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Figure 1

Illustration of batter arm and forearm position at swing follow through.

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ABSTRACT

Distal biceps tendon ruptures are relatively common sport-related injuries which are often treated surgically. The mechanism of injury to this tendon, forced extension on a flexed elbow or eccentric biceps contraction against a heavy load, has been well established and consistent in the literature. This is most notably seen in weightlifting or powerlifting activities. Baseball and softball are two of the most popular overhead sports in the United States, but biceps tendon ruptures are not frequently cited as high-volume injuries. We discuss the case of a 38-year-old male who sustained a distal biceps rupture during the course of swinging a bat during a recreational softball game. The patient underwent surgical fixation of the biceps tendon and did well postoperatively. This report serves to discuss the biomechanics at the elbow throughout the swing path and describe their role in a mechanism of injury to the distal biceps which has not been described previously.

Distal biceps tendon ruptures have an estimated incidence of 2.55-5.35 per 100,000 with the vast majority occurring in middle-aged men.[10x[10]Kelly, M.P., Perkinson, S.G., Ablove, R.H., and Tueting, J.L. Distal Biceps Tendon Ruptures: An Epidemiological Analysis Using a Large Population Database. Am J Sports Med. 2015; 43: 2012–2017https://doi.org/10.1177/0363546515587738

Crossref | PubMed | Scopus (116)
| Google ScholarSee all References
] The most frequently cited macroscopic mechanism of injury is forceful extension of a flexed elbow, commonly seen in day-to-day lifting or strength training exercises.[1x[1]Albishi, W., Agenor, A., Lam, J.J., and Elmaraghy, A. Distal Biceps Tendon Tears: Diagnosis and Treatment Algorithm. JBJS Rev. 2021; 9: 1–10https://doi.org/10.2106/jbjs.rvw.20.00151

Crossref
| Google ScholarSee all References
],[6x[6]Golshani, K., Cinque, M.E., O’Halloran, P., Softness, K., Keeling, L., and Macdonell, J.R. Upper extremity weightlifting injuries: Diagnosis and management. J Orthop. 2018; 15: 24–27https://doi.org/10.1016/j.jor.2017.11.005

Crossref | PubMed | Scopus (10)
| Google ScholarSee all References
],[9x[9]Kapicioglu, M., Bilgin, E., Guven, N., Pulatkan, A., and Bilsel, K. The Role of Deadlifts in Distal Biceps Brachii Tendon Ruptures: An Alternative Mechanism Described With YouTube Videos. Orthop J Sport Med. 2021; 9: 1–6https://doi.org/10.1177/2325967121991811

Crossref | Scopus (3)
| Google ScholarSee all References
],[10x[10]Kelly, M.P., Perkinson, S.G., Ablove, R.H., and Tueting, J.L. Distal Biceps Tendon Ruptures: An Epidemiological Analysis Using a Large Population Database. Am J Sports Med. 2015; 43: 2012–2017https://doi.org/10.1177/0363546515587738

Crossref | PubMed | Scopus (116)
| Google ScholarSee all References
],[15x[15]Schamblin, M.L. and Safran, M.R. Injury of the distal biceps at the musculotendinous junction. J Shoulder Elb Surg. 2007; 16: 208–212https://doi.org/10.1016/j.jse.2006.06.009

Abstract | Full Text | Full Text PDF | PubMed | Scopus (40)
| Google ScholarSee all References
] A variety of theories exist regarding microscopic changes attributing to an individual’s propensity for sustaining these injuries as well.[5x[5]Eames, M.H.A., Bain, G.I., Fogg, Q.A., and Van Riet, R.P. Distal biceps tendon anatomy: A cadaveric study. J Bone Jt Surg - Ser A. 2007; 89: 1044–1049https://doi.org/10.2106/JBJS.D.02992

Crossref | Scopus (147)
| Google ScholarSee all References
],[7x[7]Johnson, J., Deren, M., Chambers, A., Cassidy, D., Koruprolu, S., and Born, C. Biomechanical Analysis of Fixation Devices for Basicervical Femoral Neck Fractures. J Am Acad Orthop Surg. 2019; 27: e41–e48https://doi.org/10.5435/JAAOS-D-17-00155

