Snapped Tendons & The AMA Artform

Join us this week as Kelly talks with PM&R physician Dr. Cindy Lin about biceps tendon ruptures. They’ll cover the pertinent anatomy, common causes, and how to manage this best. Stick around to consider the art of handling AMA situations.  Leaving against medical advice is often treated like a formality, but in reality, it is a high-risk clinical encounter that hinges on communication, judgment, and documentation. We clarify commonly misused terms and bust persistent myths that increase downstream risk. With practical bedside language and documentation pearls, this conversation reframes AMA as a core clinical skill rather than a legal checkbox.

 

Biceps Tendon Rupture

Kelly Heidepriem, MD,  and Cindy Lin, MD

 

Pearls:

•  A visible “Popeye” deformity is classic for biceps tendon rupture, but its absence does not rule out injury—especially in some distal ruptures where the bicipital aponeurosis can limit retraction.
• Distal biceps ruptures are usually traumatic and frequently need urgent ortho evaluation—optimal repair is typically within 1–3 weeks before scarring/retraction complicates surgery.

 

What clinicians mean by “Popeye sign”:

• The “Popeye” appearance refers to a visible biceps muscle bulge due to tendon rupture and muscle retraction.
• Classic association is with proximal long head biceps tendon rupture:
• The long head retracts downward → muscle bunches in the mid–distal upper arm.
•  Can also be seen with a distal biceps rupture:
• Tendon tears at the elbow → muscle retracts upward.
• No Popeye deformity ≠ no rupture
• In some distal ruptures, the bicipital aponeurosis may remain intact and “hold down” the muscle, masking deformity.

 

Presentation: 

• Proximal (long head) biceps rupture
• Most commonly linked to degenerative rotator cuff disease and aging (often with shoulder impingement).
• Isolated traumatic proximal ruptures are uncommon outside of the degenerative setting.
• Patient-friendly explanation used: tendon degeneration is like a fraying rope.
• Distal (short head) biceps rupture
• Usually traumatic, often involving an unexpected force on the arm.
• Trying to hold/catch a heavy load (arm slightly extended; “waiter’s tray” position).
• Heavy lifting, like deadlifts or biceps curls.
• Symptoms commonly described:
• Sudden pop and pain.
• Significant bruising/swelling.
• Weakness with elbow flexion after injury.
• Risk factors:
• Male sex
• Smoking
• Anabolic steroid use
• Increased BMI
• No association with diabetes

Physical exam: 

• General approach
• Compare left vs right to identify subtle asymmetry and deformity.
• The Popeye sign may be visible at rest or with flexing.
• Distal biceps rupture tests:
• Hook test (best for complete rupture).
• Elbow flexed to ~90°.
• Examiner attempts to “hook” the distal biceps tendon with an index finger.
• Abnormal: unable to hook/feel the tendon → suggests complete distal rupture.
• Described as having high sensitivity/specificity for complete rupture.
• Biceps crease interval test
• Measure the distance from the antecubital crease to the lowest palpable point of the biceps muscle.
• Findings suggesting rupture/retraction:  Distance > 6 cm, or Side-to-side ratio > 1.2.
• Proximal biceps rupture tests:
• Palpation along the bicipital groove (compare sides).
• Uppercut test:
•  Patient makes a fist, elbow flexed to 90°, palm toward face.
• The examiner applies downward force on the fist.
• Pain/pop/clicking at the anterior shoulder raises suspicion for biceps tendon injury.
• Other biceps-focused shoulder tests: Speed’s and Jorgenson’s, which are useful for identifying partial tears or biceps tendonitis.

Imaging: 

• X-ray
• Normal in isolated biceps tendon rupture.
• Helpful to evaluate for fracture/dislocation when the mechanism suggests major trauma.
• Ultrasound
• Useful in trained hands:
• Can visualize retracted muscle/tendon.
• For a proximal tear, it can show an “empty” bicipital groove.
• Feasible for settings that use POCUS regularly.
• MRI
• Helpful to:
• Differentiate proximal vs distal
• Distinguish partial vs complete tear
• Typically done as an outpatient—often not emergent in ED workflow.

