Thursday, February 27, 2014

Injured: Being Afraid

To the 868 people who viewed this blog yesterday...THANK YOU!!

Climbing Mountains, Being Afraid

    Although we as triathletes push pretty hard sometimes, we’re rarely outside our comfort zone in other than a physical sense.  In a previous blog, I briefly described hiking the John Muir Trail with my son Ben a couple years ago.  This was a six day journey through wooded areas, over many creeks and streams, as well as some fairly steep mountain trails culminating in standing atop Mount Whitney, the highest peak in the lower 48 states, with it’s seeming 100 mile view.  On the third day, our longest, after traversing some pretty difficult to navigate terrain (since we were so early in the season and didn’t have the benefit of hikers preceding us foot traffic marking the correct trail), we crossed one particular river and unbeknownst to us, were off the trail.  Way off.  We tried to back track to a known point, but we were lost.  Lost in billions of acres of land…with no GPS…no cell service…no plan “B”, no nothing.  The only way out of this was to think our way out.
    It’s times like this that occasionally you don’t think terribly rationally.  Like during the run in a triathlon.  In the former, although you have a tent and food for a week, you don’t know where you are.  And, the in latter, you’ve trained for this for an awfully long time but are rapidly running out of endurance and ideas at the same time.  You may have to…oh, don’t even think it…walk! 
   But for us it was one of those times that, with no other option, no chance for help from any outside source, that with a little luck, you “just do it.”  You take the information you do have, think the problem through such as you might have done in a college course, and you’ll likely find your way back to the trail. With great relief I might add.
   Injuries to the triathlete can follow a similar path.  One can have a physical problem, seek help from a friend, an internet forum or local medical professional.  But in the end, you know vastly more about yourself athletically than most physicians.  This would include the specific training load your body has seen including any recent overload situations, one of the most common sources of injury in my experience.  With just a little help pointing you in the right direction you can frequently come up with the right diagnosis.  Or when discussing your pain with the care giver be able to provide exceptionally accurate info as to when it was first noted and under what circumstances, what has changed, etc. Like being lost in the woods, you think the problem through.  And once you have the diagnosis, the route though the woods back to your training path is revealed like the yellow brick road. 
  So, next time you find yourself injured and start to possibly lose hope that you're lost, think it through.  Use your available resources, especially your own brain, and sometimes you’ll surprise yourself.  I’ve seen it happen.

Good luck, Dorothy.

Ben Post, USN and Dad

Monday, February 24, 2014

Injured Last Year? How to Plan an Injury-Free 2014.

"Where have all the good men gone and where are all the gods?

I need a hero. I'm holding out for a hero 'til the end of the night.

He's gotta be strong and he's gotta be fast...and he's gotta be larger than life."                                                                                                                   Bonnie Tyler

Today's triathlete for sure!

Injured Last Year?  Avoiding Injury This Year.

It was below freezing on our bike ride this morning.  Much of the triathlon world is probably enjoying the same, fretting about the upcoming season and wondering how to modify their Annual Training Plan, especially if recent injury is involved. Unfortunately, statistics would say that even if you've been involved in triathlon for just a few years, your probability of sustaining an injury of some kind is nearly 100%!  So now is the time, while you're preparing for the 2014 season, to review all available data from 2013 and see if you can both figure why your injury occurred and what you can do to avoid it (and others) in the upcoming year.  As has been said in these pages before, so much of triathlon injury is self-induced. Athletes missing workouts an then doubling up, accelerating the volume/intensity of training at a pace their body can't ultimately handle, that kind of thing.

Running, of course, is the source of over half of triathlon injuries.  This is particularly true when twisted ankles or bike crash related type trauma is excluded.  And, in my mind, one of the hardest things in this search for causation is honesty.  Self delusion is a well practiced skill for those who race. "Well, it hurts, but not so much that I can't keep trying to catch that guy up there." (Sound familiar?)

But the athlete's whole focus is attempting to coerce the body to accept a greater load, to accept a higher level of stress for the same effort expended. Thus, greater speed is the outcome...and potentially a podium finish for some.  So, it's these changes in stress, increases at a tolerable rate, that get us to our goal.  It's determining this rate of change that's the tricky part, however.  Why do you think there are so many stress fractures and other stress related injuries, etc. in our sport?

