Episode #355: Deadlifting and Biceps Tendon Rupture Risk

0:05Dr. Jordan Feigenbaum:Welcome back to the Barbell Medicine Podcast. I'm Dr. Jordan Feigenbaum. Hope you've had a great week so far. In this podcast, I wanted to talk about the risk of rupturing a biceps tendon in resistance training, specifically while deadlifting with a mixed grip. For people who have spent a lot of time around the gym where people do a lot of deadlifts, you may have either seen this happen firsthand or heard about a fellow gym goer who, quote, tore their biceps while deadlifting. In this episode, I'll review the anatomy of the biceps, the mechanism for this type of injury, as well as its risk factors, and make some practical recommendations for what kind of grip to use while deadlifting.

0:36Dr. Jordan Feigenbaum:But before that, I do have a few announcements. Right now, we are running our annual July 4th sale. From now until the end of the day, Sunday, July 6th, take 20 % off all of our training programs and apparel. We also have further markdowns on apparel up to 75 % off for some of our closeout stuff. No coupon code is needed. Just head to the website, barbellmedicine.com, grab a new program or some BBM merch and get 20 % off your purchase. We also have a live two-day health and performance seminar where myself, Dr. Baraki, Leah Lutz, and Tom Capitelli will provide in-depth lifting instruction and education on a variety of topics ranging from cardiovascular health and sarcopenia to nutrition and programming.

1:14Dr. Jordan Feigenbaum:The seminar will be held in San Antonio, Texas on September 20th and 21st. Click the link in the description to get your ticket today. Alright, let's start off with the anatomy of the biceps. We'll hop a ride with Ms. Frizzle on the Magic School Bus and we'll head to the anterior or front compartment of the arm. In this area, there are three muscles. Superficially, we'll find the biceps brachii, and deep to this muscle is the coracobrachialis, that's near the shoulder, and the brachialis, which starts down by the elbow. In Latin, biceps means two-headed muscle and brachii means arm. Therefore, the biceps brachii is the two-headed muscle of the arm, whereas the biceps femoris is the two-headed muscle of the leg.

1:50Dr. Jordan Feigenbaum:You may also know that as your hamstring or part of it. Now the short head of the biceps brachii starts from the coracoid process of the scapula, which is the bird's beak-like projection coming off the front of the scapula. Meanwhile, the long head of the biceps brachii originates from just above the shoulder socket, which is called the glenoid fossa. Somewhat intuitively, the area of the bone that the long head of the biceps starts is called the supraglenoid tubercle, meaning it's above the glenoid fossa and tubercle is just a bony prominence. Now around the middle of the upper arm, both the short and long heads of the biceps form a single common muscle belly.

2:24Dr. Jordan Feigenbaum:In the forearm, the biceps brachii attaches to the radial tuberosity. Again, that's a bony feature on the radius bone in the forearm. And the biceps brachii also attaches to the fascia of the forearm by way of the lacertus fibrosis. Now if you're paying attention, you may note that I always say biceps and never the singular bicep. And that is because there are in fact at least two heads to the biceps. I say at least two heads to the biceps because there is some data showing that a number of individuals have more than two biceps heads. In one study of just over 100 human arms, about a quarter of them had three heads, where a handful had four or even five heads.

3:01Dr. Jordan Feigenbaum:These so-called accessory heads can arise from the deltoid near the shoulder or the pectoralis major muscles and or bones like the scapula and the humerus. Interesting stuff for sure, not really sure what it means, but I did find this stuff pretty interesting. To summarize the anatomy, the biceps brachii muscle has a short and a long head, both originating from different spots on the scapula. The two heads come together to form a single muscle belly in the arm, and then they attach to the forearm. Because the biceps crosses both the shoulder and elbow joints, it performs actions at both joints.

3:31Dr. Jordan Feigenbaum:The biceps is the strongest supinator of the forearm that's turning your palm towards the sky, but it also plays a role in elbow flexion, like when you're doing curls. At the shoulder, the long head of the biceps contributes to stability of the glenohumeral joint, which is fancy anatomy speak for the shoulder joint. And in more nerdy anatomy stuff, by convention, the things that connect muscles to bone, we call those tendons, and the biceps tendon near the shoulder is called the proximal biceps tendon, whereas the tendon connecting the biceps to the forearm is called the distal biceps tendon. This anatomy is going to be important for later, so put that into your brain.

