Courtesy of AAOS/OrthoInfo and Orthobullets
Biceps Tendon Tear at the Elbow (Distal Biceps Tendon Rupture)
Biceps Tendon Tear at the Elbow (Distal Biceps Tendon Rupture)
The biceps muscle is located in the front of your upper arm. It is attached to the bones of the shoulder and elbow by tendons — strong cords of fibrous tissue that attach muscles to bones.
Tears of the biceps tendon at the elbow are uncommon. They are most often caused by a sudden injury and tend to result in greater arm weakness than injuries to the biceps tendon at the shoulder.
Once torn, the biceps tendon at the elbow will not grow back to the bone and heal. Other arm muscles make it possible to bend the elbow fairly well without the biceps tendon. However, they cannot fulfill all the functions of the elbow, especially the motion of rotating the forearm from palm down to palm up. This motion is called supination.
To return arm strength to near normal levels, surgery to repair the torn tendon is usually recommended. However, nonsurgical treatment is a reasonable option for patients who may not require full arm function.
Tears of the biceps tendon at the elbow are uncommon. They are most often caused by a sudden injury and tend to result in greater arm weakness than injuries to the biceps tendon at the shoulder.
Once torn, the biceps tendon at the elbow will not grow back to the bone and heal. Other arm muscles make it possible to bend the elbow fairly well without the biceps tendon. However, they cannot fulfill all the functions of the elbow, especially the motion of rotating the forearm from palm down to palm up. This motion is called supination.
To return arm strength to near normal levels, surgery to repair the torn tendon is usually recommended. However, nonsurgical treatment is a reasonable option for patients who may not require full arm function.
Other arm muscles can substitute for the injured tendon, usually resulting in full motion and reasonable function. Left without surgical repair, however, the injured arm will have permanent weakness: loss of 50% sustained forearm supination strength, loss of 40% supination strength, and loss of 30% elbow flexion strength.
Rupture of the distal biceps tendon is uncommon. It occurs in only three to five people per 100,000 each year, and is less common in women. It is much more common in people who smoke (7.5 greater risk in smokers vs. nonsmokers) or take anabolic steroids.
Rupture of the distal biceps tendon is uncommon. It occurs in only three to five people per 100,000 each year, and is less common in women. It is much more common in people who smoke (7.5 greater risk in smokers vs. nonsmokers) or take anabolic steroids.
Anatomy
The biceps muscle has two tendons that attach the muscle to the shoulder and one tendon that attaches at the elbow. The tendon at the elbow is called the distal biceps tendon. It attaches to a part of the radius bone in the forearm called the “radial tuberosity,” a small bump on the radius bone near your elbow joint.
The biceps muscle has two tendons that attach the muscle to the shoulder and one tendon that attaches at the elbow. The tendon at the elbow is called the distal biceps tendon. It attaches to a part of the radius bone in the forearm called the “radial tuberosity,” a small bump on the radius bone near your elbow joint.
The biceps muscle helps you bend and rotate your arm. It attaches at the elbow to a small bump on the radius bone called the “radial tuberosity.”
Reproduced and modified from The Body Almanac © American Academy of Orthopaedic Surgeons, 2003.
Reproduced and modified from The Body Almanac © American Academy of Orthopaedic Surgeons, 2003.
Biceps tendon tears can be either partial or complete.
Partial tears
These tears damage the soft tissue and can be quite painful and debilitating, but do not completely sever the tendon.
Complete tears
A complete tear will detach the tendon completely from its attachment point at the bone.
In most cases, tears of the distal biceps tendon are complete. This means that the entire muscle is detached from the bone and retracted upward toward the shoulder.
Partial tears
These tears damage the soft tissue and can be quite painful and debilitating, but do not completely sever the tendon.
Complete tears
A complete tear will detach the tendon completely from its attachment point at the bone.
In most cases, tears of the distal biceps tendon are complete. This means that the entire muscle is detached from the bone and retracted upward toward the shoulder.
A complete tear of the distal biceps tendon. The tendon has pulled away from where it attached at the radial tuberosity.
Modified from Bernstein J (ed): Musculoskeletal Medicine. © American Academy of Orthopaedic Surgeons, 2003.
Modified from Bernstein J (ed): Musculoskeletal Medicine. © American Academy of Orthopaedic Surgeons, 2003.
Cause
The main cause of a distal biceps tendon tear is a sudden forceful injury. These tears are rarely associated with other medical conditions.
Injury
Injuries to the distal biceps tendon usually occur when the elbow is forced straight against resistance. It is less common to injure this tendon when the elbow is forcibly bent against a heavy load.