It's being honest in recognition of previous changes in routine.  Not just glossing through one's log thinking, "Oh, I should be able to handle this or handle that," when in fact you can't. And the change doesn't need to be Herculean. I've seen stress related injury after a single aberrant run.  For example, George goes to the beach and does his weekly 10 mile run in the hard packed sand, seemingly a soft (read non-concrete) surface and great idea.  But running out bound 5 consecutive miles at water's edge and back on the beach road, while softer on the feet, is really running 10 consecutive miles on the side of a shallow hill.  This is very different from the ever changing surfaces and angles that Georges legs see when he runs at home. Or, Sally is in Chicago visiting Aunt Minnie for Spring Break and gets fixed up with the local running group, all a tad quicker than Sally.  She executes her weekly 10 mile run with the group, pushed to her very limit, but quite satisfied at run's end with her "much better than I thought I could do" performance.  She revels in her ability to draft, to keep up despite being near exhaustion, etc....until pain develops some time later.  It's not easy for the body to accept change.

Thus when planning for 2014, review the musculoskeletal changes that didn't go as you'd planned previously. Include them in your thinking, maybe even talk it over with your "shoe guy" or other trusted adviser.  I've said in these pages before that the owner of our local running shoe store is the go-to-guy for running related problems locally. He's better than most all of the docs that I know.  If you run your plans by him/her you stand a much better chance of not repeating the same mistakes next year.

They say that knowledge is power. That's nowhere more true than in building a training plan. Good luck in your construction.

Thursday, February 20, 2014

Wrist Sprains, War on Cancer, Fastest Runner or Biker in Your Age Group?


"Some 40 years ago a metaphor was posed that cancer was such an insidious adversary that a declaration of war on the disease was justified.  Although this statement was a useful inspiration for enlistment of resources, despite extraordinary progress in our understanding of disease pathogenesis, in most cases and for most forms of cancer this war has not been won." 
                                                                                                                                 Lancet, 2/8/2014

After beating cancer, Old Greenwich resident Karen Newman won’t be scared off by a grueling race and has competed all over the world in triathlons, including, at left, in China.

This is Karen Newman of Old Greenwich, CT breast cancer survivor and terrific triathlete.  We sometimes feel because we're athletes that we may be invulnerable or immune "things that happen to other people." Maybe that's why I push pretty hard for us all to get flu shots.  Karen has an inspirational story written in the and if you have two minutes, it's a good read. 

And, she might be one to take issue with the Lancet statement.  Go Karen!

Ironman Pro Triathlon winners are well balanced

In other words, quite frequently the winner of a triathlon will not be the fastest swimmer, fastest biker, etc. but simply an athlete good at all three disciplines.  While true in the pro ranks, it is less so among age groupers where a standout biker or runner for example can take the checkered flag.  More interestingly, although most triathletes come from running backgrounds, a fast swimmer with quick ( meaning the athlete practices them a good bit) transitions, can get by with fair bike and run skills and end up at the top of the age group!

In the Hawaii setting, if you look at the top 5 swim, bike and run times in 2012, you'll find Andy Potts and Amanda Stevens with the quickest swims, Sebastian Kienle and Natasha Badmann (that's right, 46 year old Natasha!) putting up the fastest bike times and Bart Aernouts and Sonja Tajsich with the fastest runs.  But Pete Jacobs and Leanda Cave won the event without "winning" any of the three disciplines.

That almost held true in 2013 as well for World Championship winners Frederik Van Lierde and Mirinda Carfrae but when a woman breaks her own 26.2 mile run course record by pounding out a 2:50:38 finishing off an overall course record of 8:52:14, it begs one to notice.

Wrist Sprains
Bike crashes and running related falls

Although the collar bone (clavicle) is the most commonly broken bone in the body as anyone who watches the Tour de France will tell you, in bike crashes and falls while running, they have in common an outstretched wrist to attempt to break that fall.  A protective reaction I guess which you've seen in triathlons in racers near you.  It can result in a wrist sprain or worse.