4:05Dr. Jordan Feigenbaum:All right, let's now hop off the magic school bus and talk about the two major biceps tendon injuries. Now over 90 % of biceps tendon ruptures involve the long head near the shoulder. That's the proximal or long head biceps tendon. Now when you rupture this, this can produce what's known as a Popeye deformity as the upper part of the muscle belly is clearly visible under the skin and the patient's arm looks like Popeye's. For the youth that are listening to this podcast, they may not be familiar with Popeye, but Popeye the Sailor Man was a cartoon character that had huge balloon-shaped forearms, actually, not biceps.

4:40Dr. Jordan Feigenbaum:Anatomical accuracy aside, a Popeye's deformity is visible when the proximal tendon is ruptured and the muscle rolls down lower into the arm. This type of injury generally does not require surgical treatment to restore full function, but people may choose to get surgery anyway for cosmetic reasons. Down near the elbow, we find the distal tendon of the biceps. Now, if the tendon ruptures here, the muscle belly may retract upwards higher in the arm, producing a, you guessed it, reverse Popeye's deformity. Anatomists really seem to love Popeye for some reason, I guess. Now, a rupture of the distal biceps tendon is kind of a misnomer because it's not like the tendon itself is really tearing into two different pieces, whether partial or full, but rather it's an avulsion, which means that the tendon itself, for the most part, is still in one piece, but it pulls off a piece of bone from the forearm, in this case, the radius.

5:28Dr. Jordan Feigenbaum:In contrast to a proximal biceps tendon rupture that happens up near the shoulder, well, that's more common in older individuals, a distal biceps tendon rupture occurs more commonly in younger individuals, but it's relatively rare, accounting for just about 3 % of biceps ruptures overall. And it has an incidence of about 2.5 cases per 100 ,000 persons per year, mostly again in active middle-aged men and in the dominant arm. Now, with a distal biceps tendon rupture, treatment can be non-operative or surgical depending on the patient's age, their activity demands, the chronicity of the tear, and the degree of tear.

6:05Dr. Jordan Feigenbaum:Generally speaking, older, more sedentary individuals where function isn't a big concern may choose to forgo surgery, though they do tend to lose a considerable amount of supination and grip strength. For younger, more active individuals, as long as the surgery is performed shortly after the injury, usually within a few weeks at most, well, they're likely to be better candidates for surgery. For the rest of this podcast, we'll focus on distal biceps tendon ruptures, as this is the type of biceps tendon injury that occurs during the deadlift, which is what we're here for. When we come back from this break, we'll discuss how this injury occurs, its risk factors, and how to avoid it.

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11:36Dr. Jordan Feigenbaum:The apparel discount is bigger because a shirt is a shirt, and I like seeing our logo out in the wild. but everything's on sale right now and it ends monday september 7th at midnight which is the end of labor day itself so head over to barbellmedicine.com and get your savings in before you actually have to go back to work all right welcome back to the barbell medicine podcast where we're talking about biceps tendon injuries in resistance training specifically what is the actual risk of a distal biceps tendon rupture when deadlifting with a mixed grip as far as the mechanism of injury goes it is thought that rupturing the distal biceps tendon occurs when excessive forces are placed upon the biceps during an eccentric or lengthening contraction.

12:13Dr. Jordan Feigenbaum:In other words, the distal biceps tendon rupture thought to be the result of the elbow going from a flexed to an extended position with a high amount of force. Specifically to lifting, deadlifting with a mixed grip is one exercise where there is a concern for rupturing the distal biceps tendon on the underhand or supinated side. When deadlifting with a mixed grip, the underhand side often has some amount of bend or flexion in the elbow, and when someone goes to pull a heavy weight, there may be enough force to pop the distal biceps tendon. Some speculate that keeping the elbows perfectly straight all but eliminate this risk, though new data seems to challenge this theory.