Crossref | Scopus (9)
| Google ScholarSee all References
],[11x[11]Kokkalis, Z.T. and Sotereanos, D.G. Biceps Tendon Injuries in Athletes. Hand Clin. 2009; 25: 347–357https://doi.org/10.1016/j.hcl.2009.05.007

Abstract | Full Text | Full Text PDF | PubMed | Scopus (15)
| Google ScholarSee all References
],[14x[14]Pullatt, R.C., Gadarla, M.R., Karas, R.H., Alsheikh-Ali, A.A., and Thompson, P.D. Tendon Rupture Associated With Simvastatin/Ezetimibe Therapy. Am J Cardiol. 2007; 100: 152–153https://doi.org/10.1016/j.amjcard.2007.02.068

Abstract | Full Text | Full Text PDF | PubMed | Scopus (55)
| Google ScholarSee all References
],[16x[16]Seiler, J.G., Parker, L.M., Chamberland, P.D.C., Sherbourne, G.M., and Carpenter, W.A. The distal biceps tendon. Two potential mechanisms involved in its rupture: Arterial supply and mechanical impingement. J Shoulder Elb Surg. 1995; 4: 149–156

Abstract | Full Text PDF | PubMed | Scopus (210)
| Google ScholarSee all References
] Distal biceps rupture resulting from end range elbow extension and supination in the course of athletic activities such as a baseball swing is not described in the literature to our knowledge but has been seen at the national level, including in professional athletes such as Miguel Cabrera in 2018.[2x[2]Beck J. Cabrera “in shock,” set for surgery this week. MLB.com. Published 2018. Accessed February 12, 2021. https://www.mlb.com/news/miguel-cabrera-to-have-biceps-surgery-thursday-c281125774

Google ScholarSee all References
] This report serves as a demonstration of this mechanism and a review of the literature which may help explain the sport-specific biomechanics leading to injury.

CASE REPORT

The patient was a 38-year-old right-hand-dominant male who sustained injury to his left elbow while playing softball. He stated that he felt a pop and tearing sensation over the anterior aspect of his elbow while completing a swing during a game. He experienced continued pain in the anterior elbow when attempting to swing again, with elbow flexion, and when reaching to pick up balls from the ground. He presented to the orthopedic urgent care three days following the injury for initial evaluation. Ecchymosis was noted over the antecubital fossa on exam. He also demonstrated diminished elbow flexion and forearm supination strength. Hook test was noted to be positive. He was diagnosed clinically with a distal biceps tendon rupture, placed into a sling for comfort, and MRI was ordered. The patient proceeded to follow-up two days following completion of the MRI; his examination findings remained unchanged. MRI demonstrated a full-thickness tear of the distal biceps tendon with nearly 7-cm of retraction. Surgical management was discussed with the patient, and he elected to proceed with open repair of his biceps tendon.

The patient proceeded to the operating room 9 days following his initial injury. Preoperative DASH elbow scores were obtained; a score of 78. An anterior, single-incision approach was utilized. The retracted tendon was identified, the tendon edge was débrided, and it was repaired to the bicipital tuberosity of the radius using FiberLoop (Arthrex, Naples, FL, USA) and a trans-osseous BicepsButton (Arthrex, Naples, FL, USA). Appropriate positioning of the button was confirmed with fluoroscopy. The elbow was then ranged from about 10-120 degrees without excessive tension noted on the repair. A soft dressing was placed and the patient was discharged to home with non-weightbearing restrictions and instructed to perform gentle elbow range of motion exercises.

The patient was seen in clinic for his two-week postoperative visit. His incision was noted to be healing appropriately. His pain was controlled. Motion was noted to be 30-100 degrees passively. He continued gentle motion and sling wear out of the house for the next four weeks until he was seen in clinic six-weeks postoperatively. At that time his incision was well healed and his motion was painless and full from 0-130 degrees. He was released to begin physical therapy for continued work on range of motion and light strengthening exercises. At 3-months postoperatively, he was seen again in clinic and was found to have no pain, intact global sensation, and full active elbow range of motion. He was released to return to all activities as tolerated and as needed follow-up. His DASH elbow score was calculated as 0 at final follow-up.

