Orthopedics

Case Report 

Brachialis Muscle Tendon Rupture of the Distal Ulnar Attachment in a Competitive Weight Lifter

Emily J. Curry, BA; Antonio Cusano, BS; Osama Elattar, MD; Andrew Bogart, MD; Akira Murakami, MD; Xinning Li, MD

Abstract

Isolated tears of the brachialis muscle are rare and often take on the clinical appearance of other pathology, such as a distal biceps brachii tendon tear or an intramuscular tumor, thus making diagnosis especially difficult. The authors describe the case of a 31-year-old competitive male weight lifter who was found to have a full-thickness tear of the brachialis tendon at its distal ulnar attachment after performing a 40.8-kg biceps curl. The authors describe the differential diagnosis, radiographic findings, and methods used that led to the diagnosis and also provide a comprehensive review of the literature on brachialis muscle injuries. The patient decided to proceed with conservative management consisting of a period of rest and physical therapy. At 10 months after the injury, the patient went back to weightlifting and biceps curls. He had progressed to full strength and had returned to all weightlifting activities at final follow-up. Isolated full-thickness brachialis muscle ruptures can be treated successfully with conservative management, including rest and physical therapy. [Orthopedics. 201x; xx(x):xx–xx.]

Abstract

Isolated tears of the brachialis muscle are rare and often take on the clinical appearance of other pathology, such as a distal biceps brachii tendon tear or an intramuscular tumor, thus making diagnosis especially difficult. The authors describe the case of a 31-year-old competitive male weight lifter who was found to have a full-thickness tear of the brachialis tendon at its distal ulnar attachment after performing a 40.8-kg biceps curl. The authors describe the differential diagnosis, radiographic findings, and methods used that led to the diagnosis and also provide a comprehensive review of the literature on brachialis muscle injuries. The patient decided to proceed with conservative management consisting of a period of rest and physical therapy. At 10 months after the injury, the patient went back to weightlifting and biceps curls. He had progressed to full strength and had returned to all weightlifting activities at final follow-up. Isolated full-thickness brachialis muscle ruptures can be treated successfully with conservative management, including rest and physical therapy. [Orthopedics. 201x; xx(x):xx–xx.]

Isolated tears of the brachialis muscle are rare and not well documented in the literature. There have been conflicting opinions regarding the basic morphology and function of the brachialis muscle. The relative infrequency of the injury, and its similar presentation to the more commonly reported conditions such as a distal biceps brachii tendon tear or an intramuscular tumor, makes the diagnosis of a brachialis muscle tear particularly difficult. Further, there is no consensus on whether operative or nonoperative management is most effective for maximal patient outcome.

The authors describe a 31-year-old competitive male weight lifter who sustained a full-thickness tear of the brachialis tendon at its distal ulnar attachment after performing a 40.8-kg biceps curl. To the authors' knowledge, this is the first report of a full-thickness rupture of the brachialis tendon at the distal ulnar attachment site. The authors describe the clinical presentation, radiographic findings, and management of brachialis muscle injuries and also provide a review of the available literature.

Case Report

A 31-year-old, right-hand–dominant male anesthesiologist with an unremarkable past medical history presented to the authors' clinic with 1 month of progressively worsening right elbow pain after doing 40.8-kg dumbbell curls. The patient, who is a competitive weight lifter, could not recall a discrete injury. He noticed progressive right elbow pain and weakness, particularly with flexion and supination movements, that ultimately interfered with his ability to continue lifting weights. At the time of presentation, he had not tried anti-inflammatory medications, injections, or physical therapy to manage his symptoms. He reported no previous anabolic steroid use, tobacco use, or injury.

On physical examination, there were no gross deformities or muscle atrophy. Neurovascular examination revealed 2+ radial and ulnar pulses with no sensory deficits. Elbow range of motion was symmetrical to the contralateral side, with extension and flexion between 0° and 140° and supination and pronation between 0° and 85°. There was pain with elbow flexion. Flexion strength was 4+/5, supination was 5/5, and pronation was 5/5.

Plain right elbow radiographs performed at the time of presentation showed a preserved joint space, with no fractures or dislocation. Follow-up magnetic resonance imaging of the elbow was performed approximately 2 weeks later, showing a full-thickness tear of the brachialis tendon insertion with mild retraction of the torn fibers from its ulnar attachment site (Figure 1). There was a mild posttraumatic bicipitoradial bursitis but no acute injury of the distal biceps tendon insertion.