Lifting a heavy box is a good example of how this injury occurs. Perhaps you grab it without realizing how much it weighs. You strain your biceps muscles and tendons, trying to keep your arms bent, but the weight is too much and it forces your arms straight. As you struggle, the stress on your distal biceps tendon increases and the tendon tears away from the bone.
Risk Factors
Men, age 30 years or older, are most likely to tear the distal biceps tendon.
Additional risk factors for distal biceps tendon tear include:
The main cause of a distal biceps tendon tear is a sudden forceful injury. These tears are rarely associated with other medical conditions.
Injury
Injuries to the distal biceps tendon usually occur when the elbow is forced straight against resistance. It is less common to injure this tendon when the elbow is forcibly bent against a heavy load.
Lifting a heavy box is a good example of how this injury occurs. Perhaps you grab it without realizing how much it weighs. You strain your biceps muscles and tendons, trying to keep your arms bent, but the weight is too much and it forces your arms straight. As you struggle, the stress on your distal biceps tendon increases and the tendon tears away from the bone.
Risk Factors
Men, age 30 years or older, are most likely to tear the distal biceps tendon.
Additional risk factors for distal biceps tendon tear include:
- Smoking. Nicotine use can affect tendon strength and quality.
- Corticosteroid medications. Using corticosteroids has been linked to increased muscle and tendon weakness.
Symptoms
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A distal biceps tendon tear can cause the biceps muscle appear abnormal; the muscle balls up near the shoulder. Bruising at the elbow is also common.
There is often a "pop" at the elbow when the tendon ruptures. Pain is severe at first, but may subside after a week or two. Other symptoms include:
- Swelling in the front of the elbow
- Visible bruising in the elbow and forearm
- Weakness in bending of the elbow
- Weakness in twisting the forearm (supination)
- A bulge in the upper part of the arm created by the recoiled, shortened biceps muscle
- A gap in the front of the elbow created by the absence of the tendon
Physician Examination
Physical Examination
After discussing your symptoms and how the injury occurred, Dr. Jurek will examine your elbow. During the physical examination, she will feel the front of your elbow, looking for a gap in the tendon. She will test the supination strength of your forearm by asking you to rotate your forearm against resistance and will compare the supination strength to the strength of your opposite, uninjured forearm.
Imaging Tests
In addition to the examination, Dr. Jurek will likely recommend imaging tests to help confirm the diagnosis.
Physical Examination
After discussing your symptoms and how the injury occurred, Dr. Jurek will examine your elbow. During the physical examination, she will feel the front of your elbow, looking for a gap in the tendon. She will test the supination strength of your forearm by asking you to rotate your forearm against resistance and will compare the supination strength to the strength of your opposite, uninjured forearm.
Imaging Tests
In addition to the examination, Dr. Jurek will likely recommend imaging tests to help confirm the diagnosis.
- X-rays. Although x-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause elbow pain. Sometimes they show a tiny fleck of bone that has pulled off with the attached tendon and this can confirm the diagnosis.
- Ultrasound. This imaging technique can show the free end of the biceps tendon that has recoiled up in the arm. There are drawbacks associated with ultrasound, primarily that it does not provide a complete image of the elbow and potentially injured structures.
- Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears of the biceps tendon.
This MRI image shows the torn biceps tendon (red circle) which has retracted proximally. The red arrow points to the gap where the tendon used to be before it was torn. The bright white is swelling from the injury.
Treatment
Surgery to reattach the ruptured tendon to the bone is necessary to regain full arm strength and function.
Nonsurgical treatment may be considered if you are older and less active, or if the injury occurred in your nondominant arm and you can tolerate not having full arm function and strength. Nonsurgical treatment may also be an option for people who have medical problems that put them at higher risk for complications during surgery.
It is very important to note that distal biceps tendon ruptures are best treated with early surgery, usually within a couple of weeks of the injury. This is not an injury that does well with a delayed or missed diagnosis and treatment.
Nonsurgical Treatment
Nonsurgical treatment options focus on relieving pain and maintaining as much arm function as possible. Treatment recommendations may include:
Surgical Treatment
Surgery to repair the torn distal biceps tendon should be performed within the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten, and restoring arm function with surgery may not be possible. While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.
Surgery to reattach the ruptured tendon to the bone is necessary to regain full arm strength and function.
Nonsurgical treatment may be considered if you are older and less active, or if the injury occurred in your nondominant arm and you can tolerate not having full arm function and strength. Nonsurgical treatment may also be an option for people who have medical problems that put them at higher risk for complications during surgery.
