© Cambridge Fracture Clinic - Mr Lee Van Rensburg - Cambridge; United Kingdom
Cambridge Fracture Clinic

Distal Biceps tendon rupture

Rupture of the distal biceps tendon is uncommon but seems to be increasing. It occurs in men in their forties to sixties, it is extremely rare in

females.

 It usually affects the dominant arm and follows an injury where a sudden increased load is placed on the tendon while the muscle is actively

contracting.

 Most people think the biceps muscle is the main muscle that flexes your elbow. This is not the case, the main elbow flexor is a deeper muscle

(Brachialis). The biceps muscle does provide some flexion strength but its main function is powerful supination. It is important to differentiate a

rupture of the DISTAL biceps tendon (at the elbow) as opposed to a rupture of the LONG head of biceps which happens at the shoulder.

 Anatomy

 The biceps muscle has two areas of attachment at the elbow:

Biceps tendon proper (distal) - This is the principal attachment, the tendon attaches to a bony prominence on the radius called the bicipital

tuberosity. The biceps tendon proper may also have two components to it, they both attach to the bicipital tuberosity.

Lacertus fibrosis (Bicipital aponeurosis) - The lacertus fibrosis is a condensation of the forearm fascia, is less distinct than the biceps tendon

proper.

 The biceps is a weak flexor of the elbow, but a strong supinator. The nerve supply is via the musculocutaneous nerve, this nerve ends in a branch

called the Lateral antebrachial cutaneous nerve (LABCN), this supplies sensation to the lateral side of the forearm. 

 This is important as injury to the tendon and retraction of  the muscle may pull on this nerve, leading to pins and needles and pain radiating down

the lateral aspect of the forearm.

 Diagnosis

 The diagnosis may be missed as the elbow can still flex/ extend and pronation and supination is still possible using other muscles.

 The history/ story is important, loading the flexed elbow and suddenly feeling something snap in the elbow. Followed by pain and swelling around

the front of the elbow. Occasionally pain and tingling/ numbness might radiate down the forearm as one of the nerves in the elbow may be involved.

 Bruising around the elbow and forearm may develop/ come out over a few days.

 A distinct tendon is no longer felt in the front of the elbow and the biceps muscle may bunch up.

 It is possible to only tear part of the tendon and part of the biceps muscle attachment may remain intact (lacertus fibrosis). This may limit the

amount the biceps bunches up.

 Xrays of the elbow are often normal, but required to ensure no fracture and no bony abnormalities of the radius.

 An Ultrasound or MRI scan may be required if the history and physical examination are not classic.

 Several variations of injury exist:

Complete rupture of biceps tendon and lacertus fibrosis

Complete rupture of biceps tendon, leaving lacertus fibrosis intact

Partial rupture of the biceps tendon

Rupture of musculotendinous junction (here the muscle tears off the tendon as opposed to the tendon pulling off the bone)

 Treatment

 There are two treatment options:

Non operative

Operative

 As is the case with quite a lot of upper limb trauma there is no universal treatment for everyone.

 It is a case of deciding on your expectations following the injury and balancing that with the potential risks and complications you are willing to face

in order to achieve your goal.

 Most people think that following a rupture of the biceps tendon they will have a very weak arm that does not bend and will not work well.

 This is not the case, with non operative treatment and rehabilitation of the other muscles around the elbow it is possible to get a good arm, this is at

very little risk.

 If you want to "go for gold" so to speak and want the strongest/ best arm you can have then an

operation should be considered, with the attendant risks and complications.

Non operative treatment

Non operative treatment involves, relative rest for a few weeks waiting for the bruising and

swelling to resolve.

 Keep the elbow gently moving so it does not stiffen up (see stiff elbow and stretches).

 As the pain and discomfort resolves begin a gradual increase in activities and strengthening of

the remaining muscles of around the elbow. (see stiff elbow and strengthening).

 From JSES 2009 This is average muscle strength in arm following rupture of distal biceps,

median time from injury 2.9 months, range (2weeks to 3 years).

Loss of strength in flexion and extension is better represented below as a % of the uninvolved arm.

 The information on the right is from three different studies all with different angles on the same theme. (JBJS A 1985, JBJS 2009, JSES 2009)

 In essence what they and other studies have shown is that acutely flexion

and supination strength decreases with rupture of the distal biceps tendon.