A sprain is an injury to a ligament. Ligaments are strong bands of connective tissue that connect one bone to another.
A wrist sprain is a common injury. There are many ligaments in the wrist that can be stretched or torn, resulting in a sprain. This occurs when the wrist is bent forcefully, such as in a fall onto an outstretched hand.
Many ligaments support the wrist.
Wrist sprains can range from mild to severe. They are graded, depending on the degree of injury to the ligaments.
  • Grade 1. These mild sprains occur when the ligaments are stretched, but not torn.
  • Grade 2. These moderate sprains occur when the ligaments are partially torn. Grade 2 sprains may involve some loss of function.
  • Grade 3. These severe sprains occur when the ligament is completely torn. These are significant injuries that require medical or surgical care. As the ligament tears away from the bone, it may also take a small chip of bone with it, called an avulsion fracture.
Wrist sprains are most often caused by a fall onto an outstretched hand. This might happen during everyday activities, but frequently occurs during sports and outdoor recreation.
Symptoms of a wrist sprain may vary in intensity and location. The most common symptoms of a wrist sprain include:
  • Swelling in the wrist
  • Pain at the time of the injury
  • Persistent pain when you move your wrist
  • Bruising or discoloration of the skin around the wrist
  • Tenderness at the injury site
  • A feeling of popping or tearing inside the wrist
  • A warm or feverish feeling to the skin around the wrist
Sometimes, a wrist injury may seem mild with very little swelling, but it could be that an important ligament has been torn that will require surgery to avoid problems later.
Similarly, an unrecognized (occult) fracture may be mistakenly considered a mild or moderately sprained wrist. If left untreated, the broken bone may not heal and will require a surgery that could have been avoided with early, appropriate treatment. The most common example of this is an occult fracture of the scaphoid bone.
It is important in all but very mild cases for a doctor to evaluate a wrist injury. Proper diagnosis and treatment of wrist injuries is necessary to avoid long-lasting stiffness and pain.
Doctor Examination
Your doctor will discuss your medical history and any previous injuries to your hand or wrist. He or she will ask questions about how and when the current injury happened, and will review all your symptoms, including asking about any numbness in your hand.
Your doctor will examine your entire arm and hand to make sure that there are no other injuries. Tenderness in certain areas may suggest a broken bone.
Partial ligament tears are sometimes difficult to diagnose, but may cause re-occurring (chronic) disability if not treated surgically. Every effort should be made to properly diagnose the cause of persistent pain in a sprained wrist.

Imaging Tests

Your doctor may order imaging tests to help determine whether your wrist is sprained.
X-rays. Although they will not show an injury to the ligament, x-rays can show whether the injury is related to a broken bone.
Other tests. In some cases, a magnetic resonance imaging (MRI) scan, computed tomography (CT) scan, or arthrogram may also be ordered. An arthrogram involves the injection of some dye into the joint. This makes the joint and ligaments show up more clearly.

First Aid

Mild wrist sprains can usually be treated at home with the RICE protocol.
  • R Rest the joint for at least 48 hours.
  • I Ice the injury to reduce swelling.
    Do not apply ice directly to the skin. Use an ice pack or wrap a towel around the ice or a package of frozen vegetables. Apply ice for about 20 minutes at a time.
  • C Compress the swelling with an elastic bandage.
  • E Elevate the injury above the level of the heart.
A pain reliever, such as aspirin or ibuprofen, may be helpful. If pain and swelling persist for more than 48 hours, however, see a doctor.

Nonsurgical Treatment

Moderate sprains may need to be immobilized with a wrist splint for 1 or more weeks. This immobilization may cause some stiffness in your wrist and your doctor may recommend some stretching exercises to help you regain full mobility.

Surgical Treatment

Severe sprains may require surgery to repair the fully torn ligament. Surgery involves reconnecting the ligament to the bone. Your doctor will discuss the surgical options that best meet the needs of your injury.
Surgery is followed by a period of rehabilitation and exercises to strengthen the wrist and restore motion. Although the ligament can be expected to heal in 6 to 8 weeks, rehabilitation with full recovery of motion and strength can take several months. This depends on the severity of the sprain.

Because wrist sprains usually result from a fall, be careful when walking in wet or slippery conditions. Wrist sprains also occur during sports, such as triathlon, skating, skateboarding, and skiing. Wrist guard splints or protective tape can be used to support the wrist and prevent it from bending too far backward. When skiing, drop the poles during a fall to prevent wrist sprains.  Go USA Olympic Team!

