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Distal Biceps Tendon Rupture

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Other Names

  • Biceps Tendon Tear
  • Biceps Tendon Partial Tear
  • Distal Biceps Tendon Rupture
  • Distal biceps tendon tear
  • Complete distal biceps rupture
  • Partial distal biceps tendon tear
  • Biceps tendon rupture at the elbow
  • Distal biceps avulsion
  • Rupture of the distal biceps brachii tendon
  • Avulsion of the distal biceps brachii tendon

Background

  • This page refers to partial and complete tears of the distal biceps tendon of the Biceps Brachii

History

  • First published case attributed to Starks in 1843[1]

Epidemiology

  • Rare occurrence
  • Most common in active, middle age males
  • Dominant extremity most commonly involved (86% in one study)[2]

Distal Biceps Tendon Rupture

  • Most common form of distal biceps tendon injury (need citation)
  • 1.2 - 2.55 ruptures per 100,000 person years[2][3]

Introduction

Illustration and clinical example of a complete distal biceps tendon rupture
Anatomy illustration of the biceps brachii
The top picture shows the two distinct heads of the distal biceps tendon, the short and long heads. The bottom picture illustrates the footprint of each head. Notice that the short head is more distal and occupies the apex of the bicipital tuberosity while the long head is more proximal and posterior[4]

General

  • Typically occur in middle aged males from eccentric loading of a flexed elbow, typically dominant arm[5]
  • The rupture usually occurs at the tendon insertion into the radial tuberosity
  • Clinical presentation includes a painful tearing sensation in the antecubital region
  • Surgical repair is the mainstay of treatment for active patients with better outcomes with early repair[6]

Pathogenesis

  • Typically involves some form of trauma
  • Most commonly, a heavy, uncontrolled eccentric load from a flexed position
  • Seiler et al: hypovascular zone of ~ 2 cm seen in cadavar study[7]
    • Thus poor blood supply in a watershed area suspected as a predisposing risk factor

Anatomy of the Biceps Brachii

  • Distal biceps tendon is composed of two heads
    • Short Head: Medial, inserts distally, includes the apex of the bicipital tuberosity[8]
    • Long Head: Lateral, deep to short head, inserts more proximally on the bicipital tuberosity
  • Associated anatomy

Associated Conditions

Risk Factors

  • Manual labour
  • Weight training
  • Anabolic steroids
  • Tobacco Use
    • 7.5 fold greater risk[2]
  • Elevated body mass index (BMI)
  • Pre-existing tendon degeneration
  • Decreased vascularity at the insertion site[5]

Differential Diagnosis

Differential Diagnosis Elbow Pain

Clinical Features

Arrow points to biceps muscle belly retracted proximally suggesting a distal biceps tendon rupture
Clinical demonstration of the Hook Test[9]

History

  • Patients typically report a specific injury (i.e. lifting a heavy object), although sometimes injury can be more insidious
    • May have heard or felt a 'popping' sensation
    • Usually an eccentric loading of a flexed elbow
    • Patients are middle aged men, age 40-60
  • Mechanism is sometimes described as an unexpected extension force applied to a flexed arm
  • Reports pain, weakness with elbow flexion and supination

Physical: Physical Exam Elbow

  • Inspection: evaluate for ecchymosis, swelling
  • Deformity of muscle belly with proximal retraction of muscle belly
  • The bicepital aponeurosis can feel like an intact tendon despite a tear
    • This suggests a partial tear rather than ac omplete tear
  • Pain, weakness in flexion and supination
    • Weakness on supination is 100% sensitive for complete, chronic ruptures[10]

Special Tests (for tendon rupture)

Evaluation

(A) Preoperative anteroposterior and (B) preoperative lateral radiographs of the right elbow demonstrating persevered joint space, with no evidence of fracture or dislocation. (C) Preoperative sagittal fat suppressed magnetic resonance imaging view of the distal biceps tendon tear with associated soft-tissue inflammation and edema.[12]
Ultrasound findings typical of bicipitoradial bursitis. The encysted fluid with echoes and septations around the distal biceps tendon. Note the neurovascular structures are marked but not labeled[13]
MRI Elbow demonstrating distal biceps tendon rupture with significant tendon retraction.

