Distal Biceps Tendon Rupture

A distal biceps tendon rupture is a serious elbow injury. The biceps is a large muscle in the front of the upper arm. It is responsible for flexing the forearm at the elbow as well as supinating the forearm. Supination is the motion in which you turn over your forearm so that your palm faces up. The biceps tendon at the shoulder, which attaches the muscle to the top of the shoulder blade, can be injured with wear and tear over time. Distal biceps tendon injuries, or injuries to the biceps tendon in the front of the elbow, are usually traumatic injuries and can be very debilitating.

Mechanism of injury

A distal biceps tendon rupture is an uncommon injury. They may occur in older, more sedentary patients. They can occur in younger athletes, but it requires a tremendous force to cause the injury. Typically the injury involves some sort of load on the elbow, where the elbow is suddenly straightened while it is in a bent position. Examples of this mechanism include football players trying to make a tackle and having their elbow suddenly straightened against force trying to bend it or weightlifters tearing it while trying to do a biceps curl. The athlete will usually notice a popping or tearing sensation and immediate pain.

Also read:
Distal biceps tendon ruptures of the elbow – Answers to common questions
Distal Biceps Rupture

Signs and symptoms of a distal biceps tendon rupture

Within several minutes to hours, the arm will show bruising in the elbow and upper arm. A physician who examines the patient will usually be able to make the diagnosis simply by physical exam. The patient will have weakness trying to flex the elbow against resistance or supinating the forearm. Usually the biceps muscle at the arm will appear even more prominent than normal. This is called a Popeye deformity. It occurs when the tendon has pulled off the bone in the forearm, allowing the muscle to gradually migrate more towards the shoulder and causing a more prominent muscle.

Popeye deformity from a distal biceps tendon rupture
Note the bruising around the elbow as well as the prominence of the biceps muscle (“Popeye” deformity).

Non-surgical treatment

In older, less active patients, distal biceps tendon ruptures can be treated without surgery. The Popeye deformity usually persists, but this is usually only a cosmetic deformity and not a source of persistent complaints. The patient will notice some weakness with activities. In my experience, the loss of supination causes more problems than does the loss of flexion strength. Patients notice loss of supination strength turning doorknobs, operating tools and machinery, etc.

Surgery for a distal biceps tendon rupture

In high-level athletes, this injury is almost always treated with surgery. Usually surgery is done in the first week to 10 days to prevent any retraction of the tendon further into the upper arm. Surgery involves making an incision across the front of the elbow and repairing the tendon back down to bone. There are many ways to repair the tendon, including using stitches and anchors that are seated in the bone or drilling a tunnel that anchors the tendon deep within the bone. Regardless of which technique is chosen, recovery from the surgery takes many months. The surgeon has to protect the repair and get it to heal in that position. In order to get the tendon heal properly, motion is restricted initially and only slowly progressed over the first 4 to 6 weeks. Once full motion of the elbow is restored, strengthening is started. The overall process of recovery for normal activities, much less return to sports, is many months. Success rates from the operation are very good, but again, the process can take a very long amount of time.

Distal biceps tendon rupture surgery
A clamp is attached to the distal biceps tendon, which has pulled off the bone in the forearm.