Distal Biceps Rupture

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The distal biceps is important for flexing (or bending) your elbow and also for rotating your forearm outwards (supination).
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Biceps Tendon (Anatomy)

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Biceps muscle and tendon.

The biceps tendon starts in the shoulder and attaches down around the elbow joint.

In the shoulder it has two different origins, one from inside the shoulder joint and the other from a bone outside the joint.

These two tendons then join and form the main muscle mass in the front of your arm which you can easily palpate.

This muscle mass then becomes one single thick tendon (the distal biceps tendon) and attaches to the radial tuberosity which is a bone found around your elbow joint.
When you contract or flex your elbow you can easily palpate this tendon.

The distal biceps is important for flexing (or bending) your elbow and also for rotating your forearm outwards (supination). Therefore when this tendon ruptures you lose strength of flexion and supination.

How do patients present?

The overwhelming majority of patients that rupture their biceps tendons are male.

The injury usually occurs after a sudden lift or when your elbow is loaded in an unusual way (can be forced into extension). The patients are generally aged between 25 and 65 years of age and often the dominant arm is affected.

When the tear occurs you often hear or feel a snap and a tearing sensation. A lump can often be palpated in the lower arm as the tendon retracts around your elbow.
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Photo showing a distal biceps rupture with swelling and the muscle belly sitting higher than normal.

Tenderness is then felt in your elbow crease and bruising can occur within 24 hours. The pain slowly settles but you are generally left with weakness of elbow flexion and weakness of rotating your forearm outwards (the motion used for a screwdriver). When the tendon remains ruptured these actions remain permanently weak.

How are Distal Biceps Ruptures diagnosed?

The diagnosis can generally be made from the patient’s history and physical examination. As mentioned above, bruising is characteristic around the elbow joint, one also finds patients have tenderness around the normal course of the biceps tendon. The biceps tendon when completely ruptured is also very difficult to palpate or feel along its normal course as it often retracts up the arm.

If one is unsure of the clinical diagnosis then a more definitive diagnosis can be made with imaging such as an ultrasound or the gold standard test of a MRI scan. Once the diagnosis is confirmed then treatment options can be considered.

How are Distal Biceps Tendon Ruptures treated?

For the majority of patients a distal biceps rupture causes significant weakness around their elbow.

For this reason surgery is generally recommended to restore function around the elbow. Conservative or non-operative treatment is generally recommended for those that have very low demands on their elbow with the understanding that there will always be an element of weakness.

How long after I rupture my tendon have I got to have it repaired?

The sooner you are seen after you rupture your tendon the easier it is to repair.

Beyond 4 weeks after the injury it is very difficult to repair and the results are not as rewarding. After the rupture the tendon starts to retract up the arm and gets to a stage after 4 to 6 weeks where it cannot be brought down to its anatomical position of attachment.

How is the operation done?

The distal biceps tendon ruptures off the bone called the radius at its proximal end near the elbow joint.

The part of the radius it arises from is called the radial tuberosity. This part of the radius rotates around the other bone in the elbow called the ulna allowing the motion of rotation. The biceps tendon has to be surgically repaired to this anatomical part of the radius to allow full function to occur. The tendon can be repaired in two different ways – using either one or two incisions.

In my practice I prefer to use 1 small incision to allow the most anatomical repair – therefore restoring near to normal function.
The incision is made in your elbow crease at the front of your arm. This incision is about 3 cm long and through this exposure we find your ruptured tendon.
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Sutures are then woven up and down the tendon and these are then used to re-attach the tendon to the bone (radial tuberosity).
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Through this incision we dissect onto the bony attachment site for the tendon, a drill hole is made in this bony prominence for re-attachment of the tendon. The biceps is then pulled through the drill hole with an adjustable button and is secured with a screw in its anatomical position.
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Image showing biceps tendon fixed to the radius with a drilled socket, a button to tension the repair and a screw for a more secure hold.

Once the tendon is re-attached we put your elbow through a normal range of motion to check all is secure and functioning normally.

It is now up to the tendon to heal back to the bone and for your elbow to slowly regain function.

What happens after surgery for Distal Biceps Ruptures?

The surgery generally takes about an hour.

Your elbow is placed in a bandage and also a sling to protect the repair. No plaster is necessary. This operation can be performed as a day-only or sometimes an overnight procedure.

I get you to start moving your elbow the next day to prevent stiffness. The movement you start doing is called passive which means you use your other hand to hold your affected wrist as you move your arm. This prevents a load being placed on the repair.

I start with 2 exercises which are passive flexion and passive supination during the first 6 weeks as seen in these pictures.
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Passive Flexion

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Passive Supination

Unfortunately for the majority of the remaining 6 weeks you have to rest your arm in the sling to allow the tendon to heal.

During these 6 weeks you can take your arm out of the sling when sitting down or resting. One can generally do simple tasks such as using keyboards, eating and drinking. No weight heavier than a full coffee cup should be put through your elbow during this time of healing.

After 6 weeks a physiotherapy programme is started so you regain strength and function in your arm. It takes 4 to 6 months for your elbow to recover and feel reasonably normal. Heavy loads should not be put through your elbow in this time.

What is the success rate of surgery?

In my hands most patients are very happy with the operation and are very glad they have had it performed. The majority of patients recover their full range of motion and strength after a 4 to 6 month recovery period. Most patients can return to their pre-injury functional level after this period of time.

What complications can occur with this operation?

The complications after a distal biceps repair are very small but possible.

Firstly, if the tendon is of poor quality it maybe irreparable.

Some of the other complications include nerve damage as the tendon travels close to major nerves in your arm, blood vessel injury, and re-rupture of the tendon.
The other major complication that can occur is where your tendon repair heals rapidly causing extra bone to develop and subsequent loss of rotation of your forearm. If this occurs then a second operation is necessary to remove the bone so as to allow the rotation to recur.
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