Radiographs

  • Standard Radiographs Elbow
    • Screening tool to exclude other etiologies
    • Typically normal, may show soft tissue swelling
  • Potential findings
    • Hypertrophic bone at radial tuberosity

US

  • Can be considered as an alternative to MRI
    • Provides good early evaluation
    • There is a strong correlation between ultrasound findings and need for surgical intervention[14]
  • Diagnostic accuracy
    • Lobo et al: 95% sensitivity, 71% specificity, and 91% accuracy for the diagnosis of complete versus partial DBT tears[15]
    • DBT had 97% sensitivity, 100% specificity, and 98% accuracy for complete tear versus normal tendon

MRI

  • Gold standard for evaluating distal biceps tendon ruptures
    • Better at detecting partial tears and tendinopathies than ultrasound[16]
  • Findings[17]
    • Absence of the tendon distally
    • Fluid-filled tendon sheath
    • Antecubital fossa mass
    • Muscle edema and atrophy are non-specific
  • May not be indicated in patients with obvious complete rupture requiring surgical management
  • Consider FABS position (lexed, abducted, supinated position)[18]
    • 100% sensitive for complete tears, 59% sensitive for partial tears[19]

Classification

  • Partial (insertional or intrasubstance) vs Complete tears
  • Acute (< 4 weeks) vs chronic (> 4 weeks)
  • Intact or ruptured lacertus fibrosus

Management

Illustration of the Long Arm Posterior Splint[20]
Illustration of distal biceps tendon rupture surgical repair
A Photograph of the patient that shows weakness in terminal supination, after distal biceps repair through an anterior approach. This prevents him from competing as a marksman as he cannot stabilize his rifle. B Axial CT scan showing distal biceps anchors placed anterior to the proutuberance, decreasing the moment arm of the tendon, and causing his weakness. C Post-operative photograph showing the improvement in the supination strength after revision repair in an anatomic position though a posterior approach. D Post-operative x-ray showing the anatomic repair of both distal biceps tendon heads with 2 intramedullary unicortical buttons[4]

Nonoperative: Partial Tears

  • Indications
    • Non-operative approach is considered first line in most patients
  • Initial approach
  • Physical Therapy
  • Ultrasound guided injection therapy
    • Demonstrates similar overall success rates to wait and see, physical therapy approaches
    • Provides the fastest symptom relief within 1 week[21]
  • Progression to complete tears
    • Most studies suggest partial tears treatd nonoperatively will not progress to complete tears
    • There are a few case reports of partial tears progressing to complete tears[22]

Nonoperative: Complete Tears

  • Indications
    • Older, low demand individuals
    • Most experts agree than acute tears are a surgical injury with patients generally having good results
  • Outcomes are better in surgically treated patients[23][24]
  • Nonoperative management can be considered in low-demand, sedentary patients after discussion of risks/benefits
    • Lose: 50% supination strength, 30% flexion strength, 15% grip strength (need citation)
  • Treatment

Operative: Partial Tears

  • Indication
    • Failure of non-operative management
  • Technique
    • Tenotomy and then tendon repair with debridement of surrounding tissue

Operative: Acute Tears

  • Indications
    • Operative management is indicated in most cases
  • Technique
    • Single- or double- incision

Operative: Chronic Tears

  • Challenging to manage surgically due to tendon retraction and muscle atrophy, scarring of fibrous tissue

Rehab and Return to Play

Distal biceps tendon rupture rehab

Rehabilitation

  • Operative[25]
    • Immobilized in flexion for a period ranging from 1-6 weeks, typically ~2 weeks
    • Early range of motion
    • Strengthening begins at the 6-8 week mark
  • Early range of motion
    • Early versus delayed mobilization protocols demonstrate no clinically significant differences in patient-reported outcomes, range of motion, or complication rates[26]

Rehab Protocol PDFs

Return to Play

  • General[27]
    • Return to sport rates range from 91-97%
    • Ocurr at a mean of 6.0-6.3 months postoperatively
    • 85% of patients returning to preinjury levels or higher
    • Return to work averages 14.4 weeks (range 3-4 months)
  • Factors assocaited with higher return to play
    • Bone tunnel fixation
    • ≤2 weeks of postoperative immobilization
    • Early initiation of active ROM
    • Strengthening at ≤10 weeks

