Distal Biceps Tendon Tear: Causes, Symptoms and Treatments

Anatomy and function of the proximal and distal biceps

The biceps brachii muscle is a large muscle that sits in the front of the arm between the shoulder and the elbow joints. It has two attachments near the shoulder.

1. one inside the shoulder joint (the “long head biceps tendon”)
2. one in front of the shoulder joint (the “short head biceps tendon”)

Near the elbow, the two heads of the biceps muscle come together to form a single tendon – the “distal biceps tendon” – which then attaches to the radius (one of the two bones in the forearm). The two main functions of the biceps muscle are elbow flexion (bending) and supination (twisting the forearm from a “palm down” to a “palm up” position – such as turning a doorknob).

Distal biceps injuries: tears and ruptures

Distal biceps tendon injuries can take the form of a partial biceps tendon tear or a complete distal biceps tendon rupture, where the tendon tears away from its insertion point on the radius bone. They usually occur in middle-aged adults and are more common in male than female patients. The reported incidence of distal biceps tendon injuries has increased in recent years, likely due to the combination of an increasingly active aging patient population and an increase in the utilization of advanced diagnostic imaging studies.

What causes a distal biceps tendon tear?

Distal biceps tendon injuries often result from a forceful, eccentric contraction of the elbow. This means that the biceps muscle is contracting but the elbow is straightening, resulting in lengthening of the muscle-tendon unit. For example, this can occur when a patient attempts to pick up a heavy piece of furniture by bending the elbow, but the weight of the furniture causes the elbow to straighten instead.

Biceps tendon ruptures can occur due to acute injuries alone or may be due to an “acute-on-chronic injury,” meaning that the tendon has already experienced some level of pre-existing disease or degeneration, called tendinosis. Other risk factors such as diabetes, tobacco use, anabolic steroid use, and increased body mass index (BMI) may make some patients more prone to injury.

What are the symptoms of a distal biceps tendon rupture?

Classic symptoms of biceps tendon injuries include feeling a “pop” or tearing sensation in the front of the elbow associated with pain. There may also be associated swelling and bruising in the area. At times, patients may only have a partial rupture, where the tendon is torn but incompletely. Often, these patients have anterior elbow pain and pain with forearm twisting (supination).

In the case of a complete distal biceps tendon rupture, the tendon and muscle can also retract toward the shoulder. If this occurs, a cosmetic deformity may be noticeable that looks like a rounded mass in the upper arm. This is sometimes referred to as a “reverse Popeye deformity” as the muscle-tendon unit “balls up” given the lack of distal tension. There may also be a hollow area or indentation at the elbow where the tendon used to attach to the bone. Often, however, there is not much of a noticeable change in appearance of the arm, so lack of a deformity does not rule out the possibility of a distal biceps injury.

From a functional standpoint, if a complete distal biceps tendon rupture has occurred, some weakness is expected with both elbow flexion (bending) and forearm supination (twisting the palm up). Supination is typically affected more so than elbow flexion. However, there are multiple muscle groups other than the biceps which contribute to both motions. The other muscle groups can help to compensate for the non-functioning, injured biceps, but in a complete distal biceps tendon rupture, some residual weakness with heavy lifting or twisting motions is expected.

How is a distal biceps tear diagnosed?

The diagnosis of a distal biceps rupture can usually be made based on the patient’s history and clinical examination. The physician will examine the patient to determine if there is a deformity, locate the site of the injury, feel if the tendon is still intact, and assess for pain and weakness with elbow flexion and supination. Magnetic resonance imaging (MRI) can be used to confirm the suspected diagnosis and to further evaluate whether there is a partial tendon injury or if there is concern for an associated injury (such as a fracture, ligament tear, etc.).

How are distal biceps tendon ruptures treated?

Options for the treatment of a distal biceps tendon rupture include conservative (non-operative) treatment and surgical intervention. Partial injuries are typically first treated with a course of conservative management. Surgery is typically recommended in patients with full-thickness tendon ruptures, patients who are very active, and those who have failed non-operative treatment. However, there is sometimes a role for non-operative management of full-thickness ruptures in patients who are not highly active or in those who are poor candidates for surgery. The orthopedic surgeon will discuss these options and help decide the ideal treatment plan based on the patient’s needs, physical examination findings, and the extent of the injury based on imaging studies, which typically include elbow X-rays and an MRI.

Nonsurgical treatment

For patients electing to undergo non-operative treatment, a physical therapy treatment program will often focus first on reducing pain and maintaining full motion of the elbow. Oral NSAIDs (nonsteroidal anti-inflammatory drugs, such as ibuprofen) may also be prescribed to help reduce pain and inflammation. Once the pain and swelling have been controlled following the initial injury, treatment typically progresses to include strengthening of the other muscles around the elbow. The goal of conservative management is to reduce pain and restore elbow function. However, some residual weakness and early fatigue with supination may still be expected with non-operative treatment.

Surgical treatment

For patients electing to undergo surgical treatment, this consists of reattaching the distal biceps tendon to the bone. This can be achieved through a variety of techniques including suture anchors, surgical buttons, bone tunnels, and/or screws. Chronic ruptures (those which occurred several weeks or months prior to seeking treatment) are often more challenging to treat surgically because the tendon can retract and scar tissue will have formed. Sometimes, if the tendon cannot be directly reattached to the bone, grafts (from donor tendon tissue) need to be used in this setting.

What is the surgery for a distal biceps tendon rupture?

Surgical treatment of distal biceps tendon ruptures consists of distal biceps tendon repair. Repair involves surgical reattachment of the distal biceps tendon to the radius bone at the radial tuberosity, where the tendon naturally inserts into the bone.

Surgery is typically performed through a single incision in the front of the elbow or two-incision approach, in which a small second incision is made at the back of the elbow. Both methods have resulted in good surgical outcomes, and the approach is typically selected according to surgeon preference. Advantages of the single-incision approach include improved cosmetic appearance, decreased surgical time, and decreased risk of heterotopic ossification (abnormal bone growth). Advantages of the two-incision approach include fewer nerve complications and potentially slightly better functional outcomes.

The method used for reattaching the distal biceps tendon to the bone also varies from surgeon to surgeon. Fixation methods include the use of suture anchors, unicortical buttons (buttons that sit inside the bone), bicortical buttons (buttons that sit outside the bone), bone tunnels, and/or screw fixation.

If a surgical repair is performed many weeks after the rupture, this may require more extensive release of scar tissue from around the biceps muscle and tendon. It may also involve the need for of tendon autograft (a patient’s own tendon tissue harvested from another part of the body) or tendon allograft (cadaver donor tendon tissue) if the distal biceps cannot readily be reattached to the radius without resulting in excessive tension. The surgical approach, method of fixation, potential use of additional tendon tissue, and potential complications should all be discussed with your surgeon if surgical intervention is chosen.

What is the recovery like for distal biceps tendon repair?

After surgery, the elbow is typically immobilized in a splint or brace for a few weeks and then gentle, progressive range-of-motion exercises are initiated. The repair is protected from stress (such as heavy lifting) for the first 2 to 3 months to allow for adequate tendon-to-bone healing, and then light strengthening exercises are initiated. Return to full activity is variable based on patient progress and physical activity demands, but most patients can expect to be back to their preoperative activities by approximately 4 to 5 months after surgery.

Updated: 4/12/2024

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References

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