It is very important to note that distal biceps tendon ruptures are best treated with early surgery, usually within a couple of weeks of the injury. This is not an injury that does well with a delayed or missed diagnosis and treatment.
Nonsurgical Treatment
Nonsurgical treatment options focus on relieving pain and maintaining as much arm function as possible. Treatment recommendations may include:
- Rest. Avoid heavy lifting and overhead activities to relieve pain and limit swelling. Your doctor may recommend using a sling for a brief time.
- Nonsteroidal anti-inflammatory medications. Drugs like ibuprofen and naproxen reduce pain and swelling.
- Physical therapy. After the pain decreases, Dr. Jurek may recommend rehabilitation exercises to strengthen surrounding muscles in order to restore as much movement as possible.
Surgical Treatment
Surgery to repair the torn distal biceps tendon should be performed within the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten, and restoring arm function with surgery may not be possible. While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.
This intraoperative photograph shows the detached stump of the biceps tendon. This is what is repaired back down to the radial tuberosity during surgery.
Procedure
There are several different procedures to reattach the distal biceps tendon to the forearm bone. Some doctors prefer to use one incision at the front of the elbow, while others use small incisions at both the front and back of the elbow. Dr. Jurek usually prefers to use a single small incision at the front of the elbow. She typically reattaches the tendon utilizing strong stitches that pull the tendon into a tunnel drilled into the bone and secured with a small metallic button designed specifically for this surgery. Be sure to ask Dr. Jurek any questions you may have about the repair technique.
There are several different procedures to reattach the distal biceps tendon to the forearm bone. Some doctors prefer to use one incision at the front of the elbow, while others use small incisions at both the front and back of the elbow. Dr. Jurek usually prefers to use a single small incision at the front of the elbow. She typically reattaches the tendon utilizing strong stitches that pull the tendon into a tunnel drilled into the bone and secured with a small metallic button designed specifically for this surgery. Be sure to ask Dr. Jurek any questions you may have about the repair technique.
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One method for reattaching the tendon is through a single incision at the inside of the elbow.
Reproduced from Mirzavan R, Lemos SE, Brooks K: Surgical treatment of distal biceps tendon rupture. Orthopaedic Knowledge Online Journal 2007; accessed January 2016. |
This is a close-up illustration of the button used to secure the tendon back down to bone. (This image and all of the following images are courtesy of Arthrex)
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1. The distal end of the tendon is secured with suture, which is attached to the button. The radial tuberosity is drilled bicortically (through both the inner and outer cortices) with a guide pin in the desired location of the repair.
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2. A reamer is drilled over the guide pin, opening up a hole in the near cortex of the bone. This creates a socket or bone tunnel into which the tendon will be secured.
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3. The button is passed through both the inner and out cortices of the radius and flipped perpendicular so that pulling on the sutures will allow the tendon to be pulled into the bone tunnel.
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4. The sutures are pulled in alternating fashion to seat the tendon fully into the bone socket. Once this is accomplished, one end of the suture is passed through the tendon with a needle to lock the repair in place.
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5. The suture ends are tied, completing the repair.
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These x-rays show the appearance of the bone socket and button following the surgical repair of the distal biceps (black arrow).
Complications
Surgical complications are generally rare and temporary.
- Numbness and/or weakness in the forearm can occur and usually goes away.
- New bone may develop around the site where the tendon is attached to the forearm bone. While this usually causes little limitation of movement, sometimes it can reduce the ability to twist the forearm. This may require additional surgery.
- Although quite uncommon, the tendon may re-rupture after full healing of the repair.
Rehabilitation
Immediately after surgery, your arm may be immobilized in a splint or brace (view postoperative protocol here).
- Dr. Jurek will soon begin having you move your arm, often with the protection of a brace. She may prescribe physical therapy to help you regain range of motion and strength.
- Resistance exercises, such as lightly contracting the biceps or using elastic bands, may be gradually added to your rehabilitation plan.
- Be sure to follow the treatment plan. Since the biceps tendon takes over 3 months to fully heal, it is important to protect the repair by restricting your activities.
- Light work activities and activities of daily living such as brushing your teeth can begin soon after surgery. It is very important to note that heavy lifting and vigorous activity should be avoided for several months.
- Although it is a slow process, your commitment to your rehabilitation plan is the most important factor in returning to all the activities you enjoy.
Surgical Outcome
Almost all patients have full range of motion and strength at the final follow-up doctor visit.
- After approximately three months time, return to heavy activities and jobs involving manual labor is a reasonable expectation.
This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon.