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: https://www.orthobullets.com/shoulder-and-
elbow/3081/distal-biceps-avulsion
Revista de Medicina Desportiva informa july 2018 · 7