Sagittal proton density (A) and axial T2-weighted fat-saturated (B) magnetic resonance images of the elbow showing a full-thickness tear of the brachialis tendon insertion (arrow) and the mild bicipitoradial radial bursitis (arrowhead).

Figure 1:

Sagittal proton density (A) and axial T2-weighted fat-saturated (B) magnetic resonance images of the elbow showing a full-thickness tear of the brachialis tendon insertion (arrow) and the mild bicipitoradial radial bursitis (arrowhead).

After being counseled regarding different treatment options, including nonoperative management, platelet-rich plasma injections, ultrasound therapy, and surgical intervention (debridement only or debridement and reattachment), the patient elected to receive conservative nonoperative treatment with a formal physical therapy regimen. The patient conservatively managed his condition during the next 10 months and made every attempt to avoid overloading his right elbow (no heavy biceps curls) except for when he was required to perform his clinical obligations as an anesthesiologist.

After 10 months, he gradually progressed to a mild workout routine initially with 9.1- to 13.6-kg biceps curls and ultimately advanced as tolerated. He did not use any pain or anti-inflammatory medications but did ice the elbow nightly. Eighteen months after the injury, the patient has no pain, has full flexion strength, and is performing his pre-injury weight-lifting regimen (Figure 2).

Clinical photograph 18 months after the injury showing normal symmetrical contour of both arms (A). The patient was able to return to the pre-injury weightlifting regimen of 40.8- to 45.4-kg biceps curls (B).

Figure 2:

Clinical photograph 18 months after the injury showing normal symmetrical contour of both arms (A). The patient was able to return to the pre-injury weightlifting regimen of 40.8- to 45.4-kg biceps curls (B).

At the most recent follow-up at 18 months after injury, the patient's Oxford Elbow Score and Disabilities of the Arm, Shoulder and Hand score were 48 and 0, respectively. At the time of initial injury, the Oxford Elbow Score and the Disabilities of the Arm, Shoulder and Hand score were 37 and 34.2, respectively. Further, the visual analog scale score had improved from 4 at the time of initial injury to 0 on the most recent evaluation.

Discussion

Isolated full-thickness tears at the distal ulnar attachment of the brachialis muscle are extremely rare and have not been described in the literature. Van den Berghe et al1 were the first to describe a case of a brachialis rupture in 2001. Since then, several other cases have been reported with varying brachialis muscle tendon tear locations, including intra-substance muscle belly tears and partial tears to the distal ulnar attachment and myotendinous junction (Table 1).2–8 A few unusual cases of brachialis injuries have also been reported, including a brachialis necrosis due to exercise,9 tuberculous abscess of the brachialis and biceps,10 and atraumatic snapping of the brachialis tendon.11,12

Summary of Current Brachialis Muscle Tear Case Reports

Table 1:

Summary of Current Brachialis Muscle Tear Case Reports

The presentation of a true brachialis injury is often similar to that of an intramuscular tumor or a tear to the distal biceps tendon. This similarity, and the relative infrequency of a brachialis muscle rupture, makes the diagnosis of a true brachialis muscle tendon injury difficult. The brachialis muscle travels over the biceps brachii when the arm is eccentrically contracted.13 As such, it is particularly susceptible to injury when an individual eccentrically contracts the arm with both the forearm and the elbow pronated and extended, respectively. In case reports describing isolated brachialis tears, patients report a range of injury mechanisms but most commonly describe a traumatic hyperextension injury typically related to weighted resistance.4,7,8 Other case reports have described a heavy lifting event1,6 and insidious onset of pain in 1 elderly patient.5

In terms of patient history and physical examination, unlike most other tendon ruptures, most patients do not report feeling a “pop” at the time of injury, as seen with the current patient. Furthermore, onset of pain reported by patients also varies and can be either immediate or delayed along with decreased function and swelling. Swelling, ecchymosis, and localized tenderness in the anterior mid-arm is also common.1,5 However, unlike in the case of a distal biceps muscle injury, where a noticeable gap is often found on physical examination, a brachialis injury may be more difficult to appreciate because of its position deep to the overlying biceps brachii muscle.8 This varied patient presentation further complicates the possibility of making a clear diagnosis.