Initial management in the ED

• Pain control.
• Rest the arm.
• Sling for comfort - but as always, avoid prolonged immobilization to reduce the risk of stiffness/frozen shoulder.

Follow-up and precautions:

• Avoid heavy lifting and activities that worsen pain.
• Work restrictions for manual labor; avoid overhead sports early on.
• Referral:
• Urgent orthopedics if you have a high suspicion of complete rupture (especially distal).
• Otherwise: sports medicine + physical therapy can be appropriate for non-operative cases.

Definitive management:

• Distal biceps rupture:
• Complete distal ruptures are generally managed operatively, especially in young/active patients, to restore function.
• Optimally done within 1-3 weeks to reduce tendon retraction and scarring. 
• Delayed repairs (4–6+ weeks) may require more complex reconstruction techniques (allograft/autograft) due to retraction and scarring.
• Operative outcomes are better than non-operative care for partial/high-grade and complete distal tears.
• Non-operative management is reserved for older/sedentary patients who accept:
• Some loss of elbow flexion/supination strength.
• Cosmetic deformity.
• Proximal long head rupture:
• Often managed non-operatively, especially when tied to degenerative rotator cuff pathology.
• Activity modification, PT, injections for pain if needed.
• Surgery is considered in select cases:
• Younger/athletic patients.
• Significant cosmetic concerns.
• Persistent cramping, pain, or weakness limiting activity.

References:

1. Zwerus EL, van Deurzen DFP, van den Bekerom MPJ, The B, Eygendaal D. Distal Biceps Tendon Ruptures: Diagnostic Strategy Through Physical Examination. Am J Sports Med. 2022;50(14):3956-3962. PMID: 36349931
2. Looney AM, Day J, Bodendorfer BM, et al. Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022;31(4):e169-e189. PMID: 34999236

 

 

The Art of the AMA

Geoff Comp, DO, and Dr. Heidepriem, MD

 

Pearls:

• AMA is not a form—it is a clinical encounter that requires assessment of capacity, a risk–benefit discussion, and clear documentation. 
• Legal risk is driven far more by bedside communication and reasoning than by whether a form was signed.
• Capacity, engagement, and shared decision-making matter more than signatures or length of documentation. Clear reasoning and specific risk discussions are what reviewers look for.
• High-risk presentations (e.g., chest pain, intoxication, trauma, psychiatric complaints) require explicit documentation of capacity, specific risks, alternatives offered, and patient understanding
• AMA does not “cleanly resolve” responsibility.

Definitions: 

• There are many classifications or potential disposition options you can chart when patients leave the department outside the usual admit/discharge paradigm. More commonly used terms include:
• Leaving Against Medical Advice (AMA)
• Elopement
• Left Before Results
• Left Without Being Seen (LWBS)
• Refusal of Care
• To more clearly document the situation, we need to have our terms defined correctly.
• This becomes important from an operations aspect as AMA and LWBS are often closely tracked as quality metrics, and inaccurate labeling creates downstream difficulties both clinically and administratively.
• Leaving Against Medical Advice (AMA):
• A patient with decision-making capacity declines recommended evaluation or treatment after a risk–benefit and alternatives discussion.
• Requires demonstration of decision-making capacity, understanding of risks and alternatives.
• The protective value lies in documentation of the conversation—not the form itself. A signed form without a documented discussion carries little medicolegal weight.
• Elopement:
• The patient leaves without a clinician discussion or before the assessment is complete.
• This is often mislabeled as AMA.
• To be AMA, it must be a meaningful discussion between the patient and clinician, not nursing or other staff in the department.
• If that discussion did not occur, the event should be documented as an elopement.
• E.g., the patient yells “I’m leaving” at the nursing staff and storms out without further discussion. This would be elopement, not AMA.
• Left Without Being Seen (LWBS):
• Patient registers in the ER but then leaves before provider evaluation without informing staff of their intent to leave.
• Left Before Results:
• Occasionally, patients will request to leave before results are back, but your concern doesn’t rise to the level of necessitating the utilization of AMA documentation. 
• How much you document depends on your suspicion of serious pathology and where in the workup you are.
• This only applies to low-risk situations or patients you feel are at low risk for significant pathology.
• For a low-risk person with flu-like symptoms during flu season, it may be reasonable for them to go home before flu swab results are back without utilizing AMA documentation.
• However, a low-risk patient with something like a second troponin pending or advanced imaging like CT or MRI who requests discharge before the results are available would require much stronger documentation.
• Refusal of care:
• Patient declines a specific test, medication, or intervention but remains engaged in care.
• Generally, this is part of shared decision-making and doesn’t require specific documentation outside your usual shared decision-making discussion.

