Distal Biceps Tendon Rupture
Biceps is a large muscle in the front of your upper arm. It is attached to the radius bone of the forearm by a strong tendon (distal biceps tendon). This tendon can rupture with a very strong contraction of the biceps muscle. It may be felt as a pop in the elbow. This usually happens when the tendon is already worn and prone to injury. It typically occurs in men over the age of 35 years, with high rates seen in strength athletes, bodybuilders and manual workers.
How is the diagnosis made?
The diagnosis can be made with a careful history and physical examination. Pain and bruising are usually localised to the front of the elbow. The biceps muscle belly may bunch up in the upper part of the arm creating a prominent bump (reverse ‘Popeye’ sign). The biceps muscle does not move on rotation of the forearm. The sharp edge of the tendon cannot be felt at the front of the elbow and there may be weakness of forearm rotation and elbow flexion. If there is doubt about the injury then an ultrasound scan may be helpful. Most surgeons prefer a magnetic resonance imaging (MRI) scan. This is best performed with the patient lying on their tummy (prone) with the shoulder flexed to 180 degrees and the elbow flexed to 90 degrees with the palm facing the top of the head (Flexion Abduction Supination-FABS view).
What is the treatment?
Some people will notice that the arm feels weaker when doing activities that require a repetitive twisting motion such as using a screwdriver. Others may experience a cramping pain in the biceps muscle. Many individuals do not like the bunched up (retracted) appearance of the biceps muscle in the upper arm.
In an acute distal biceps tendon rupture surgical repair can restore full strength and correct the deformity. Results are best when this is done within 3 weeks of the injury.
Surgery is usually performed as a day case under a general anaesthetic and you are able to go home 4 hours later. We use a small metal button through an incision at the front of the elbow. This is the strongest method of reattaching the tendon to the bone and permits movement immediately after the surgery.
Rehabilitation is supervised by one of our team of physiotherapists. The sling is discarded at 2 weeks to encourage active movement. Strengthening is started at 6 weeks. By 12 weeks you should be able to return to normal activity including sports. It can however take up to 6-12 months to regain the full strength.
A biceps tendon rupture that is over 4 weeks old (sub-acute) is more difficult to repair directly. The tendon is often retracted up the arm and stuck, so a second higher incision may be made to retrieve it.
A distal biceps tendon rupture that is more than 8 weeks old (chronic) can be left untreated if the individual is managing daily activities, occupation and hobbies without pain or weakness. If however the individual has symptoms these can be addressed by bridging the gap between the retracted tendon and radius bone. This can be done using a graft taken from the patient themselves (autograft) or from a tissue donor (allograft).
Risks of Surgery
Risks include infection, nerve injury (weakness of the fingers or a fuzzy sensation on the outer aspect of the foremarm), elbow stiffness, fracture of the radius, bone forming in the soft tissues (heterotopic ossification) and re-rupture. The risks can be minimised by following your team’s instructions.