In each previously documented case, imaging that led to a diagnosis included plain radiographs, magnetic resonance images, and/or ultrasound. Plain radiographs can rule out fractures as a more probable cause of acute elbow pain in the setting of trauma. More sensitive imaging modalities such as ultrasound or magnetic resonance imaging are essential for the diagnosis and identifying injury to the brachialis muscle. In this regard, cost and ease of access are 2 major advantages of ultrasound vs the more conventional magnetic resonance imaging.6 Schönberger and Ernst6 recently described the efficacy of ultrasound in the diagnosis of a brachialis muscle rupture. They were able to visualize a heterogeneous structure with low echogenicity at the ulnar attachment of the brachialis muscle directly distal to the coronoid, as well as a second area of low echogenicity within the brachialis muscle itself. This is consistent with a brachialis rupture in a patient who felt an immediate snap in his left elbow and associated pain and weakness after lifting a motorcycle.

Conclusion

Every reported case of isolated traumatic brachialis muscle injury was treated nonoperatively and responded well to conservative treatment. In the absence of concomitant injuries, the authors recommend a nonoperative course consisting of rest and physical therapy focused on maintaining range of motion and strengthening, with the expectation that patients will be able to return to full activities in 3 weeks to 10 months depending on their age, symptoms, tear location, severity, and pre-injury activities. However, the current patient— an anesthesiologist and competitive body builder whose daily workout regimen included heavy weightlifting with biceps curls up to 45.4 kg—had a more severe full-thickness rupture of the distal ulnar attachment of the brachialis. He started weightlifting activities 10 months after the initial injury and had a full return to activity at 18 months without strength deficits. However, this patient was able to maintain his full activities of daily living throughout the post-injury period and did not take time off from work for his injury.

References

  1. Van den Berghe GR, Queenan JF, Murphy DA. Isolated rupture of the brachialis: a case report. J Bone Joint Surg Am. 2001;83(7):1074–1075. doi:10.2106/00004623-200107000-00015 [CrossRef]
  2. Costa JH, Marques TP. Traumatic rupture of the brachialis muscle in a 52-year-old man. BMJ Case Rep. 2015;2015. doi:10.1136/bcr-2015-209421 [CrossRef]
  3. Krych AJ, Kohen RB, Rodeo SA, Barnes RP, Warren RF, Hotchkiss RN. Acute brachialis muscle rupture caused by closed elbow dislocation in a professional American football player. J Shoulder Elbow Surg. 2012;21(7):e1–e5. doi:10.1016/j.jse.2011.11.007 [CrossRef]
  4. Murugappan KS, Mohammed K. Acute traumatic brachialis rupture in a young rugby player: a case report. J Shoulder Elbow Surg. 2012;21(6):e12–e14. doi:10.1016/j.jse.2011.10.009 [CrossRef]
  5. Nishida Y, Tsukushi S, Yamada Y, Hosono K, Ishiguro N. Brachialis muscle tear mimicking an intramuscular tumor: a report of two cases. J Hand Surg Am. 2007;32(8):1237–1241. doi:10.1016/j.jhsa.2007.06.002 [CrossRef]
  6. Schönberger TJ, Ernst MF. A brachialis muscle rupture diagnosed by ultrasound: case report. Int J Emerg Med. 2011;4(1):46. doi:10.1186/1865-1380-4-46 [CrossRef]
  7. Wasserstein D, White L, Theodoropoulos J. Traumatic brachialis muscle injury by elbow hyperextension in a professional hockey player. Clin J Sport Med. 2010;20(3):211–212. doi:10.1097/JSM.0b013e3181df1ed4 [CrossRef]
  8. Winblad JB, Escobedo E, Hunter JC. Brachialis muscle rupture and hematoma. Radiol Case Rep. 2015;3(4):251. doi:10.2484/rcr.v3i4.251 [CrossRef]
  9. Farmer KW, McFarland EG, Sonin A, Cosgarea AJ, Roehrig GJ. Isolated necrosis of the brachialis muscle due to exercise. Orthopedics. 2002;25(6):682–684.
  10. Abdelwahab IF, Kenan S. Tuberculous abscess of the brachialis and biceps brachii muscles without osseous involvement: a case report. J Bone Joint Surg Am. 1998;80(10):1521–1524. doi:10.2106/00004623-199810000-00014 [CrossRef]
  11. Coonrad RW, Spinner RJ. Snapping brachialis tendon associated with median neuropathy: a case report. J Bone Joint Surg Am. 1995;77(12):1891–1893. doi:10.2106/00004623-199512000-00015 [CrossRef]
  12. Rudy BS, Armstrong AD. Atraumatic snapping brachialis in a 37-year-old woman. JAAPA. 2007;20(1):48, 50–51. doi:10.1097/01720610-200701000-00010 [CrossRef]
  13. Kulig K, Powers CM, Shellock FG, Terk M. The effects of eccentric velocity on activation of elbow flexors: evaluation by magnetic resonance imaging. Med Sci Sports Exerc. 2001;33(2):196–200. doi:10.1097/00005768-200102000-00004 [CrossRef]