DISCUSSION

Distal biceps tendon ruptures are a relatively common upper extremity sports injury. Forced extension of the elbow from a flexed position or rapid eccentric contraction of the biceps tendon are the most common, if not only, mechanisms of injury reported in the literature. This has most commonly been associated with weight-lifting activities. Baseball and softball are two of the most popular overhead sports in the United States and account for a large amount of sports-related upper extremity injuries. Elbow injuries are often attributed to overhead throwing mechanics and are a frequent topic of research; however, distal biceps tendon ruptures are not mentioned as a common injury resulting from overhead throwing or swing attempts.[3x[3]Camp, C.L., Dines, J.S., van der List, J.P., Conte, S., Conway, J., Altchek, D.W. et al. Summative Report on Time Out of Play for Major and Minor League Baseball: An Analysis of 49,955 Injuries From 2011 Through 2016. Am J Sports Med. 2018; 46: 1727–1732https://doi.org/10.1177/0363546518765158

Crossref | PubMed | Scopus (75)
| Google ScholarSee all References
],[17x[17]Trehan, S.K. and Weiland, A.J. Baseball and softball injuries: Elbow, wrist, and hand. J Hand Surg Am. 2015; 40: 826–830https://doi.org/10.1016/j.jhsa.2014.11.024

Abstract | Full Text | Full Text PDF | PubMed | Scopus (7)
| Google ScholarSee all References
]

The biomechanics of the baseball or softball swing have been extensively studied. Maximal force vectors and extension angular velocities of greater than 600 degrees/sec are reached just prior to ball contact.[12x[12]Loftice, J., Fleisig, G.S., Zheng, N., and Andrews, J.R. Biomechanics of the elbow in sports. Clin Sports Med. 2004; 23: 519–530https://doi.org/10.1016/j.csm.2004.06.003

Abstract | Full Text | Full Text PDF | PubMed | Scopus (64)
| Google ScholarSee all References
] The bat reaches maximal velocity just prior to ball contact as well, coinciding with maximal force generation. This results in a moment arm dominated by a pulling motion away from the hands and, therefore, the elbow.[4x[4]Crisco, J.J., Osvalds, N.J., and Rainbow, M.J. The kinetics of swinging a baseball bat. J Appl Biomech. 2018; 34: 386–391https://doi.org/10.1123/jab.2017-0337

Crossref | PubMed | Scopus (0)
| Google ScholarSee all References
] The wrists and forearms also progress through a rotational moment arm, reaching its maximum torque at about 20-degrees prior to impact with the lead arm progressing from pronation to full supination at the end of follow-through.[13x[13]Milanovich, M. and Nesbit, S.M. A three-dimensional kinematic and kinetic study of the college-level female softball swing. J Sport Sci Med. 2014; 13: 180–191 (No doi)

Google ScholarSee all References
] The elbow is typically noted to be in a position of about 175-degrees of extension at time of impact; the elbow then flexes in order to facilitate negative acceleration of the bat following contact.[12x[12]Loftice, J., Fleisig, G.S., Zheng, N., and Andrews, J.R. Biomechanics of the elbow in sports. Clin Sports Med. 2004; 23: 519–530https://doi.org/10.1016/j.csm.2004.06.003

Abstract | Full Text | Full Text PDF | PubMed | Scopus (64)
| Google ScholarSee all References
]

The biomechanical analysis of the baseball or softball swing is not consistent with the force vectors of the commonly-cited mechanism of distal biceps ruptures. The dynamic forces at the elbow during the course of a swing do not mirror those seen in activities such as deadlifting or heavy curls which most-frequently contribute to such injuries. The maximum force at the elbow during the swing path is actually with the elbow in near-full extension followed by active flexion, quite the opposite of commonly described clinical histories.