Sunday, February 16, 2014

Little Evidence that Antimicrobial Soap Works/Believe What You Read in Triathlon Lit?

FDA Pushes Makers of Antimicrobial Soap to Prove Safety and Effectiveness

Each year US consumers are exposed to 2.2 million pounds of antimicrobial agents in soaps and body washes, according to the US Food and Drug Administration (FDA). Recent evidence from animal and cell-based studies that has raised questions about potential health risks associated with this widespread exposure prompted the FDA last month to ask the makers of these products to prove their safety and effectiveness.
Use of antimicrobial soaps and body washes is ubiquitous in homes and public places, despite the low risks of bacterial infection associated with these environments, explained Sandra Kweder, MD, deputy director of the Office of New Drugs at the FDA Center for Drug Evaluation and Research, during a December press briefing. There is also little evidence to suggest that these products offer any benefit compared with washing with ordinary soap and water, she noted.

To read the full piece in JAMA go to .
"It's good to be the King." (Pete Jacobs bike, Kona)

"I read it on the internet, so it must be true."

In other words, don't believe everything you read.  Here, or anywhere. (Although I do strive for accuracy in these writings.

I belong to the Arthroscopy Association of North America, ANNA, and in a recent Journal an editorial by Gary Poehling, MD et al  speaks to this phenomenon that I'll partially repeat.  We have so many "experts", web sites, mags, blogs and tweets which purport to tell us what we should do to improve/get faster/lead better lives, that we need to remain vigilant as to the source, veracity, and reliability of the information we take in.  In triathlon, bogus information may simply alter performance.  In medicine or your work, faulty or inaccurate communication could have a much more significant consequence.

"Mark Twain once said, “Facts are stubborn, but statistics are more pliable.”1
In an ever more technologically driven society, we strive for endless precision. The written word often carries unwarranted credence simply because it is written, or precise. Surely the phrase, “I read it on the Internet, so it must be true,” sounds familiar. (It should … a Google search of that quote alone yielded 864 million hits in 0.17 seconds.) Likewise, data with clever statistical tweaks can be guilty of the same problem. What researchers and clinicians should strive to discover, on the other hand, is its accuracy—how true it is.
Little has changed in the scientific method since the time of Aristotle, but much has changed in the ability to detect differences. We now have computing power nearly the size of a Cray computer in the palms of our hands. Recall the size of a hard drive in the early 1990s with 2 Megabytes being almost the size of a toaster. Now a typical thumb drive can carry over 8 Gigabytes, or 8,000 Megabytes, of data.
Technology provides us with the ability to calculate data points to the nth decimal. The clinical significance of that datum may be several decimal points to the left, or perhaps, even a whole integer.
Fortunately, we recognize that tremendous progress has been made from the days when “might made right.” We have shied away from expert opinion and veered dramatically toward higher levels of evidence. Terms like prospective, randomized, controlled, blinding, a priori power analysis, narrow confidence interval, outcome measure, and systemic review, appear regularly in most study reports. Most importantly, you, the reader, possess an uncanny ability to separate the wheat from the chaff.
In the future, newer tools will evolve to help us. Perhaps outcome measures, for example, can be standardized and updatable. In the meantime, we must keep our eye on the ball as we will be challenged to produce clinically accurate conclusions with the exponential increase in technology. As Gertrude Stein said, “Everybody gets so much information all day long that they lose their common sense.” Precisely … ."

Gary G. Poehling, MD

Heading West to Kona

Craig Alexander, pre-dawn hours of the transition area in Kona
As you can see by the above photo, it's still night when the transition area opens in Kona on race morning.  While the location of the pros bikes may be well lit, this is not the case for all of the age groupers.  There are a number of flashlights manned by the race volunteers but the thinking triathlete simply remembers to pack a camping/trail running style head lamp for this function.  After use, it's left in the pre-swim bag and retrieved at race's end.

Many athletes see this visit to the Big Island as a time to buy gifts for family and friends, a sort of pay back if you will.  It is incredibly easy to disregard this increase in ones return baggage until packing for home and the weight of your bag far exceeds the airline limit.  I, personally have had the privilege of compensating the airline $125 for this grievous act.  Why not plan on bringing pre-addressed 9"X12" manila envelopes, add a copy of the race program and a flat box of chocolate covered macadamia nuts, and drop them in the mail?  The post office is 3 blocks from the start/finish line of the race.