12:50Dr. Jordan Feigenbaum:At least two papers have been published that have reviewed YouTube videos of distal biceps tendon ruptures that happened while people were lifting weights. In all but one of these witnessed distal bicep tendon ruptures, the arm was supinated, or underhand. Now when broken down by exercise, yep, the most common exercise being performed was in fact the deadlift with a mixed grip, though one biceps tendon rupture occurred during the deadlift when an individual was using a double underhand grip, which is strange because almost nobody does that. Don't do that. Now for completeness, the second most common injury which one of these distal biceps tendon ruptures occurred was the biceps curl, and the third most was arm wrestling.

13:28Dr. Jordan Feigenbaum:All but one of these injuries were in men. Now when it comes to elbow flexion, And however, about 75 % of the ruptures that occurred during the deadlift with the mixed grip, well, the elbow was actually extended. And only a quarter of them, well, the elbow had a slightly flexed position. Based on this data alone, it would seem that deadlifting with a mixed grip is inherently risky when it comes to suffering a distal biceps tendon rupture, even if the lifter keeps their elbows perfectly extended. But allow me to offer a slightly nuanced perspective. It is likely true that deadlifting using a mixed grip does increase the relative risk of distal biceps tendon rupture compared to using the hook grip or a double overhand grip.

14:08Dr. Jordan Feigenbaum:However, the absolute risk is still quite low because distal biceps tendon ruptures are just not that common at all, especially in the gym. For example, consider the fact that the studies looking at YouTube videos where a biceps tendon rupture occurred could only find about 60 total examples, despite YouTube being around for over 20 years and people doing a lot of deadlifts. Of course, many distal biceps tendon ruptures that happen in the gym probably didn't make it to YouTube, but even then, think about how many deadlifts are done every single day with a mixed grip. If the absolute risk were that high, we would expect distal biceps tendon ruptures to be way more common.

14:45Dr. Jordan Feigenbaum:We would also expect them to occur at nearly every powerlifting or strongman competition, yet that is decidedly not the case. Now in reality, distal biceps tendon ruptures occur at a rate of about 2.5 to 3 per 100 ,000 people per year. Of course, any increase in risk of an injury that is likely to need surgery may be deemed unacceptable, especially for an individual who is not competing in a barbell sport, but rather lifting for health and or cosmetic purposes. I'll get into some practical recommendations here in just a moment, but I briefly wanted to talk about the risk factors that may predispose an individual to a distal biceps tendon rupture while exercising.

15:22Dr. Jordan Feigenbaum:Now the major risk factors for a distal biceps tendon rupture and really any tendon injury in general are overuse, smoking, and corticosteroid use. Overuse of the tendon via too much training load for the individual can lead to pain, tendinopathy, and subsequently increase the vulnerability of the tendon to rupture. If presented with the need to withstand a high force, yeah, that may be too much to ask of the tendon that's already kind of outkicked its coverage, if you will. Smoking is another significant risk factor for tendinopathy because it reduces blood supply, subsequently affecting the integrity of the tendon itself.

15:57Dr. Jordan Feigenbaum:Similarly, corticosteroids reduce tendon strength by reducing the activity of fibroblasts, the cells that produce and maintain the tendon itself. Now, other risk factors include obesity as up to two-thirds of all distal biceps tendon ruptures are seen in individuals with obesity. It is thought that obesity-related inflammation and and reduced immune system response to stresses that are placed upon the tendon may increase the risk of rupture. Finally, anabolic steroids are also thought to be a risk factor due to the relatively rapid increase in strength, along with potentially some tendon stiffening and maybe a decrease in tensile strength of the tendon compared to the rapid increase in strength.

16:33Dr. Jordan Feigenbaum:People just get too strong and their tendons are kind of too late to the party as far as adaptation goes. To summarize, anything that compromises the normal function and the adaptability of the tendon to loading likely increases the risk of rupture. But as I've said a number of times, the overall risk is low. Cannot make that clear enough. The overall risk of distal biceps tendon rupture is low. However, making decisions about what grip to use in the gym when you're deadlifting depends on who you are and what your goals are. Now, if you're a barbell sport athlete, that is, you're participating in Olympic weightlifting, in strongman, in powerlifting, or CrossFit, well, you're going to need to train your grip specifically for your sport.

