Biceps Tendon Tear (Distal Biceps Tendon Rupture)

The biceps brachii muscle is a two-headed muscle located in the upper arm. Its primary functions include forearm supination (rotating the palm upward – primary function) and elbow flexion. The distal biceps tendon attaches the biceps muscle to the radius, allowing for powerful arm and hand movements.

A rupture of this tendon impairs strength and function, particularly in activities requiring supination and lifting. Several muscles work to flex or bend the elbow, however, so deficits in strength may not significantly affect most people’s daily function.

Individuals who experience a distal biceps tendon rupture often report:

• A sudden, sharp pain in the front of the elbow
• A popping sensation at the time of injury
• Swelling and bruising around the elbow and forearm
• Weakness in elbow flexion but more so in forearm supination (e.g., twisting open a jar)
• A visible deformity, sometimes called the “Popeye sign,” where the biceps muscle retracts upward toward the shoulder
• Difficulty turning a screwdriver or lifting objects

A physical examination, along with imaging studies such as MRI or ultrasound, can confirm the diagnosis and assess the extent of the tear.

For patients with low physical demands or partial tears, nonsurgical management may be an option. Conservative treatments include:

• Rest and Activity Modification: Avoiding activities that strain the biceps can help reduce symptoms and prevent further damage.
• Physical Therapy: Strengthening exercises for the surrounding muscles can help compensate for the lost function.
• Bracing or Sling: A temporary sling or brace may provide support during healing.
• Pain Management: Nonsteroidal anti-inflammatory drugs (NSAIDs) and ice therapy can alleviate pain and swelling.

However, nonsurgical treatment often results in a significant loss of supination strength (up to 40%) and elbow flexion strength (up to 30%), making it less suitable for individuals who need full arm function for manual or physically intensive work or sports.

Surgical repair is the preferred treatment for most active individuals and those with complete ruptures. The goal of surgery is to reattach the torn tendon to the radial tuberosity, restoring arm function.

Several techniques may be used with comparable outcomes. For chronic injuries, a graft from another tendon (e.g., hamstring or Achilles tendon) may be used to bridge the gap.

The surgery is typically performed on an outpatient basis, with most patients returning home the same day. Rehabilitation begins shortly after surgery.

Recovery from distal biceps tendon repair generally takes several months, with full strength and function returning after 6 to 12 months. The typical postoperative timeline includes:

• Weeks 1-6: Immobilization in a brace with gradual range-of-motion exercises
• Weeks 6-12: Progressive strengthening exercises focusing on elbow flexion and supination
• Months 3-6: Advanced strengthening and return to daily activities
• Months 6-12: Return to heavy lifting and sports

Long-term outcomes for surgical repair are generally favorable, with most patients regaining near-normal strength and function. However, potential complications include:

• Nerve Injury: The lateral antebrachial cutaneous nerve or posterior interosseous nerve may be affected, leading to numbness or weakness.
• Heterotopic Ossification: Abnormal bone growth near the tendon attachment can limit motion.
• Re-Rupture: Though rare, improper healing or excessive early activity can lead to a repeat tear.

In contrast, nonsurgical treatment often results in persistent weakness, particularly in supination, which can affect activities such as using tools or lifting objects.