Prognosis and Complications

Prognosis

  • General
    • Outcomes are generally excellent with surgical repair
    • 90% of patients achieving good-to-excellent results and return to sport rates of 91-97%
    • Operative treatment results in superior strength recovery compared to nonoperative management
  • Surgical outcomes
    • Patients undergoing surgical repair can expect near-complete restoration of strength and function
    • Operative treatment results in superior supination strength, flexion strength, and patient-reported outcomes compared to nonoperative care[28]
    • Anatomic reinsertion produces excellent or good results in 90% of patients at an average follow-up of 3 years[29]
  • Nonsurgical outcomes
    • Can yield acceptable outcomes with modestly reduced strength, supination (63% of contralateral arm strength) compared to flexion (93% of contralateral arm)[30]
    • Patient-reported outcomes remain satisfactory, with median Mayo Elbow Performance Index scores of 95 and DASH scores of 9

Complications

  • Permanent functional deficits
    • Losses of up to 40% in supination strength and 30% in flexion strength[31]
  • Residual weakness
  • Loss of strength
  • Disability
  • Surgical
  • Re-rupture[32]
    • Correlate with postoperative immobilization protocols
    • More conservative immobilization appears protective, with re-rupture occurring in 14% of cast users versus 100% of those using no immobilization

See Also

Internal

References

  1. ↑ McReynolds IS. Avulsion of the insertion of the biceps brachii tendon and its surgical treatment. J Bone Joint Surg Am. 1963;45:1780-81.
  2. ↑ 2.0 2.1 2.2 Safran, Marc R., and Scott M. Graham. "Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking." Clinical Orthopaedics and Related Research (1976-2007) 404 (2002): 275-283.
  3. ↑ Kelly, Mick P., et al. "Distal biceps tendon ruptures: an epidemiological analysis using a large population database." The American journal of sports medicine 43.8 (2015): 2012-2017.
  4. ↑ 4.0 4.1 Carrazana-Suarez, Luis F., Sean Cooke, and Christopher C. Schmidt. "Return to play after distal biceps tendon repair." Current reviews in musculoskeletal medicine 15.2 (2022): 65-74.
  5. ↑ 5.0 5.1 Ramsey, Matthew L. "Distal biceps tendon injuries: diagnosis and management." JAAOS-Journal of the American Academy of Orthopaedic Surgeons 7.3 (1999): 199-207.
  6. ↑ Srinivasan, Ramesh C., William C. Pederson, and Bernard F. Morrey. "Distal biceps tendon repair and reconstruction." The Journal of hand surgery 45.1 (2020): 48-56.
  7. ↑ Seiler JG 3rd, Parker LM, Chamberland PD, Sherbourne GM, Carpenter WA . The distal biceps tendon. Two potential mechanisms involved in its rupture: arterial supply and mechanical impingement. J Shoulder Elbow Surg. 1995;4:149-56
  8. ↑ Athwal GS, Steinmann SP, Rispoli DM. The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am 2007;32:1225-1229.
  9. ↑ www.merckmanuals.com
  10. ↑ 10.0 10.1 Zwerus, Elisa L., et al. "Distal biceps tendon ruptures: diagnostic strategy through physical examination." The American Journal of Sports Medicine 50.14 (2022): 3956-3962.
  11. ↑ Caputo, Vincent, et al. "The utility of the biceps palpation-rotation test in diagnosing partial distal biceps tendon tears." Journal of Shoulder and Elbow Surgery 31.8 (2022): 1603-1609.
  12. ↑ Khan, Zeeshan A., et al. "Single-incision distal biceps tendon repair with bicortical tensionable locking button fixation." Arthroscopy Techniques 12.11 (2023): e2063-e2069.
  13. ↑ Case courtesy of Maulik S Patel, Radiopaedia.org, rID: 48835
  14. ↑ Blasi, Marc, et al. "Ultrasound classification of traumatic distal biceps brachii tendon injuries." (2018): 519-532.