 With time as the injury resolves and the other muscles around the elbow

and forearm take up some of the work of the biceps muscle, the deficit in

strength reduces.

 On average with non operative treatment you are likely to regain:

70% flexion strength around 3 months (JSES 2009)

85% flexion strength after 1 year (JBJS 2009)

50% Supination strength around 3 months (JSES 2009)

75% supination strength after 1 year (JBJS 2009)

This is maximum strength.

Patients often complain of a degree of fatiguability of the muscles. In reality

the muscles do not fatigue faster, the symptoms of fatigability probably relate to the fact that you start off with relatively lower peak strengths.

 This is most likely to be noticed in actions requiring repeated supination (eg. using a screwdriver).

 Operative treatment

Operative treatment involves re-attachment of the biceps tendon to the bicipital tuberositity.

 There are several methods of exposing the tendon and several methods of re-attaching the tendon to bone, using transosseous sutures, bone

anchors, endobuttons and or interference screws.

 I use a single incision endobutton technique for acute repairs.

 It is much easier to repair the tendon if done acutely (within 3-4 weeks). If delayed longer than this the skin wound needs to be larger and if the

muscle and tendon have retracted proximally a long way then on occasion the gap needs to be grafted. I use a hamstring from behind the knee.

 As with all surgery there are always the potential of risks and complications.

 The more difficult the surgery the higher the potential for risks and complications.

 It is important to balance these potential risks and complications with the potential benefits (gain in function) after surgery.

In essence an acute repair (ie within 3-4 weeks) is relatively straightforward and can usually be accomplished through a 4 cm cut on the front of the

forearm.

If surgery is delayed longer than this things become more complicated, rehab time may be longer and I always discuss the potential need for a

tendon graft if the muscle has retracted proximally a long way.

Complications of operative treatment

Complication rates of up to 25% have been reported following surgical repair . Mostly related to injuries of the nerves around the elbow.

 Other complications include:

Nerve injury

Heterotopic ossification (the formation of extra bone, this is a bigger problem with the two incision technique)

Persistent pain

Stiffness (both flexion and extension, more problematic is rotation)

Infection

Complex regional pain syndrome

Re rupture

Ultimately no right or wrong

Benefits of operative treatment

 Surgery can restore near full flexion and supination strength (over 90%).

 Some patients treated non operatively will have persistent pain. It is still possible to operate at a later date but is technically more demanding and a

primary repair may not be possible, needing a tendon graft.

 Cosmetically, with non operative treatment the shape of the biceps muscle will never return to normal.

 Benefits of Non operative treatment

Avoid all the risks of surgery. No restriction on return to activity/ work, as bruising and swelling resolves increase use of arm gradually loading and

rehabilitating the tendon. Acute loss of strength will improve with time achieving 85% of flexion strength and 75% supination strength.

 Ending up with good residual strength and arm function and little overall disability.

If you want a good arm with very little risk and are willing to accept the cosmetic appearance and only slightly reduced strength then it is best not to

have an operation. Avoiding all the potential risks and complications of an operation.

 If you want to go for Gold and have the strongest arm and more normal appearance AND you are willing to undertake the risks and potential

complications of an operation then it is best to have an acute repair.

References

Proximal radial fracture after revision of distal biceps tendon repair: A case report; Alejandro Badia, S.N. Sambandam, Prakash Khanchandani; Journal

of Shoulder and Elbow Surgery; March 2007 (Vol. 16, Issue 2, Pages e4-e6)

Elbow strength and endurance in patients with a ruptured distal biceps tendon.; Nesterenko S, Domire ZJ, Morrey BF, Sanchez-Sotelo J.; J Shoulder

Elbow Surg. 2009 Aug 5

Nonoperative Treatment of Distal Biceps Tendon Ruptures Compared with a Historical Control Group; Carl R. Freeman, Kelly R. McCormick, Donna

Mahoney, Mark Baratz, and John D. Lubahn; J. Bone Joint Surg. Am., Oct 2009; 91: 2329 - 2334.

 Rupture of the distal tendon of the biceps brachii. A biomechanical study; Morrey BF, Askew LJ, An KN, Dobyns JH. . J Bone Joint Surg Am.

