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Proximal long-head biceps tendon rupture — MSRA MCQ

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HardShoulder InjuriesProximal long-head biceps tendon ruptureMSRA

A 49-year-old self-employed joiner presents 2 days after feeling a sudden painful snap at the front of his dominant shoulder while lifting a heavy door. He had no fall and no previous shoulder instability. Bruising has developed over the proximal upper arm, and there is a prominent distal bulge of the biceps muscle when he flexes the elbow. Active and passive shoulder abduction are both 160 degrees. Resisted external rotation and abduction are full strength. Elbow flexion and forearm supination are full strength and painless. There is no antecubital fossa tenderness or bruising. Distal neurovascular examination is normal. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Provide analgesia and refer for musculoskeletal physiotherapy without routine orthopaedic referral

Explanation lettering: D = shown as A · C = shown as B · A = shown as C · B = shown as D

This is a rupture of the long head of biceps at the shoulder. The proximal anterior shoulder pain, subsequent upper-arm bruising and Popeye-type distal muscle bulge are characteristic. The decisive negative findings are preserved painless elbow flexion and supination, with no antecubital fossa tenderness or bruising: these argue strongly against distal biceps rupture, for which early specialist assessment is important, particularly in active patients. Full abduction and external-rotation strength also make an acute clinically significant rotator-cuff tear unlikely. NHS Tayside guidance states that long-head biceps ruptures at the shoulder are not routinely repaired; where pain is the predominant problem, MSK physiotherapy is appropriate. Analgesia and rehabilitation are therefore the appropriate primary-care management. A is attractive because he is a manual worker with a biceps injury, but the lesion is proximal rather than distal. C would be appropriate if traumatic cuff tear were suggested by objective abduction or external-rotation weakness. D is not indicated without features suggesting a labral injury, such as instability, catching or persistent mechanical symptoms. E risks avoidable stiffness and offers no benefit for an isolated proximal long-head rupture.

Reference: NHS Tayside RefGuide: Shoulder and Elbow (Current page; accessed 15 August 2026) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-refguide/surgery-and-orthopaedics/orthopaedic-and-trauma-surgery/shoulder-and-elbow/?organization=nhs-tayside&useNavigation=true