Image 1 Google Images

Wednesday, February 12, 2014

The Female Triathlete, Knee Pain

"Luck has nothing to do with it, because I have spent many, many hours, countless hours, on the court working for my one moment in time, not knowing when it would come."                     Serena Williams

US Naval Vessels near Sochi Olympics: It's interesting to see what lengths we need to go to as a society to protect athletes.  In London 2012 there were 6 sites where surface to air missiles were positioned to counter the threat of terrorism.  These missiles are part of an elaborate plan to thwart a potentially hijacked plane.

Knee pain in female athletes

Much has  been written regarding exercise based knee pain, particularly in women. Traditionally, when we see female athletes/runners in the office, the most common location of pain is over the anterior knee, the so-called patella femoral pain syndrome or PFPS.  This is best described as pain when running, squatting, up and down stairs and especially after prolonged sitting.  A study published in the Journal of Bone and Joint Surgery compared the rehabilitative efforts of two groups of female runners randomly assigned to either the common knee exercise program of quadriceps strengthening, etc., or one centered on hip strengthening.  Both groups did flexibility exercises before performing the strengthening program.

After 4 weeks of either exercise regimen both groups were re-evaluated.  Interestingly, less knee pain was found in the hip exercise group than the knee exercise group.  The authors concluded that in females with PFPS, performing the hip program was more effective at reducing pain in the first 4 weeks of rehabilitation.

So what does this mean to you?  Well, first off it's that the running stride/pedaling stroke is not done in isolation. As has been sung for many years, "The shin bone connected to the knee bone," is in fact correct.  Simply said, knee pain is not necessarily corrected by attention to the knee.  This is one of the reasons that I am such a staunch supporter of your local running shoe store where, when pain arises, a quick eval by the owner, who's seen more feet than just about anyone, can often point us in the right direction by examining the whole of our running mechanics.  And, as the above study suggests, perhaps a hip strengthening program is just what the doctor ordered.

Lastly, although this is still February, many thousands of young women are either participating in, or soon will be, a series of work outs to get them ready for the outdoor track season, triathlon, etc.  If some attention is paid to the athlete as a whole, and not to simply running a distance to fill in a log book, a higher percentage of these young athletes can participate pain free this Spring. 

Image 1, Google images
Image 2, Mandy Baskin

Monday, February 10, 2014

Absolute Entry Into Kona/Absolutely Out of Kona

Say Cheese!

Absolutely Out of Kona

This photo was taken a couple days before the Ironman World Championship in Kailua-Kona, HI this past October.  Although it's not easy to see, this gent has on the Ironman race entry wrist band and is pointing to his name, one among all 2197 race entrants. (39 year old Adrian Maizey is #2197 in our program.  But Adrian has an entry and most of us don't.)  While I doubt this is Adrian, this athlete has done what it takes to be treading water at the start line on Saturday.  Why him and not you?

Well, one thing might have been his ability to control his enthusiasm last February.  So many of us now have ratcheted up our training, consciously or not, possibly exceeding our annual training plan, thinking it the best way to achieve our absolute peak performance come summer, when it's the exact opposite of what our body wants.  I'd bet twenty-five cents that if you were ask Alysia Robichau, Phil Skiba, Jordan Metzl, or P.Z. Pearce, any of the big sports docs in our world, they'd tell you that the number one reason racers end up in their office is not trauma or illness but overuse injury.  IT Band issues, patella tendinitis, rotator cuff tendinitis, Achilles problems, you name it, so much is self-induced difficulty. 

Nathan Koch points out in Friel and Vance's Triathlon Science text " that "Overuse accounted for  68% of preseason injuries reported ..."  Also, I learned from him that, "Increasing  years of triathlon experience was the most significant predictor of pre-season injury risk." 

Joe Friel has been quoted many times as teaching, "I'd rather have an athlete over rested than over trained."

The moral of this story is one that you already know.  Think when creating your training plan taking previously tolerated injury free training loads into account and listen to your body when those little pains start to pop up.  Please don't simply ignore them until they're quite symptomatic.  If you do, maybe you can have your picture taken in front of the King Kamehameha Kona Beach Resort like this fella.  Just maybe.