 

AMA and risk:

• AMA cases carry an elevated risk for both patient and provider.
• These are often disproportionately high-risk presentations; they have higher rates of bounce-back morbidity and mortality, and often involve time pressure, emotional escalation, and diagnostic uncertainty.
• Patients who leave AMA are almost 10 times more likely to sue than average ER patients.
• ~1 in 300 AMA cases result in legal action, compared to ~1 in 20-30,000 typical ED visits.
• Angry or dissatisfied patients are more likely to pursue legal action.
• AMA cases often involved higher acuity presentations with greater potential damages.

 

Documenting Capacity: What do we need to include?

• Capacity is a core element of determining whether a patient can leave AMA or not.
• Capacity is task-specific and can fluctuate throughout an ED visit.
• Core components to document when discussing capacity:
• Patient's understanding of the medical situation
• The potential consequences of leaving
• Their ability to communicate a choice and reason through the options.
• Documenting capacity should not only be in the medical decision making poriton of your note, but should also include exam findings such as whether they are alert and oriented, any potentially distracting injuries, or whether there is any evidence of psychiatric illness.
• Utilizing an interpreter is very important when patients leave AMA.
• You must be sure the patient understood the conversation completely and utilizing family or partial understanding of a second language is not advisable. 
• Psychiatric illness and intoxication present grey areas in capacity.
• These do not automatically make them incapable of capacity, but you need to carefully document things like clear speech, coherent reasoning, the ability to reiterate their situation and risks.
• Psychiatric consultation is not generally required for capacity assessment in the ED. We do this regularly and are skilled at determining capacity.

 

AMA documentation: Outside capacity, what else should I document?

• Capacity is very important to document but multiple other elements should be included in your AMA documentation.
• The specific risks discussed 
• e.g. MI, arrhythmia, seizure, death. Not just “bad outcome”.
• Alternatives offered to the patient.
• The patient's understanding of the risks and alternatives, as well as their ability to reason through these.
• The patient's mental status and behavior in the department.
• Quotes from the patient can be helpful in establishing these elements in your documentation.
• AMA form signatures support, but do not replace, documentation.
• The presence of the form alone is rarely determinative in legal review.
• Documenting the conversation is much more important, and having the nursing staff document their impression of the discussion and conversations they had with the patient is also helpful.

 

Approach to the AMA Conversation

Tone and Framing

• Utilizing a calm, curious, non-confrontational approach will be much more successful in gaining an understanding of the situation and navigating the AMA process.
• Avoid punitive or defensive framing and try to preserve the therapeutic alliance.

Key Goals

• We should demonstrate concern, ensure our understanding of the situation, and identify and address reasons for leaving, such as:
• Discomfort with the room, or with the idea of staying in the hospital.
• Family responsibilities (or the dog/cat these patients inevitably seem to have at home).
• Prior bad experiences in the hospital or emergency department.
• Problem-solve when possible:
• Can someone else help with the family or pet? Could you or another staff member help call that person?
• How can we make them more comfortable physically or psychologically?
• Would the patient be comfortable with a time-limited observation (i.e., 6 hours and recheck)
• Adjusting the plan:
• Could you offer oral antibiotics as some measure of treatment?
• Could you help arrange close outpatient follow-up?
• Would they be more comfortable being admitted to a different hospital?