Our patient, in addition to the more popularized injury of professional baseball player Miguel Cabrera, demonstrated a rarely reported mechanism of distal biceps tendon rupture. We must acknowledge that these individuals may have had microscopic or macroscopic predispositions toward this injury as described by previous authors, including tendinopathy or mucoid degeneration.[8x[8]Kannus, P. and Józsa, L. Histopathological Preceding Changes Rupture of a Tendon. J Bone Joint Surg Am. 1991; 73: 1507–1525

Crossref | PubMed | Scopus (1094)
| Google ScholarSee all References
],[11x[11]Kokkalis, Z.T. and Sotereanos, D.G. Biceps Tendon Injuries in Athletes. Hand Clin. 2009; 25: 347–357https://doi.org/10.1016/j.hcl.2009.05.007

Abstract | Full Text | Full Text PDF | PubMed | Scopus (15)
| Google ScholarSee all References
] We theorize that antecedent tendon degeneration in combination with aggressive forearm supination, near full elbow extension, and shoulder abduction and extension tensions the distal biceps tendon beyond its maximal load to failure, leading to rupture at its distal insertion as seen in our patient (Figure 1). This is quite different to the frequently cited mechanisms involving sudden extension force on a flexed elbow or eccentric contraction of the biceps against heavy loads as seen in weightlifting exercises.[1x[1]Albishi, W., Agenor, A., Lam, J.J., and Elmaraghy, A. Distal Biceps Tendon Tears: Diagnosis and Treatment Algorithm. JBJS Rev. 2021; 9: 1–10https://doi.org/10.2106/jbjs.rvw.20.00151

Crossref
| Google ScholarSee all References
],[6x[6]Golshani, K., Cinque, M.E., O’Halloran, P., Softness, K., Keeling, L., and Macdonell, J.R. Upper extremity weightlifting injuries: Diagnosis and management. J Orthop. 2018; 15: 24–27https://doi.org/10.1016/j.jor.2017.11.005

Crossref | PubMed | Scopus (10)
| Google ScholarSee all References
],[8x[8]Kannus, P. and Józsa, L. Histopathological Preceding Changes Rupture of a Tendon. J Bone Joint Surg Am. 1991; 73: 1507–1525

Crossref | PubMed | Scopus (1094)
| Google ScholarSee all References
, 9x[9]Kapicioglu, M., Bilgin, E., Guven, N., Pulatkan, A., and Bilsel, K. The Role of Deadlifts in Distal Biceps Brachii Tendon Ruptures: An Alternative Mechanism Described With YouTube Videos. Orthop J Sport Med. 2021; 9: 1–6https://doi.org/10.1177/2325967121991811

Crossref | Scopus (3)
| Google ScholarSee all References
, 10x[10]Kelly, M.P., Perkinson, S.G., Ablove, R.H., and Tueting, J.L. Distal Biceps Tendon Ruptures: An Epidemiological Analysis Using a Large Population Database. Am J Sports Med. 2015; 43: 2012–2017https://doi.org/10.1177/0363546515587738

Crossref | PubMed | Scopus (116)
| Google ScholarSee all References
],[15x[15]Schamblin, M.L. and Safran, M.R. Injury of the distal biceps at the musculotendinous junction. J Shoulder Elb Surg. 2007; 16: 208–212https://doi.org/10.1016/j.jse.2006.06.009

Abstract | Full Text | Full Text PDF | PubMed | Scopus (40)
| Google ScholarSee all References
] While this mechanism has not been previously reported and similar activities, it should be recognized as potential risk factors for such injuries.

 Opens large image

Figure 1

Illustration of batter arm and forearm position at swing follow through.

CONCLUSION

The mechanism of distal biceps rupture evidenced in this patient is relatively inconsistent with the commonly described modes of injury in the literature. Given the documented biomechanics and forces at the elbow during the course of the baseball or softball swing, it is not surprising that this activity could represent a risk to individuals at risk for this injury.

ACKNOWLEDGMENTS

The authors would like to thank the Hughston Foundation for their assistance with medical illustrations and manuscript editing.

