induced Muscle Damage

This investigation evaluated the effects of oral creatine (Cr) supplementation on markers of exercise-induced muscle damage following high-force eccentric exercise in subjects randomly administered Cr or placebo (P) in a double-blind fashion. When injected, exogenous phosphocreatine has been shown to stabilize the muscle membrane in cardiac tissue and enhance recovery of strength and power following injury. Twenty-three men aged 18-36 years ingested either 20 g of Cr or P for 5 days. Criterion measures were maximal isometric force of the elbow flexors (MIF), range of motion (ROM) about the elbow, mid and distal arm circumference (CIR; to assess swelling), soreness with movement and palpation (SOR), and blood levels of creatine kinase (CK) and lactate dehydrogenase (LDH). Following the supplementation period, subjects performed 50 maximal eccentric contractions of the elbow flexors. Criterion measures were assessed pre-exercise, immediately postexercise, and for 5 days after exercise. Both groups experienced a significant loss of MIF and ROM (time effect, p < 0.05). There was a significant increase in CIR of the mid and distal biceps, SOR with movement and palpation, CK, and LDH (time effect, p < 0.05), indicating that there was significant muscle damage. However, there were no significant differences in any of the criterion measures between groups (group x time interaction term, p > 0.05). The pattern of change over the 6 days, in response to the eccentric exercise, was nearly identical between groups. These data suggest that 5 days of Cr supplementation does not reduce indirect markers of muscle damage or enhance recovery from high-force eccentric exercise.