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Eddy "Bicep rupture" Hall - or how surgeon and physio will save the day

Updated: Sep 20, 2021

Like most of you (I’m sure), we have been waiting patiently for the highly anticipated exhibition boxing match between strongmen Hafthor ‘The Mountain from Game of Thrones’ Bjørnsson and Britain’s very own, Eddie ‘The Beast’ Hall, the first man to deadlift 500kg. The Mountain called out The Beast approximately a year ago after he beat Eddie’s 500 kg deadlift world record by 1 kg during lockdown in his home country Iceland – naturally Eddie accepted, and we have been glued to the screen following their build up ever since.

Now this isn’t the topic of this article, but as we have followed the build up towards the fight that was due to take place in September 2021– an absolute disastrous event occurred during Eddie’s training as he through a heavy (but a bit lazy) left hook and tore his distal biceps clean off (opens in YouTube, 26 second mark).

If you are interested in following his recovery, it is quite impressive. He was seen in Harley street within hours and was booked in for surgery within a day. He is expected to make a full recovery and to be back in training within 8 weeks. It got us thinking about biceps ruptures in general and we wanted to do a little piece on it.

Here’s the deal:

Biceps tendon ruptures mainly occur between the ages of 40 and 60 but there are many factors that can increase likelihood such as steroid use, smoking, corticosteroids and gender (it is more common in men). Heavy weightlifting / manual labour involving a lot of lifting and repetitive sharp movements causing overuse and microtrauma over time are significant factors – now these will predominantly rupture the long head of the biceps and that is the most common rupture. In fact there isn’t much data on distal ruptures at all as they make up only 3% of total ruptures.

Contact sports with the risk of falling on an outstretched hand are also relevant such as in rugby or American football – in those sports a posterolateral dislocation of the ulna, or a rupture of the distal biceps are the likely outcomes.

The rupture is most common when there is a sudden contraction (as with most ruptures) with resistance of the elbow and supination of the forearm. If there is already degeneration of the tendon present, chances of rupture are higher. As with other ruptures such as the Achilles, they are usually asymptomatic and sudden.

The biceps brachii muscle consists of two heads – the long and short. The long heads primary purpose is to depress the humeral head, stabilise the shoulder joint and supinate the forearm, whereas the short head predominantly flexes the elbow.

Typical symptoms of a rupture include the classic loud pop reported by the patient following by a sharp pain and a ‘pop eye’ sign in the muscle belly as the tendon retracts. It is relatively simple to investigate using imaging, and whist there are some differentials to think of, such as acromioclavicular dislocation / separation or septic arthritis proximally – a standard distal tear like Eddie suffered is relatively easy to identify with clinical history, objective presentation and finally to confirm with MRI and ultrasound.

"Popeye sign"

For young healthy fit and active people reattaching the tendon to the bone (tenotomy) normally provides satisfactory outcomes and allows return to sports / active lifestyles if rehabilitated correctly, although a decrease in supination strength is often the case. There are different types of surgical approaches; direct repair, the suture anchor method and graft repair.

For older populations it’s always a judgement call, it will depend on their profession (car mechanic might need a lot of supination for ex) – otherwise it could be managed conservatively with immobilisation for a few weeks to allow swelling to reduce and a gradual and progressive flexibility and strengthening program to try and utilise supporting muscles to compensate, or alternatively in the cases of only a partial rupture; regain as much power and movement as possible in the shoulder or elbow.

In physiotherapy, we then focus on getting you back gradually to your activities and sport objectives. For Eddie and his physio, it might just be fighting the The Mountain from Game of Thrones... Let's get it! 💪

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