Summary of Current Brachialis Muscle Tear Case Reports

StudyYearJournalNo. of PatientsAge, ySexMechanism of InjuryChief ConcernImaging Used for DiagnosisMuscle InvolvedTear Location and PatternOperative or Nonoperative ManagementRecovery TimeOverall Outcome
Van den Berghe et al12001Journal of Bone and Joint Surgery— American167MaleLifting heavy nativity scene at churchSwelling, tenderness, erythema, burning sensation, palpable massPlain radiographs, MRIDistal brachialisProximal to musculotendinous junction; linear tearNonoperative10 moReturn to full activities
Nishida et al52007The Journal of Hand Surgery216MaleJudo trainingPain, swelling anteriorly, no sudden acute pain, mid-arm swellingPlain radiographs, MRIBrachialisPartial tear of muscle bellyNonoperative2 moReturn to full activities (including sports)
67MaleNo specific injury–possibly golfingPain, swelling, anterior burning sensation, palpable massPlain radiographs, MRIBrachialisPartial tear of muscle bellyNonoperative3 moReturn to full activities (including golf)
Wasserstein et al72010Clinical Journal of Sports Medicine128MaleElbow hyperextension while shooting puck during professional hockey gameGeneralized swelling and tenderness proximal to medial humeral condylePlain radiographs, MRIBrachialisGrade II injury at the muscle's distal humeral origin; edema in the common flexor origin (grade I)Nonoperative3 wkPain free and full return to play
Schönberger and Ernst62011International Journal of Emergency Medicine145MaleLifting motorcycleImmediate snap in left elbow with pain and weaknessPlain radiographs, ultrasoundBrachialisIntrasubstance tear of muscle belly and ulnar attachmentNonoperative10 wkReturn to full activities
Murugappan and Mohammed42012Journal of Shoulder and Elbow Surgery117MaleHyperextension injury while playing rugbySevere anterior elbow pain, limited motion, ecchymosisUltrasound, MRIBrachialisEdema at myotendinous junction of brachialis muscle approximately 6 cm from muscle insertion, but tendon was intactNonoperativeReturn to sport at 4 mo; last follow-up was 1 yReturn to full activities (including sports)
Winblad et al82015Radiology Case Reports117MaleHyperextension during football tackleImmediate pain, swelling; no poppingPlain radiographs, MRIBrachialisTendon insertion at ulna normal; intrasubstance tear in the muscleNonoperativeUnknownReturn to full activities
Costa and Marques22015BMJ Case Reports152MaleHyperextension injury from fallSudden snap in left elbow with pain and weakness, ecchymosis, palpable massUltrasound, MRIBrachialisHumeral attachment of brachialis muscleNonoperative12 wkReturn to full activities
Authors

The authors are from the Boston University School of Public Health (EJC) and the Department of Orthopaedic Surgery (EJC, AC, OE, XL), the Department of Anesthesiology (AB), and the Department of Radiology (AM), Boston University School of Medicine, Boston, Massachusetts.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Xinning Li, MD, Department of Orthopaedic Surgery, Boston University School of Medicine, 850 Harrison Ave, Dowling 2-North, Boston, MA 02118 ( Xinning.li@gmail.com).

Received: May 08, 2018
Accepted: July 18, 2018

10.3928/01477447-20190221-04

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