REFERENCES

  1. [1]Albishi, W., Agenor, A., Lam, J.J., and Elmaraghy, A. Distal Biceps Tendon Tears: Diagnosis and Treatment Algorithm. JBJS Rev. 2021; 9: 1–10https://doi.org/10.2106/jbjs.rvw.20.00151
  2. [2]Beck J. Cabrera “in shock,” set for surgery this week. MLB.com. Published 2018. Accessed February 12, 2021. https://www.mlb.com/news/miguel-cabrera-to-have-biceps-surgery-thursday-c281125774
  3. [3]Camp, C.L., Dines, J.S., van der List, J.P., Conte, S., Conway, J., Altchek, D.W. et al. Summative Report on Time Out of Play for Major and Minor League Baseball: An Analysis of 49,955 Injuries From 2011 Through 2016. Am J Sports Med. 2018; 46: 1727–1732https://doi.org/10.1177/0363546518765158
  4. [4]Crisco, J.J., Osvalds, N.J., and Rainbow, M.J. The kinetics of swinging a baseball bat. J Appl Biomech. 2018; 34: 386–391https://doi.org/10.1123/jab.2017-0337
  5. [5]Eames, M.H.A., Bain, G.I., Fogg, Q.A., and Van Riet, R.P. Distal biceps tendon anatomy: A cadaveric study. J Bone Jt Surg - Ser A. 2007; 89: 1044–1049https://doi.org/10.2106/JBJS.D.02992
  6. [6]Golshani, K., Cinque, M.E., O’Halloran, P., Softness, K., Keeling, L., and Macdonell, J.R. Upper extremity weightlifting injuries: Diagnosis and management. J Orthop. 2018; 15: 24–27https://doi.org/10.1016/j.jor.2017.11.005
  7. [7]Johnson, J., Deren, M., Chambers, A., Cassidy, D., Koruprolu, S., and Born, C. Biomechanical Analysis of Fixation Devices for Basicervical Femoral Neck Fractures. J Am Acad Orthop Surg. 2019; 27: e41–e48https://doi.org/10.5435/JAAOS-D-17-00155
  8. [8]Kannus, P. and Józsa, L. Histopathological Preceding Changes Rupture of a Tendon. J Bone Joint Surg Am. 1991; 73: 1507–1525
  9. [9]Kapicioglu, M., Bilgin, E., Guven, N., Pulatkan, A., and Bilsel, K. The Role of Deadlifts in Distal Biceps Brachii Tendon Ruptures: An Alternative Mechanism Described With YouTube Videos. Orthop J Sport Med. 2021; 9: 1–6https://doi.org/10.1177/2325967121991811
  10. [10]Kelly, M.P., Perkinson, S.G., Ablove, R.H., and Tueting, J.L. Distal Biceps Tendon Ruptures: An Epidemiological Analysis Using a Large Population Database. Am J Sports Med. 2015; 43: 2012–2017https://doi.org/10.1177/0363546515587738
  11. [11]Kokkalis, Z.T. and Sotereanos, D.G. Biceps Tendon Injuries in Athletes. Hand Clin. 2009; 25: 347–357https://doi.org/10.1016/j.hcl.2009.05.007
  12. [12]Loftice, J., Fleisig, G.S., Zheng, N., and Andrews, J.R. Biomechanics of the elbow in sports. Clin Sports Med. 2004; 23: 519–530https://doi.org/10.1016/j.csm.2004.06.003
  13. [13]Milanovich, M. and Nesbit, S.M. A three-dimensional kinematic and kinetic study of the college-level female softball swing. (No doi)J Sport Sci Med. 2014; 13: 180–191
  14. [14]Pullatt, R.C., Gadarla, M.R., Karas, R.H., Alsheikh-Ali, A.A., and Thompson, P.D. Tendon Rupture Associated With Simvastatin/Ezetimibe Therapy. Am J Cardiol. 2007; 100: 152–153https://doi.org/10.1016/j.amjcard.2007.02.068
  15. [15]Schamblin, M.L. and Safran, M.R. Injury of the distal biceps at the musculotendinous junction. J Shoulder Elb Surg. 2007; 16: 208–212https://doi.org/10.1016/j.jse.2006.06.009
  16. [16]Seiler, J.G., Parker, L.M., Chamberland, P.D.C., Sherbourne, G.M., and Carpenter, W.A. The distal biceps tendon. Two potential mechanisms involved in its rupture: Arterial supply and mechanical impingement. J Shoulder Elb Surg. 1995; 4: 149–156
  17. [17]Trehan, S.K. and Weiland, A.J. Baseball and softball injuries: Elbow, wrist, and hand. J Hand Surg Am. 2015; 40: 826–830https://doi.org/10.1016/j.jhsa.2014.11.024

Institutional review board approval was not required for this case report.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Patient consent: Obtained

CONSENT

Consent was obtained from the patient prior to surgical intervention and manuscript creation.

 

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