  15. ↑ Lobo LdaG, Fessell DP, Miller BS, et al. The role of sonography in differentiating full versus partial distal biceps tendon tears: correlation with surgical findings. AJR Am J Roentgenol 2013;200:158-162.
  16. ↑ Chen, Karen C., et al. "ACR Appropriateness Criteria® Acute Elbow and Forearm Pain." Journal of the American College of Radiology 21.11 (2024): S355-S363.
  17. ↑ Falchook FS, Zlatkin MB, Erbacher GE et-al. Rupture of the distal biceps tendon: evaluation with MR imaging. Radiology. 1994;190 (3): 659-63.
  18. ↑ Giuffrè BM, Moss MJ. Optimal positioning for MRI of the distal biceps brachii tendon: flexed abducted supinated view. AJR Am J Roentgenol 2004;182:944-946.
  19. ↑ Festa A, Mulieri PJ, Newman JS, et al. Effectiveness of magnetic resonance imaging in detecting partial and complete distal biceps tendon rupture. J Hand Surg Am. 2010;35(1):77– 83.
  20. ↑ Gluck, Matthew J., et al. "Comparative strength of elbow splint designs: a new splint design as a stronger alternative to posterior splints." Journal of Shoulder and Elbow Surgery 28.4 (2019): e125-e130.
  21. ↑ Jansen, Neal, et al. "Efficacy of conservative Treatment Strategies for Partial Distal Biceps Tendon Ruptures. A case-control study." Journal of Shoulder and Elbow Surgery (2025).
  22. ↑ Kelly EW, Steinmann S, O’Driscoll SW. Surgical treatment of partial distal biceps tendon ruptures through a single posterior incision. J Shoulder Elbow Surg. 2003;12(5):456 – 461.
  23. ↑ Chillemi C, Marinelli M, De Cupis V . Rupture of the distal biceps brachii tendon: conservative treatment versus anatomic reinsertion—clinical and radiological evaluation after 2 years. Arch Orthop Trauma Surg. 2007;127:705-8
  24. ↑ Hetsroni I, Pilz-Burstein R, Nyska M, Back Z, Barchilon V, Mann G . Avulsion of the distal biceps brachii tendon in middle-aged population: is surgical repair advisable? A comparative study of 22 patients treated with either nonoperative management or early anatomical repair. Injury. 2008;39:753-60
  25. ↑ Boufadel, Peter, et al. "Return to Sport After Distal Biceps Tendon Repair: A Systematic Review." The American Journal of Sports Medicine 53.7 (2025): 1769-1778.
  26. ↑ Simpson, Evan R., et al. "No Clinically Significant Differences in Patient-Reported Outcomes and Range of Motion Between Early and Delayed Mobilization After Primary Distal Biceps Tendon Repair: A Systematic Review and Meta-analysis." The American Journal of Sports Medicine (2025): 03635465251317207.
  27. ↑ Gowd, Anirudh K., et al. "Return to sport and weightlifting analysis following distal biceps tendon repair." Journal of Shoulder and Elbow Surgery 30.9 (2021): 2097-2104.
  28. ↑ Looney, Austin M., et al. "Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis." Journal of shoulder and elbow surgery 31.4 (2022): e169-e189.
  29. ↑ Rantanen, Jussi, and Sakari Orava. "Rupture of the distal biceps tendon." The American Journal of Sports Medicine 27.2 (1999): 128-132.
  30. ↑ Freeman, Carl R., et al. "Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group." JBJS 91.10 (2009): 2329-2334.
  31. ↑ Stoll, Laura E., and Jerry I. Huang. "Surgical treatment of distal biceps ruptures." Orthopedic Clinics 47.1 (2016): 189-205.
  32. ↑ Rosenthal, Ron, Ryan S. Ting, and Doron Sher. "Management of distal biceps tendon ruptures: a survey of fellowship-trained subspecialist elbow surgeons." Journal of Shoulder and Elbow Surgery 32.10 (2023): e495-e503.
Created by:
John Kiel on 18 June 2019 01:55:03
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2 April 2026 10:59:08
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