Sports Medicine Physician Princeton Spine and Joint Center, LLC Princeton, New Jersey, United States
Case Diagnosis: Dynamic Impingement of a tendiopathy distal biceps brachii tendon in a weightlifter.
Case Description: 48 year old male weightlifter presented with 8-month exacerbation of episodic right forearm pain described as deep sharp pain under the medial border of the brachioradialis in the anterior elbow. Pain recurred after focused arm training with Frenchy pull-ups and reverse grip bicep curls. Exam is normal except for pain reproduced only with a specific movement of elbow flexion, maximal pronation and wrist flexion with heavy resistance. Radiography of the elbow is unremarkable. Dynamic ultrasonographic evaluation shows thickening at the distal bicipital insertion which is seen impinging between the radius and ulna on maximal pronation.
Discussions: Differential of anterior elbow pain in athletes includes nerve entrapments, distal biceps or brachialis tendon pathology, annular ligament injury, bursitis, osteochondritis dissecans or osteoarthritis. The patient described symptoms only with maximally pronated forearm and flexed elbow, with an otherwise unremarkable exam. Differential includes brachialis tendinopathy, however the brachialis inserts on the coronoid process of the ulna, and pronation of the forearm is less likely to provoke symptoms. The patient was advised on a progressive overload training program with avoidance of weight-lifting grips that result in impingement.
Conclusions: The distal biceps tendon is an uncommon location for tendinopathy. It occurs in athletes such as overhead throwers, gymnasts, rock climbers and weightlifters. In non-athletes, this tendinopathy occurs typically in middle-aged men, who present with acute distal biceps rupture. The anatomy of the distal biceps insertion may play a role in development of mechanical impingement. Ultrasonography can demonstrate bursitis, tendinopathy or enthesophytes contributing to mechanical impingement. Best conservative treatment for unruptured tendons is unclear. Progressive loading rehabilitation and avoidance of compression at the insertion have been described as successful. Surgical treatment is reserved for severe tendinopathy or rupture.