1985;67:418-21

Last updated 13/02/2012

© Advanced Nerve Blocks

Distal Biceps tendon

rupture

Rupture of the distal biceps tendon

is uncommon but seems to be

increasing. It occurs in men in their

forties to sixties, it is extremely rare

in females.

 It usually affects the dominant arm

and follows an injury where a

sudden increased load is placed on

the tendon while the muscle is

actively contracting.

 Most people think the biceps

muscle is the main muscle that

flexes your elbow. This is not the

case, the main elbow flexor is a deeper muscle (Brachialis). The biceps

muscle does provide some flexion strength but its main function is

powerful supination. It is important to differentiate a rupture of the

DISTAL biceps tendon (at the elbow) as opposed to a rupture of the

LONG head of biceps which happens at the shoulder.

 Anatomy

 The biceps muscle has two areas of attachment at the elbow:

Biceps tendon proper (distal) - This is the principal attachment, the

tendon attaches to a bony prominence on the radius called the

bicipital tuberosity. The biceps tendon proper may also have two

components to it, they both attach to the bicipital tuberosity.

Lacertus fibrosis (Bicipital aponeurosis) - The lacertus fibrosis is a

condensation of the forearm fascia, is less distinct than the biceps

tendon proper.

 The biceps is a weak flexor of the elbow, but a strong supinator. The

nerve supply is via the musculocutaneous nerve, this nerve ends in a

branch called the Lateral antebrachial cutaneous nerve (LABCN), this

supplies sensation to the lateral side of the forearm. 

 This is important as injury to the tendon and retraction of  the muscle

may pull on this nerve, leading to pins and needles and pain radiating

down the lateral aspect of the forearm.

 Diagnosis

 The diagnosis may be missed as the elbow can still flex/ extend and

pronation and supination is still possible using other muscles.

 The history/ story is important, loading the flexed elbow and suddenly

feeling something snap in the elbow. Followed by pain and swelling

around the front of the elbow. Occasionally pain and tingling/ numbness

might radiate down the forearm as one of the nerves in the elbow may

be involved.

 Bruising around the elbow and forearm may develop/ come out over a

few days.

 A distinct tendon is no longer felt in the front of the elbow and the

biceps muscle may bunch up.

 It is possible to only tear part of the tendon and part of the biceps

muscle attachment may remain intact (lacertus fibrosis). This may limit

the amount the biceps bunches up.

 Xrays of the elbow are often normal, but required to ensure no fracture

and no bony abnormalities of the radius.

 An Ultrasound or MRI scan may be required if the history and physical

examination are not classic.

 Several variations of injury exist:

Complete rupture of biceps tendon and lacertus fibrosis

Complete rupture of biceps tendon, leaving lacertus fibrosis intact

Partial rupture of the biceps tendon

Rupture of musculotendinous junction (here the muscle tears off

the tendon as opposed to the tendon pulling off the bone)

 Treatment

 There are two treatment options:

Non operative

Operative

 As is the case with quite a lot of upper limb trauma there is no universal

treatment for everyone.

 It is a case of deciding on your expectations following the injury and

balancing that with the potential risks and complications you are willing

to face in order to achieve your goal.

 Most people think that following a rupture of the biceps tendon they

will have a very weak arm that does not bend and will not work well.

 This is not the case, with non operative treatment and rehabilitation of

the other muscles around the elbow it is possible to get a good arm, this

is at very little risk.

 If you want to "go for gold" so to speak and want the strongest/ best

arm you can have then an operation should be considered, with the

attendant risks and complications.

Non operative treatment

Non operative treatment involves, relative rest for a few weeks waiting

for the bruising and swelling to resolve.

 Keep the elbow gently moving so it does not stiffen up (see stiff elbow

and stretches).

 As the pain and discomfort resolves begin a gradual increase in

activities and strengthening of the remaining muscles of around the

elbow. (see stiff elbow and strengthening).

 From JSES 2009 This is average muscle strength in arm following rupture

of distal biceps, median time from injury 2.9 months, range (2weeks to 3

years).

Loss of strength in flexion and extension is better represented below as

a % of the uninvolved arm.

 The information on the right is from three different studies all with

different angles on the

same theme. (JBJS A

1985, JBJS 2009, JSES

2009)

 In essence what they

and other studies have

shown is that acutely

flexion and supination

strength decreases

with rupture of the

distal biceps tendon.

