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Distal Biceps Tear

The biceps brachii muscle forms the anterior curve of the upper arm. It is connected to the shoulder and elbow by tendons. The biceps tendon at the elbow is known as the distal biceps. Tearing of the distal biceps is uncommon, and usually occurs as the result of an accident. It can, however, be the source of significant functional disability, strength deficits, cramps, pain and aesthetic deformation of the arm. Once torn, the biceps tendon does not grow back into the bone, and it never heals. Although other muscles can at least partially compensate for its absence, surgical management is often necessary for optimal functional recovery.

Anatomy

The biceps brachii is the main muscle at the front of the arm. It consists of two tendons that attach it to the shoulder and forearm. The tendon at forearm level is called the "distal biceps". It is attached to the radius bone, close to the elbow, on a bony protuberance called the radial tuberosity. 
At the elbow, the biceps brachii muscle plays an important role in elbow flexion and forearm rotation (supination), as required when using a screwdriver or opening a door.

Distal biceps tears

Distal biceps tears may be partial or complete.

  • Partial tears: these injuries damage the tendon but do not completely separate it from the bone.
  • Complete tears: A complete tear completely detaches the tendon from its insertion on the bone.

Distal biceps tears are generally total. This means that the entire muscle is detached from the bone and pulled back towards the shoulder. Other muscles can compensate for the damaged tendon, usually allowing full movement, but without surgical repair, the injured arm will show a 30-40% reduction in strength, mainly in forearm rotation (supination) and elbow flexion.

Causes of distal biceps tears

Distal biceps tears typically occur as a result of an accident, typically a fall, a forced movement to catch a falling object, or an effort to lift a heavy object.

Risk factors :

Men aged between 30 and 40 are more likely to suffer from this type of injury. 
Other risk factors include:

  • Smoking: smokers are 7 times more likely to suffer a distal biceps tear than non-smokers.
  • Steroids and other anabolic products.

Symptoms of distal biceps tear

The main clinical signs of a distal biceps tear are:

  • A loud snap at the time of the accident. 
  • Intense pain at first, which may subside after a week or two. 
  • A swelling/hematoma in the elbow and/or forearm.
  • Weakness when flexing the elbow and rotating the forearm (supination).
  • A lump in the upper arm caused by retraction of the biceps brachii muscle.
  • A hollow forms at the elbow crease due to the disappearance of the distal biceps tendon.

Treating distal biceps tear

Conservative treatment:

Conservative or non-surgical treatment may be considered for patients with a small (partial) tear or patients with a complete tear but with low functional demand or who can tolerate the associated loss of function. The main goal is to relieve pain and maintain/improve elbow function wherever possible. Treatment recommendations may include activity adaptation (temporary or permanent), analgesic treatment and targeted physiotherapy.

Surgical treatment:

However, an untreated complete tear of the distal biceps may ultimately be the source of significant functional disability, strength deficit, cramping, pain and aesthetic deformity of the arm. Surgical repair is therefore highly recommended. In this case, it is important to be examined shortly after the injury, as the ideal time for surgical repair is 2 to 3 weeks after the injury. After that, the biceps tendon and muscle tend to heal and shorten, and it may not be possible to restore arm function surgically. Although other options are available for late surgical management, they have inferior functional results and a higher complication rate.

The surgical procedure

The goal of the procedure is to reattach the distal biceps tendon to its anatomical location, the tuberosity of the radius. There are a number of different surgical techniques, varying mainly in the type of incision, approach to the surgical site and method of fixation of the tendon to the bone. Each method has its advantages and disadvantages. In the vast majority of cases, Dr. Martinho uses a minimally invasive surgical technique with a single incision at the anterior aspect of the elbow/forearm to reinsert the tendon onto the bone with a small implant called an anchor.

Complications

Surgery is generally safe and well-controlled, but like any procedure, it carries a risk of potential complications. These complications are generally rare and mostly temporary, and may include:

  • Numbness and/or weakness of the forearm, wrist or hand may temporarily occur. 

  • Additional bone (heterotopic ossifications) may form near the site where the tendon is reinserted on the radius. This usually results in little or no limitation of range of motion. However, when the limitation is severe enough to have a functional impact, it may require further surgery.

Rehabilitation

Rehabilitation begins immediately after surgery, under the supervision of a physiotherapist. The rehabilitation protocol includes immediate mobilization of the elbow, protected by an articulated splint for the first 6 weeks. It is essential to follow the treatment plan to optimize the chances of full functional recovery. As the tendon takes 3 to 4 months to heal completely, it is important to protect the repair by limiting certain activities. Light activities can begin soon after the operation. On the other hand, heavy lifting and vigorous activity should be avoided for several months.

Results of surgery

Surgery enables full functional recovery, in terms of mobility and strength, and resumption of all activities in the majority of cases.

When should you contact the Doctor?

Intense pain near the elbow, difficulty in moving the arm after trauma, swelling and significant bruising require rapid consultation. Early diagnosis and treatment are essential to optimize the chances of recovery.

Care at Hôpital de La Tour

Distal biceps rupture is diagnosed clinically. Additional tests, such as a standard X-ray, ultrasound or MRI, may be ordered to confirm the diagnosis. If a tendon tear is confirmed, surgical treatment is generally proposed within 2 to 3 weeks, to allow optimal reinsertion of the tendon.

FAQ on distal biceps tears

1. What are the main causes of distal biceps tears?
Rupture of the distal biceps usually follows an accident, such as a fall, a sudden movement to catch an object, or an effort to lift a heavy object. Men between the ages of 30 and 40 are most affected. Risk factors include smoking and the use of steroids or other anabolic products.

2. Does a distal biceps tear require surgery?
In most cases, surgical repair is recommended for a complete distal biceps tear, and should be performed promptly after injury. Conservative treatment may be considered for small tears or for patients with low functional demand.

3. What are the symptoms of a distal biceps tear?
The main symptoms are an audible pop, intense elbow pain, swelling and bruising around the elbow joint. Muscle weakness in the affected arm and difficulty in turning the palm upwards or bending the elbow are also indicators of a rupture. If you suspect a rupture, you should seek urgent medical advice.

4. What are the risks if a distal biceps tear is untreated?
An untreated tear can lead to significant functional disability, reduced muscle strength, cramping, chronic pain and aesthetic deformation of the arm. Early diagnosis and management are crucial to optimize the chances of recovery.