Scad J Med Sci Sports 1994: 4: 259-260 Printed in Denmark All rights reserved

I Jensen IH, Kramharft M. Distal rupture of the biceps femoris muscle. Scand J Med Sci Sports 1994: 4: 259-260. 0 Munksgaard, 1994

Total rupture of the femoral biceps muscle is a rare diagnosis, probably because it is disregarded. Few cases have been reported in the literature, and in all cases surgery has been performed. The 2 patients described both had a complete rupture of the femoral biceps tendon a few centi- metres proximally to its insertion at caput fibulae. Both sustained the injury during a soccer game. One patient was treated conservatively and the other operated. The final results were similar, but the conservatively treated patient was fully restored after 2 to 3 weeks, whereas the operated patient took more than 3 months to obtain full function.

Copyright Q Munksgaard 1994 Scandinavian Journal of

MEDICINE & SCIENCE IN SPORTS

ISSN 0905-7188

Case report

Distal rupture of the biceps femoris muscle

Total rupture of the biceps femoris muscle tendon is a rare injury, probably because it is a disregarded diagnosis. Few cases are reported in the literature, and only cases for which surgical treatment has been chosen are described. We have treated 2 patients with a total rupture of the femoral musculus biceps ten- don proximal to its insertion at caput fibula, and this article discusses whether surgical treatment is prefer- able to conservative treatment.

Case 1 While playing soccer, a 30-year old professional player experienced a sudden snap in the posterior- lateral region of his left knee. He was standing on his right leg with a flexed left hip joint. While stretching his left knee to kick the ball, he felt the snap at the back of the knee. Physical examination revealed a palpaple gap proximate to m. biceps fem- oris point of insertion at caput fibula. At muscle con- traction a bulk was visible immediately proximal to this point. Beyond this, the only finding during examination was distinct tenderness of the injured area.

As the soccer team urgently needed the player, conservative treatment was preferred to surgery, be- cause surgery and the following recuperation were foreseen to give more inconvenience in form of days lost through sickness, rehabilitation and possible postoperative complications.

Furthermore, a lack of the femoral biceps muscle was not thought likely to pose any essential problem besides a possible occasional feeling of muscle weak- ness. The patient was treated conservatively with ul-

I. H. Jensen, M. Kramhsft Department of Orthopaedic Surgery, Naestved Centralsygehus, Denmark

Key words: beceps femoris; tendon rupture; conservative/operative treatment

Ina Hedegaard Jensen, Aaboulevard 1, DK-1635 Copenhagen V, Denmark Accepted for publication December 7, 1993

trasound for as long as pain persisted and restricted mobility, guided by pain, was recommended. Only 2-3 weeks after the injury he was fully restored and was fully able to take up soccer again.

At follow-up, 6 years after the injury, he still had full function of his left leg, and the control also re- vealed a continuous femoral biceps tendon; however the tendon was slightly thicker a few centimetres proximal to its insertion at caput fibula.

Case 2 A 35-year-old man was admitted to hospital under the diagnosis of ruptura musculi biceps femoris dx. During a soccer game, he had made a kick up in the air. During this his hip was bent, and his knee fully stretched. He felt a snap in the right knee hamstring. Initially the thought he had been kicked by another player but then discovered that no one was close to him.

At physical examination, there was tenderness of the lateral part of the knee and palpation and visual inspection revealed a deficient femoral biceps ten- don. Surgical treatment was decided, confirming that the biceps-femoris tendon had ruptured at the muscle/tendon junction. After re-insertion the pa- tient was equipped with a range of motion splint for 6 weeks, which restricted movement and weight- bearing.

After 6 weeks a considerable muscular hypotrophy of the affected leg called for an extensive rehabili- tation programme. At physical examination after 3 months, atrophy of the muscle can still be recognized

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but there is good performance power and the ten- dom is present.

Discussion Spontaneous rupture of the muscle-tendon unit is one of the most frequent injuries treated by orthopaedic surgeons. Tendon ruptures are most common in middle-aged and elderly patients, supposedly as a re- sult of intrinsic trauma of the tendon secondary to re- petitive microtrauma. In addition, conditions such as rheumatoid arthritis, uraemia, lupus erythematosis, diabetes mellitus, hyperparathyroidism and renal fail- ure cause a weakening of tendons. Lack of strength, due to inadequate training or warming up, and poor conditioning and strength of muscles also influence the risk of injury. It is also well known that systemic steroids and injection of steroids directly into a tendon may predispose the tendon to rupture.

The treatment of a total rupture of the Achilles tendon has been discussed for years, and no investi- gations indicate that functional recovery and strength differ sigmflcantly according to method of treatment. However, the incidence of rerupture is twice as high (20% vs 10%) for conservative treat- ment versus surgery. On the other hand, conservative treatment has a recovery time more than 30% less than surgery (9 vs 13 weeks) and a complication rate 50% lower (1 0% vs 2Ph) than surgery (1).

A study of the plantaris longus tendon in rabbits performed by Carlstedt (2) concludes that tendon healing as measured by biomechanical and biochem- ical parameters was not improved by surgical treat- ment compared with conservative treatment.

Burkett (3) concludes that the hamstring is strain- ed when the hamstring and the quadriceps contract at the same time, drawing in opposite directions. The stronger quadriceps muscle makes the hamstring yield. McGoldrick 8z Colville (4), Sebastianelli et al. (5 ) and Verburg 8z Keeman (6) all describe a total rupture of the tendon of the femoral m. biceps in

athletes. In all 4 cases described operation was de- cided with a successful result.

The cases described in this article deal with quite healthy and sporty patients. Both lesions occurred during soccer games with a sudden strain of the ham- strings. Both patients, at the time of injury, were standing on one leg while stretching and kicking with a stretched leg. In this positition, when the stretched and kicking leg reached full extension in the knee joint, the injury occurred. As to the cases described here, the patient who

was operated took more than 3 months to obtain full function. The patient who was treated conservatively was fully restored after 2 to 3 weeks only, and an intact tendon was later observed.

Conclusion The diagnosis of total femoral biceps rupture is probably often disregarded and treated as a minor knee injury with support and rest. The above-men- tioned case where conservative treatment was given deliberately resulted in a considerably faster recov- ery. Both conservative and operative treatments re- sulted in full recovery.

References 1.

2.

3.

4.

5.

6.

Wills CA, Washburn S, Caiozzo V, Prietto CA. Achilles tendon rupture. A review of the literature comparing surgi- cal versus nonsurgical treatment. Clin Orthop 1986 207: 156-63. Carlstedt CA. Mechanical and chemical factors in tendon healing. Acta Orthop Scand 1987: suppl224 58. Burkett LN. Investigations into hamstring strains. The case of the hybrid muscle. J Sports Med 1975: 3(5): 228-31. McGoldrick F, Colville J. Spontaneous rupture of the bi- ceps femoris. Arch Orthop Trauma Surg 1990 109(4): 234. Sebastianelli WJ, Hanks GA, Kalenak A. Isolated avul- sion of the biceps femoris insertion. A case report. Clin Orthop 1990.259: 200-3. Verburg H, Keeman JN. Complete ruptuur van de M. bi- ceps femoris-pees. Ned Tijdschr Geneeskd 1991: 135(42): 1970-1.

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Scmd J Med Set Sports 1994: 4: 261-287 Printed RI D-rk . All rights reserved

Abstracts

Second Scandinavian Congress

Copyright 0 Munksgaord 1994

Scandinovion Journal of MEDICINE & SCIENCE

IN SPORTS ISSN 0905-7188

of Sports I

Medicine, Copenhagen, Denmark, November 2427,1994

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