Distal biceps tendon ruptures

Ruptures (tears) of the distal (bottom end, near the elbow) biceps tendon are almost always caused by a sudden injury to the elbow. This can happen when lifting objects that are too heavy, resulting in the elbow being forced straight when the bicep is under tension. Also, a common mechanism of injury is forced extension (straightening) of a flexed (bent) elbow as may occur in a collision during rugby, for example. This tears the biceps tendon from the bone either partially or fully.

You may feel a tearing sensation at the elbow and the area may be bruised. It isn’t generally a very painful injury, unless you are being examined for it, in which case there may be some localised pain. You may notice a flattened area of the biceps muscle belly, just above the elbow and the antecubital fossa (the front of the elbow) may feel empty and soft. You may see that your biceps muscle belly is riding higher on the ruptured side than the normal side, the so called ‘reverse-Popeye sign’.

From the emergency department you will be referred on to see the orthopaedic team for assessment. Diagnosis can be difficult and sometimes an MRI scan is recommended. The examination tests the surgeon may use are the Hook test, passive supination (and look for biceps muscle movement) or indeed the Ruland test.

Will a biceps tendon heal by itself ?

Once a biceps is torn, it unfortunately will not reattach itself to the bone and heal on its own. There are, however, a variety of treatment options available depending on the severity of your injury and whether it was a partial or complete tear.

How is a torn distal biceps tendon treated ?

Most people with a torn distal tendon will still be able to move their arm reasonably well, they may see a decrease in palm-up rotation strength, called supination. This is the movement we do to screw-in a screw with a screw-driver (unscrewing a screw is called pronation). The estimated loss of strength of supination is though to be about 20% of your pre-injury strength. You probably won’t notice much difference in your elbow flexion strength because there are other muscles which can do this job. The vast majority of people who don’t have surgery will go on to lead perfectly active lives and will, more than likely, forget about their injury in the due course of time.

I usually don’t address partial tears with surgery. They usually heal within 6-8 weeks. One should protect the tendon during this time by avoiding heavy lifting and gym work to this arm. It is likely that normal function and strength will resume in time.

Surgical repair

You don’t NEED to have the tendon repaired surgically. Full tears CAN be surgically repaired to help restore range of motion and strength to the elbow. This procedure is an open surgical procedure which can be performed as a day-case. The goal is to reattach the tendon to the radius (forearm) bone using a bone anchor with sutures.

The procedure requires a general anaesthetic (going to sleep) and takes about an hour. You will have a cut at the front of the elbow. The tendon is found just about the elbow and is brought down back to where it should be, deep inside the forearm. I use a metal button technique whereby I drill a small hole in the far cortex of the radius and pass the button through the hole. I over-drill the near cortex to 8mm so that the tendon is dragged right into the bone to try and encourage a stronger fix between the tendon and the bone. Afterwards you just have a bandage on the elbow and a sling. The sling is to slow you down. I prefer it if you wear it for the first 2 weeks but you can remove it to do some gentle movements of the elbow but you mustn’t fully straighten it at this stage. You can shower but you must keep your wound dry by having the shower head in the other hand and keeping the water off your dressing.

At 2 weeks you’ll see the team to have your wound checked and stitches trimmed or removed. After this you don’t need a dressing on the wound and you can shower normally. From this point you can move the elbow quite normally, gradually getting it more straight under guidance from a physio. Don’t force it straight. The tendon probably takes 4-6 months to heal. You should not resume regular training in a gym until at least 3 months have passed since your surgery. Some loss of extension (the ability to fully straighten your elbow) is normal but not the case with everyone. If you imagine cutting a piece of string and then tying the two ends together, the end-result will be a shorter piece of string because some of the length is lost in the knot. Well the same is true for a tendon repair. The tendon will stretch out to some degree, but it takes time.

Arthrex biceps button

This is the button that I use which is made of titanium. It remains in the body and does not need to removed after the tendon heals.

Loading the button

The button is attached to an inserter handle and the sutures are threaded through the button as shown in the image.

Stitching the tendon

The distal 3cm, or so, of the tendon is whip-stitched (sometimes called a rugby ball stitch). This gets a very good hold of the tendon. The suture material is extremely strong. The radius is drilled with a pin through both cortices (sides of the bone).

Seating the tendon

The button is passed through the radius and 'flipped' so that it doesn't pass back through the bone. The tendon is then shuttled down by pulling on the sutures. The near-side cortex of the bone is over-drilled so that the tendon is seated within the bone, which is thought to be better than seating it on the surface of the bone.

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