17:09Dr. Jordan Feigenbaum:For Olympic weightlifters, that means primarily training with the hook grip for the snatch, the clean and jerk, and their variance. Now, when it comes time to deadlifting, and I know those can be controversial amongst Olympic weightlifters, like do you deadlift or do you not, but let's just assume you're doing some deadlifts or overload pulls. Well, I would recommend continuing to use the hook grip for sports specificity or using straps when you're needed. Whether your hands are chewed up, whether your grip strength is fatigued, straps would then be preferred to using the mixed grip in this particular setting.

17:34Dr. Jordan Feigenbaum:I just don't see a benefit to training the mixed grip in this situation. Again, that's for competitive Olympic weightlifters. In contrast, a competitive powerlifter who goes to meets, well, they're going to have to find a viable grip for the deadlift. It is unlikely that even a person with an impressively strong grip will be able to deadlift maximal weights with a double overhand grip, which then leaves two choices, the hook grip or the mixed grip. Now, I would recommend trying to use the hook grip first. Yes, many people find it uncomfortable initially, but this type of grip offers a competitive advantage by reducing the range of motion in the deadlift slightly, the bar sits a little bit lower in the hand, and because the bar is easier to keep on the legs during the pull.

18:14Dr. Jordan Feigenbaum:Plus, let's not forget the moral superiority and admiration of dudes everywhere because you're using the hook grip. Now, copious use of chalk and a single layer of tape placed around the thumb may make the hook grip easier to get the hang of, but for some, no matter what the amount of training or practice with the hook grip, they just won't be able to make it work. Now for these folks, and this is the category that I personally fall into, the mixed grip is the grip of choice. Most people will prefer the dominant hand to be overhand and the non-dominant hand to be underhand, although personal preference predominates here.

18:45Dr. Jordan Feigenbaum:Like other desirable musculoskeletal adaptations, we want the body to get used to the tasks that it has to perform. Now for this reason, I do not recommend alternating which hand is supinated and which hand is pronated. Rather, I recommend keeping it the same and gradually increasing the training load over time. Now here's where it gets interesting. For general strength and conditioning for both health and non-barbell sports performance, I think that a case could be made for judicious use of straps when deadlifting. While it is true that grip strength specific to the deadlift is likely to remain undertrained, this has effectively no consequences for health or sports performance, unless your sport has deadlifts in it, in which case this advice doesn't apply to you.

19:28Dr. Jordan Feigenbaum:You can rewind a couple seconds, figure out what I recommended for barbell sport athletes. Now, as a health metric, grip strength is not a great proxy for total body strength because grip strength does not tend to improve proportionally with total body strength. We're just measuring the muscular force production of the intrinsic muscles of the hand. It doesn't necessarily correlate to how much you can squat, how much you can deadlift, how much you can bench press. Oh, and by the way, it's not granular enough to identify those who are at risk of disease or losing their independence due to low muscular strength before it's too late.

19:58Dr. Jordan Feigenbaum:So for these folks, I'd say use straps. Of course, there's going to be people out here that fall into this demographic who are highly motivated and they really want to deadlift heavy sans any accoutrements. Well, in that case, do the hook grip. I recommend they use the hook grip. Again, there's maybe some performance advantage, and I think there's effectively zero risk of a distal biceps tendon injury. In fact, the biggest risk here is that you might rip some skin off your thumb. But I would just prefer either using the straps or the hook grip in this particular situation. Of course, if somebody is willing to accept a very small but non-zero risk of biceps tendon rupture during the deadlift, then they can, of course, use a mixed grip.

20:36Dr. Jordan Feigenbaum:But they'd be totally fine using straps exclusively for the deadlift if they wanted to. We discussed this in far more detail in an article on our website called What Grip Should You Use in the Deadlift, which I've linked in the show notes below. Okay, that's it for this episode of the Barbell Medicine Podcast. If you liked this episode, share it with a friend and leave us a five-star review. Thanks for listening. Oh