 

Structuring the AMA conversation:

• For high-risk cases, consider a witness (e.g., a nurse present) so someone can corroborate the events in their own words in the chart.
• First, acknowledge the patient's goals and concerns. As discussed before, try to get to the reason they feel they need to leave..
• Next, explainthe  medical concern clearly.
• Name specific risks and offer reasonable alternatives.
• Invite questions.
  ○ Leave the door open for return. We ultimately want them to complete the workup, and the patient should be aware that they can choose to return as soon as they leave the department or at any point in the future to accomplish that.
• Consider the following helpful language:
• “I am concerned about…”
• “The risk I worry about most is…”
• “Here is what I recommend and why…”
• “If you change your mind, please return immediately.”
• “You’re the captain. I make recommendations; you make decisions.” (personal favorite of Dr. Heidepriem)

 

Practical Strategies: Tips to potentially avoid the AMA and keep the conversation from escalating.

• Approach the conversation with curiosity instead of authority.
• Start with trying to gain an understanding of the patient's reasoning, not by entering the room to “tell them how it is”.
• Pause and reset if the conversation escalates.
• Consider bringing in another clinician for a second voice if helpful.
• Involve consultants selectively (e.g., patients' PCP or cardiologist).
• Our clinic-based colleagues put a lot of effort into the patient/provider relationship, and sometimes the patient will want to leave despite your recommendation, but if their PCP recommends staying, they will.
• Involve security only if the patient lacks capacity or is a danger to self or others.
• Security presence during the AMA conversation can cause the tension to escalate and decrease any rapport you may have built during the visit.
  
  

Myth Busting

Myth #1: Insurance Won’t Pay if They Leave AMA

• False. Multiple studies have shown that insurance usually covers visits, even when patient leaves AMA.
• Using financial threat as leverage is inappropriate and potentially manipulative.

 

Myth #2: We Cannot Prescribe if Patient Leaves AMA

• False.
• Risk mitigation continues even if the patient leaves AMA.
• Optimize care when possible:
• Appropriate prescriptions
• Outpatient coordination
• Not an all-or-nothing scenario.

 

Myth: AMA Cleanly Resolves Responsibility

• False. High-risk presentations remain high risk.
• Ensure the patient has capacity, document well your conversation with the patient and include nursing staff or others so they can do the same.

 

Dr. HeidepriemComp’s dot phrase for AMA encounters:

 

The patient is presenting with [] and on our evaluation likely has [].  The patient is requesting to leave.  The patient is clinically sober and appears free from distracting injury.  The patient appears to have intact insight, judgment, and reason.  In my opinion, this patient has the capacity to make decisions.  The patient has verbalized understanding of my concerns of diagnosis.  I have discussed the need for continued treatment including further evaluation in the ED and possible admission.

 

I have told the patient that by leaving with this diagnosis, the condition may worsen and result in critical illness, disability, and/or death, specifically [].  I have asked the patient the reason for wanting to leave.  The reason is []. I have offered to address these needs with [].  I also spoke with [], but was still unable to convince the patient to stay. 

 

Given that I am unable to convince the patient to stay, I have asked the patient to return as soon as possible to complete the workup and treatment.  The patient will follow up with PCP.  He is refusing further care and is leaving against medical advice.

 

 

 

References:

1. Pages KP, Russo JE, Wingerson DK, Ries RK, Roy-Byrne PP, Cowley DS. Predictors and outcome of discharge against medical advice from the psychiatric units of a general hospital. Psychiatr Serv. 1998;49(9):1187-1192. PMID: 9735960
2. Devitt PJ, Devitt AC, Dewan M. An examination of whether discharging patients against medical advice protects physicians from malpractice charges. Psychiatr Serv. 2000;51(7):899-902. PMID: 10875955