Distal Biceps Tendon Rupture

Distal biceps tendon injuries are very serious injuries. 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.

Note the bruising around the elbow as well as the prominence of the biceps muscle (“Popeye” deformity).

Distal biceps tendon ruptures are uncommon injuries. 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. 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.

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

In older, less active patients, distal biceps tendon ruptures can be treated nonoperatively. 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.

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.

8 Responses to Distal Biceps Tendon Rupture

  1. I am a 72-year-old female. I am looking for the cause of an enormous bruise on my inner forearm. I did not have any sort of collision or bump. It just showed up as a small bruise and grew to almost cover the entire forearm over the next few weeks. It is now subsiding. There is pain that follows a path from my outer inner wrist to my elbow then again to my armpit. It occurred while driving from Atlanta to Calif….sitting for 3 days. No one can explain this. My theory is that it is caused by floroquinolones. After 2 prescriptions several years ago I had a tricep tear in my left arm while watching TV. Ditto 4months later in my right arm. Then a year later, over-night neuropathy in my feet (different from normal neuropathy in that it is painful, lumpy and the tendons are tight, keeping my toes from extending). Floroquinolones are known to tear tendons and stay in the body for years. They now have a black-box warning. I do not know how to find out what this is. If you can help or direct me to someone who can help, it would be appreciated. BTW, I am on a new drug Ibrutinib, which exacerbates bruising, but does not cause it. Nor does it cause tendon tears.
    Fran Conn, Roswell, Ga franc513@mac.com

  2. I’m pretty sure now that I’ve read this article that I’ve ruptured my bicep just over two months ago. I want to know what I should do this late in the game, I’m 51 years old a builder remodeling professional ie… I work hard. I did hear the tearing sound when I caught my father from falling off of the boat dock.
    What advise do you have for me please

  3. I have a Distal Biceps Tendon Rupture. I have been told for several years that there is nothing that can be done. I am now loosing mobility & strength. It also ache all the time. I live in Greenwood SC. Is there something you can suggest.

    • Old, chronic tears often cannot be directly reattached. When distal biceps tendon ruptures are seen early, they usually can be reattached.

  4. Hello Doctor Geier,
    I’m a 51 year old male and was rather active at playing sports. In September of 2014 I ruptured my right distal bicep tendon while lifting furniture at work. I had successful surgery done in October 2014 and went through extensive PT. It has been over two years since all that and really have not done any heavy lifting or have played any sports since. I used to play volleyball a lot and I would like to try to get back to playing volleyball and also, I used to bowl a lot and would like to get back to bowling.
    Do you feel it is safe to do so if I start out slowly?
    My Doctor is one of the best and came highly recommended. He felt that my arm was fully healed or at least as much as possible.
    I know you cannot physically check but I wanted to get a second opinion.
    I think physically I’m ready but mentally, I’m a bit apprehensive to try.
    Bob Stewart

    • I can’t say in your case specifically, but usually patients can return to full activity that far out from surgery.

  5. I have a distal bicep rupture. I ruptured while playing basketball. I am 55 yo and still active. I had the surgery in sept and six weeks later it rupture again as seen on MRI I had no brace or anything on during the night I am restless sleeper and I felt the pain. Had surgery to repair 2nd time the the dr was able to cut back a little bit of tendon and use the button procedure again. This time used sling 7 days with immobilized then used a brace limited use up until 6 weeks. no weights at all while stretching to put coat on ruptured again. I am hesitant to have surgery 3rd time. What is the long term effect of not having surgery? Will muscle atrophy. The MRI in each case shows rupture. the Dr tested the arm for twisting strength and it had strength, but will that disappear over time?

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