It’s Not About The Biceps

Document Type : CASE REPORT


1 Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, The Netherlands

2 Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands

3 Comprehensive Care Dell Medical School University of Texas, Austin, TX, USA


In the biomedical paradigm all symptoms and limitations are ascribed to discrete pathophysiology. However, a
biopsychosocial health model that accounts for the important influence of mind-set and circumstances on illness may
be preferable in the vast majority of cases. Some of the shortcomings of the biomedical model include an overreliance
on tests and treatments. One major issue of the biomedical model is the raging epidemic of opioid misuse and opioid
related overdose deaths as previously reported in North America.
Emblematic of these issues is a 56-year-old male that had surgery for a rupture of the distal biceps in our clinic with
psychosocial aspects of the illness that were underappreciated by the care team and had disastrous opioidcentric
attempts at pain control leading to threats to hospital staff, and finally resulting in forcible removal by hospital security
from the ward and national police from the hospital. One might argue that there is no higher priority than rejecting the
biomedical model, understanding illness is its full complexity, and learning from the world’s mistakes so that we don’t
repeat them.
Level of evidence: V


Main Subjects

1. Ring D, Lubahn JD, Beredjiklian P. Clinical faceoff:
distal biceps rupture: operative versus nonoperative
treatment. Clin Orthop Relat Res. 2017; 475(2):324-7.
2. Beks RB, Claessen FM, Oh LS, Ring D, Chen NC. Factors
associated with adverse events after distal biceps
tendon repair or reconstruction. J Shoulder Elbow
Surg. 2016; 25(8):1229-34.
3. Kodde IF, Baerveldt RC, Mulder PG, Eygendaal D,
van den Bekerom MP. Refixation techniques and
approaches for distal biceps tendon ruptures: a
systematic review of clinical studies. J Shoulder Elbow
Surg. 2016; 25(2):e29-37.
4. Watson JN, Moretti VM, Schwindel L, Hutchinson
MR. Repair techniques for acute distal biceps tendon
ruptures: a systematic review. J Bone Joint Surg Am.
2014; 96(24):2086-90.
5. Kokkalis ZT, Ballas EG, Mavrogenis AF, Soucacos
PN. Distal biceps and triceps ruptures. Injury. 2013;
6. Kortlever JT, Janssen SJ, van Berckel MM, Ring D,
Vranceanu AM. What is the most useful questionnaire
for measurement of coping strategies in response
to nociception? Clin Orthop Relat Res. 2015;
7. Vranceanu AM, Hageman M, Strooker J, ter Meulen D,
Vrahas M, Ring D. A preliminary RCT of a mind body
skills based intervention addressing mood and coping
strategies in patients with acute orthopaedic trauma.
Injury. 2015; 46(4):552-7.
8. Dowell D, Haegerich TM, Chou R. CDC Guideline for
prescribing opioids for chronic pain--United States,
2016. JAMA. 2016; 315(15):1624-45.
9. Olsen Y. The CDC guideline on opioid prescribing:
rising to the challenge. JAMA. 2016; 315(15):1577-9.
10. Morris BJ, Mir HR. The opioid epidemic: impact on
orthopaedic surgery. J Am Acad Orthop Surg. 2015;
11. Lindenhovius AL, Helmerhorst GT, Schnellen AC,
Vrahas M, Ring D, Kloen P. Differences in prescription
of narcotic pain medication after operative treatment
of hip and ankle fractures in the United States and The
Netherlands. J Trauma. 2009; 67(1):160-4.
12. Houweling PL, Molag ML, van Boekel RL, Verbrugge
SJ, van Haelst IM, Hollmann MW. ‘Postoperative pain
treatment’ practice guideline revised. Ned Tijdschr
Geneeskd. 2013; 157(49):A7005.
13. Helmerhorst GT, Vranceanu AM, Vrahas M, Smith M,
Ring D. Risk factors for continued opioid use one to
two months after surgery for musculoskeletal trauma.
J Bone Joint Surg Am. 2014; 96(6):495-9.
14. van Dijk PA, Bot AG, Neuhaus V, Mudgal CS, Ring D.
The correlation of phrases and feelings with disability.
Hand (N Y). 2014; 9(1):67-74.
15. Menendez ME, Ring D, Bateman BT. Preoperative
opioid misuse is associated with increased morbidity
and mortality after elective orthopaedic surgery. Clin
Orthop Relat Res. 2015; 473(7):2402-12.
16. Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D.
Opioid use after fracture surgery correlates with pain
intensity and satisfaction with pain relief. Clin Orthop
Relat Res. 2014; 472(8):2542-9.
17. Nota SP, Spit SA, Voskuyl T, Bot AG, Hageman MG,
Ring D. Opioid use, satisfaction, and pain intensity
after orthopedic surgery. Psychosomatics. 2015;