Absolutely In Kona

Each Spring, the Ironman Foundation auctions off a number of slots to the highest bidder with the profits going to charity. This will be the auctions twelfth year.  The number of available slots has varied over the years having settled at 4 a number of years ago.  That said, in 2013 two additional slots were added benefitting World Bicycle Relief and the YMCA of Greater Seattle.  They start the biding at $10,000 and in the past has gone considerably higher.  But it's tax deductible and if you really, really want to race in Kona all it takes is your check book.  


"Walk this way"  Aerosmith

Thursday, February 6, 2014

Teaching Doctors/Addicted to Exercise? Who me?

Teaching Doctors

I’m on my way back home.  I’m leaving SW Florida where the daily high temps have been in the mid 80’s bound for the land of ice and snow up north.  If I’m lucky I won’t be spending the night sleeping on the floor of an airport.

This morning I was privileged to speak before an audience of mostly Primary Care physicians from all over the country about various orthopedic topics.  As you’d expect, each has his/her own knowledge base with differing strengths and weakness.  Often, the most rewarding part of these talks is the question and answer sessions at the end where I can go one-on-one with these folks and particular issues they may be having in their own practice.  Or even their own body.  This is where the real learning takes place.  The fact that they are so incredibly appreciative of this time makes one look forward to the opportunity to do it again.

Saying “No thanks” to a Kona Slot

Yes, it does happen.  Actually more often than you might think.  My first experience with this “phenomenon” was a number of years ago, talking with the winner of my age group at Eagleman Ironman 70.3 as we began to clean up our small part of the transition area post-race.  “Nope, I’m not going to take the Hawaii slot, too many things hurt,” he casually mentioned.  This from the mouth of one who simply crushed the age group today!  “Couldn’t have hurt too much with a dominant performance like that,” I thought but had the courtesy not to say.  I suppose this is why slots often go the 2nd, 3rd or lower racer in an age group.  Yet, those who know they have no chance of achieving this high finishing position, ever, just shake their heads.   

Addicted to Exercise? Who me?

"I'd take any risk to turn back the hands of time." Styx
I didn't race at IMH this year...and likely my body's been sending messages loud and clear that I'm done with iron distance racing. And been done for a while.  But on Sunday morning after the Kona event, I went for a bike ride and was astonished to see a couple runners on famed Alii Drive.  Pushing it!  At first I thought they were tourista like me but as I approached, I could see that they both had on brightly colored Ironman racer wrist bands and a race day sunburn on their neck and shoulders from an especially hot day the day before. (There's almost no shade on the Big Island bike route. Maybe one could ride in the shade of an overflying seagull or two...but that would present it's own potential hazard!)

Running? The day after Ironman Hawaii? What were they thinking? Or, were they thinking? Maybe getting a jump start on training for their next iron distance weekend? Or, maybe they're just not able to turn it off.  Maybe they should've taken the bus.

Driven with Aloha
Racing and training at this level causes significant breakdown of bodily systems that need recuperation time be it from training or racing. Although there are a select few of us who can get by with less...and these are the ones we hear about in the press...most of have neither a cape nor an "S" on our chests. And Kryptonite doesn't bother us one bit.

Why not take the first several days after a race to let the soreness fade, blisters, if present resolve, and only then begin a few low effort, short workouts focusing on form and style, not quantity. Many would suggest that it be a full 10-14 days or even longer before getting back into full training after a 140.6 effort, assuming you already have a race scheduled. New research has shown that even the articular cartilage in your knee needs a little calm down time as well. That time would be well spent on family activities, reading (no, not about triathlon), maybe even go see the new Jack Ryan movie for something completely different.  Maybe it's time to simply be a husband, wife, father or mother and not an athlete. Although no one would fault you for drifting into thoughts about picking up a pair of the new Adidas Energy Boost shoes on your way home while the credits are rolling.

Sunday, February 2, 2014

Bicep Tendon Tear, Shoulder Part 2

Bicep Tendon Tears, Part 2 of 2
On Wednesday I introduced you Part 1 of Bicep Tendon Tears and today I discuss the causes and what to do about it, if anything.

