Revista de Medicina Desportiva (English) July 2018 - Page 9

Rev. Medicina Desportiva informa, 2018; 9(4):7-10. Distal Avulsion of the Bicipital Tendon Associated with Prolonged use of Anabolic Androgenic Steroids Dr. André F. Couto 1 , Dr. Miguel Lopes 1 , Dr. Acácio Ramos 2 , Dr. Fernando Amaro 3 , Dr. Telmo Sacramento 4 1 Resident. Orthopedics, S. João Hospital Center, Porto; 2 Specialist. Orthopedics, Vila Franca de Xira; 3 Specialist. Orthopedics, Hospital Center of the Algarve; 4 Specialist. Orthopedics, H ospital Center of the Algarve. Portugal. ABSTRACT The use of anabolic steroids to improve athletic performance is a reality in sports activity. It is necessary to be able to recognize abuse signs, design the prevention and deal properly with possible complications. The authors describe a case of distal bicipital tendon avulsion in a Bodybuilding athlete, that was consumer of injectable steroids to gain muscle mass. He had an acute and sudden pain, with bicipital retraction and medial ecchimosis with weakness during supination and flexion of the forearm. Patients who wish to maintain total limb function have the best option by going into early surgical repair. The authors opted for this option using an anterior incision technique and tendon fixation with two suture anchors to radial tuberosity. A period of brachiopalmar immobiliza- tion was followed for three weeks; after he performed an eight-week rehabilitation program with full recovery of function. KEYWORDS Tendon, biceps, avulsion, steroids Introduction Anabolic androgenic steroids (AAS) are synthetic testosterone analogues and derivatives, manipulated in the laboratory to maximize anabolic effects and minimize androgenic side effects. 1-2 Often, the abuse of ergogenic supplements – substances used to improve athletic perfor- mance, energy, physical appear- ance or working capacity – have been used not only by professional athletes, but also by amateurs. 1,3 Adverse effects can cause damage to multiple organs and systems, and tendinopathies and the tendon ruptures are some examples. 1,2,5 It is believed that this effect is due not only to the irreversible alteration of the collagen structure, dimin- ishing its elasticity, but also to the disproportionate strength of the hypertrophy muscles, not allow- ing an equivalent adaptation of the tendons. 1 One of the most important injuries among AAS consumers is the distal bicipital tendon avulsion (or rupture), that can be partial or complete. In the past it has been described as a rare pathology, but several cases have been pub- lished with a growing frequency 8 : it represents about 10% of bicipital muscle ruptures, of which 86% are at the dominant limb and 93% in male patients (between the 40 and 60 years). 6-8 The annual incidence is estimated to be 1.2/100000 people 7 , only 29% of these patients have an intense and demanding sports activity. 6 The injury occurs when an unex- pected extension force is applied to the arm on a flexed position. 7,8 The avulsion (or rupture) typically occurs at the tendon insertion on radial tuberosity 8 , that is an area typically with low vascularization and/or with a pre-existing degenerative process 6 , which can be assigned to the intrin- sic aging process of the tendon 6 , to the repeated use of injectable ster- oids at the tendon insertion level 7 or to a local mechanic impingement. 6 In addition, some studies show that smokers have a risk of rupture 7.5 times higher than the non-smoking population. 7 Clinically, patients refer the onset of acute sudden pain during a unexpected elbow extension with the elbow on a flexed postion. 6,7 On the physical exam, there is a retrac- tion of the bicipital muscle (Reverse Popeye Sign) and a medial elbow bruise 6 (Figure 1), associated with pain and weakness during supina- tion and flexion of the elbow (there is greater loss of strength on supina- tion). 6,7 The X-ray, CT scan and MRI can be useful to distinguish between partial ant total rupture, to clarify the pathological spot (rupture in the tendon or in the muscle), to evaluate the how big is the tendon retraction and to program the surgical inter- vention 8,9 However, the diagnosis is clinical. 6,9 The most applied provocative test for diagnosis is the Hook test (Figure 2). The elbow is positioned at 90° of flexion and the forearm on maxi- mum supination: with the index finger the examiner should be able to hook the distal lateral part of the tendon. If the tendon is not palpable, the test is positive and is a definitely a pathognomonic sign of avulsion (or rupture) of the tendon. 6,7 If there is a partial rupture, the tendon is palpable, but the test is pain- ful. 7 This test is important mainly because of its reliability: it has sen- sitivity, specificity and positive and negative predictive values close to 100%, surpassing the corresponding values associated with the MRI. 7 Another possible provocative test is the Ruland test (Squeeze test). The elbow is positioned at 60-80° of flexion and the forearm is on slight pronation: one examiner’s hand immobilizes the elbow and the other hand squeezes the distal portion of the biceps (Figure 3). If there is no supination of the forearm the test is Figure 1 – Retraction of the biceps muscle after avulsion (or rupture) of the distal bicipital tendon Source: elbow/3081/distal-biceps-avulsion Revista de Medicina Desportiva informa july 2018 · 7