 With time as the injury

resolves and the other

muscles around the

elbow and forearm

take up some of the

work of the biceps

muscle, the deficit in

strength reduces.

 On average with non operative treatment you are likely to regain:

70% flexion strength around 3 months (JSES 2009)

85% flexion strength after 1 year (JBJS 2009)

50% Supination strength around 3 months (JSES 2009)

75% supination strength after 1 year (JBJS 2009)

This is maximum strength.

Patients often complain of a degree of fatiguability of the muscles. In

reality the muscles do not fatigue faster, the symptoms of fatigability

probably relate to the fact that you start off with relatively lower peak

strengths.

 This is most likely to be noticed in actions requiring repeated supination

(eg. using a screwdriver).

 Operative treatment

Operative treatment involves re-attachment of the biceps tendon to the

bicipital tuberositity.

 There are several methods of exposing the tendon and several methods

of re-attaching the tendon to bone, using transosseous sutures, bone

anchors, endobuttons and or interference screws.

 I use a single incision endobutton technique for acute repairs.

 It is much easier to repair the tendon if done acutely (within 3-4 weeks).

If delayed longer than this the skin wound needs to be larger and if the

muscle and tendon have retracted proximally a long way then on

occasion the gap needs to be grafted. I use a hamstring from behind the

knee.

 As with all surgery there are always the potential of risks and

complications.

 The more difficult the surgery the higher the potential for risks and

complications.

 It is important to balance these potential risks and complications with

the potential benefits (gain in function) after surgery.

In essence an acute repair (ie within 3-4 weeks) is relatively

straightforward and can usually be accomplished through a 4 cm cut on

the front of the forearm.

If surgery is delayed longer than this things become more complicated,

rehab time may be longer and I always discuss the potential need for a

tendon graft if the muscle has retracted proximally a long way.

Complications of operative treatment

Complication rates of up to 25% have been reported following surgical

repair . Mostly related to injuries of the nerves around the elbow.

 Other complications include:

Nerve injury

Heterotopic ossification (the formation of extra bone, this is a

bigger problem with the two incision technique)

Persistent pain

Stiffness (both flexion and extension, more problematic is

rotation)

Infection

Complex regional pain syndrome

Re rupture

Ultimately no right or wrong

Benefits of operative treatment

 Surgery can restore near full flexion and supination strength (over 90%).

 Some patients treated non operatively will have persistent pain. It is still

possible to operate at a later date but is technically more demanding

and a primary repair may not be possible, needing a tendon graft.

 Cosmetically, with non operative treatment the shape of the biceps

muscle will never return to normal.

 Benefits of Non operative treatment

Avoid all the risks of surgery. No restriction on return to activity/ work, as

bruising and swelling resolves increase use of arm gradually loading and

rehabilitating the tendon. Acute loss of strength will improve with time

achieving 85% of flexion strength and 75% supination strength.

 Ending up with good residual strength and arm function and little

overall disability.

If you want a good arm with very little risk and are willing to accept the

cosmetic appearance and only slightly reduced strength then it is best

not to have an operation. Avoiding all the potential risks and

complications of an operation.

 If you want to go for Gold and have the strongest arm and more normal

appearance AND you are willing to undertake the risks and potential

complications of an operation then it is best to have an acute repair.

References

Proximal radial fracture after revision of distal biceps tendon repair: A

case report; Alejandro Badia, S.N. Sambandam, Prakash Khanchandani;

Journal of Shoulder and Elbow Surgery; March 2007 (Vol. 16, Issue 2,

Pages e4-e6)

Elbow strength and endurance in patients with a ruptured distal biceps

tendon.; Nesterenko S, Domire ZJ, Morrey BF, Sanchez-Sotelo J.; J

Shoulder Elbow Surg. 2009 Aug 5

Nonoperative Treatment of Distal Biceps Tendon Ruptures Compared

with a Historical Control Group; Carl R. Freeman, Kelly R. McCormick,

Donna Mahoney, Mark Baratz, and John D. Lubahn; J. Bone Joint Surg.

Am., Oct 2009; 91: 2329 - 2334.

 Rupture of the distal tendon of the biceps brachii. A biomechanical

study; Morrey BF, Askew LJ, An KN, Dobyns JH. . J Bone Joint Surg Am.

1985;67:418-21

Last updated 13/02/2012

Cambridge Fracture Clinic