Anytime you're in the "sin bin" is a bad time.

There are two main causes of biceps tendon tears: injury and overuse.


If you fall hard on an outstretched arm or lift something too heavy, you can tear your biceps tendon.


Many tears are the result of a wearing down and fraying of the tendon that occurs slowly over time. This naturally occurs as we age. It can be worsened by overuse - repeating the same shoulder motions again and again.
Overuse can cause a range of shoulder problems, including tendonitis, shoulder impingement, and rotator cuff injuries. Having any of these conditions puts more stress on the biceps tendon, making it more likely to weaken or tear.

Risk Factors

Your risk for a tendon tear increases with:
Age. Older people have put more years of wear and tear on their tendons than younger people.
Heavy overhead activities. Too much load during weightlifting is a prime example of this risk, but many jobs require heavy overhead lifting and put excess wear and tear on the tendons.
Shoulder overuse. Repetitive overhead sports - such as swimming or tennis - can cause more tendon wear and tear.
Smoking. Nicotine use can affect nutrition in the tendon.
Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.
  • Sudden, sharp pain in the upper arm
  • Sometimes an audible pop or snap
  • Cramping of the biceps muscle with strenuous use of the arm
  • Bruising from the middle of the upper arm down toward the elbow
  • Pain or tenderness at the shoulder and the elbow
  • Weakness in the shoulder and the elbow
  • Difficulty turning the arm palm up or palm down
  • Because a torn tendon can no longer keep the biceps muscle tight, a bulge in the upper arm above the elbow ("Popeye Muscle") may appear, with a dent closer to the shoulder.
Doctor Examination

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your shoulder. The diagnosis is often obvious for complete ruptures because of the deformity of the arm muscle ("Popeye Muscle").

A biceps tendon tear is made more obvious by contracting the muscle ("Popeye Muscle").
Partial ruptures are less obvious. To diagnose a partial tear, your doctor may ask you to bend your arm and tighten the biceps muscle. Pain when you use your biceps muscle may mean there is a partial tear.
It is also very important that your doctor identify any other shoulder problems when planning your treatment. The biceps can also tear near the elbow, although this is less common. A tear near the elbow will cause a "gap" in the front of the elbow. Your doctor will check your arm for damage to this area.
In addition, rotator cuff injuries, impingement, and tendonitis are some conditions that may accompany a biceps tendon tear. Your doctor may order additional tests to help identify other problems in your shoulder.

Imaging Tests

X-rays. Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause shoulder and elbow pain.
Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears.

Nonsurgical Treatment

For many people, pain from a long head of biceps tendon tear resolves over time. Mild arm weakness or arm deformity may not bother some patients, such as older and less active people.
In addition, if you have not damaged a more critical structure, such as the rotator cuff, nonsurgical treatment is a reasonable option. This can include:
Ice. Apply cold packs for 20 minutes at a time, several times a day to keep down swelling. Do not apply ice directly to the skin.
Nonsteroidal anti-inflammatory medications. Drugs like ibuprofen, aspirin, or naproxen reduce pain and swelling.
Rest. Avoid heavy lifting and overhead activities to relieve pain and limit swelling. Your doctor may recommend using a sling for a brief time.
Physical therapy. Flexibility and strengthening exercises will restore movement and strengthen your shoulder.

Surgical Treatment

Surgical treatment for a long head of the biceps tendon tear is rarely needed. However, some patients who require complete recovery of strength, such as athletes or manual laborers, may require surgery. Surgery may also be the right option for those with partial tears whose symptoms are not relieved with nonsurgical treatment.
Procedure. Several new procedures have been developed that repair the tendon with minimal incisions. The goal of the surgery is to re-anchor the torn tendon back to the bone. Your doctor will discuss with you the options that are best for your specific case.
Complications. Complications with this surgery are rare. Re-rupture of the repaired tendon is uncommon.
Rehabilitation. After surgery, your shoulder may be immobilized temporarily with a sling.
Your doctor will soon start you on therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.
Be sure to follow your doctor's treatment plan. Although it is a slow process, your commitment to physical therapy is the most important factor in returning to all the activities you enjoy.
Surgical Outcome. Successful surgery can correct muscle deformity and return your arm's strength and function to nearly normal.