Tendons are thick fibrous bands of connective tissue that connect muscle to bone. They transfer the force created by our muscles to our skeleton, allowing us to move. The distal biceps tendon starts at the bottom of our biceps muscle and goes down into the elbow joint, where it attaches onto the radius bone in the forearm.
When the biceps muscle contracts, the tendon pulls on your radius, allowing your elbow to bend and your forearm to rotate (like when using a screwdriver or turning a door handle). When these functions are taken to an extreme, such as when picking up something heavy, the tendon can tear a bit or even break off the bone entirely.
Distal biceps tendon tears are also known as distal biceps tears at the elbow or distal biceps avulsions. Tears can be partial or complete: A partial tear means that some of the tendon is torn but that some fibers are still connected to the bone. A complete tear means the tendon is totally detached from the bone. When a complete tear happens, often the biceps muscle shrinks up the front of the arm.
“The distal biceps tendon helps bend the elbow and rotate the arm.”
Symptoms
This type of injury announces itself immediately with:
- A popping noise
- A tearing sensation
- Pain
- Swelling
- Bruising in the front of the arm
- Weakness in bending the elbow
- Difficulty rotating the wrist
- A deformity in the front of the arm
A side effect of damage to the tendon is a bulge that may appear at the site of the injury, caused by the biceps muscle no longer being properly tethered by the distal biceps tendon.
Causes
A tear in the distal biceps tendon is a relatively rare event. It generally occurs during an eccentric load on a flexed biceps muscle. In other words, if you try to lift a very heavy object off the ground with a slight bend in the elbow and your arm is forced into a straight position, your biceps tendon can suddenly tear off the elbow. It most often occurs in the dominant arm of men aged 40–50.
Diagnosis
Distal biceps tendon injuries are usually diagnosed by a physical exam but may also require imaging. Dr. Romeo will check for the unique physical signs of this injury—such as the protruding muscle (sometimes called a reverse Popeye deformity) and a gap at the front of the elbow created when the tendon tore. Depending on the injury, an x-ray, ultrasound, and MRI may be required.
Nonsurgical treatment options
People with partially torn distal biceps tendons can sometimes be treated conservatively with:
- Rest
- Exercise
- Physical therapy
Conservative treatment is best for people with smaller tears and those who are not athletes or whose job does not require manual labor. Unfortunately, distal biceps tears that are not treated surgically often result in a permanent loss of strength and function of the biceps muscle. People will maintain some ability to flex the elbow and rotate the wrist, but their strength will be 30%–50% less.
If the tear is complete, or an athlete sustains a partial biceps tendon tear, then surgery should be performed quickly—within a couple of weeks. Otherwise, it can retract (shrink back) and scar into place, which makes it more difficult to repair later on.
How surgery is performed
First, during a distal biceps tendon repair, a small cut is made in the front of the forearm. Then, the part of the biceps tendon still attached to the muscle that has shrunk up the front of the arm has to be located and pulled back down to the radius bone. Then, thick, strong stitches (sutures) are sewn into the end of the tendon, and the sutures are attached to an anchor.
Next, a hole is drilled into the radius bone. Using a special technique, the anchor and the distal biceps tendon are inserted into place in the hole and reattached to the bone. This surgery allows for the full return of flexional and rotational strength of the elbow. (Watch as Dr. Romeo explains distal bicep tendon surgery here or watch an animation of the surgery here.)
“You can expect to reclaim full strength, range of motion, and rotational function in your arm, elbow, and wrist once healing is complete.”
Recovery time
A distal biceps repair surgery is an outpatient procedure, meaning you can go home the same day. After surgery, you will need to wear a hinged elbow brace for a month to protect your arm. This brace will allow your elbow to do simple movements.
You may experience swelling, and Dr. Romeo recommends ice packs as an effective form of relief during the first days after surgery. An ice pack should be applied once every one to two hours, for twenty minutes at a time. Dr. Romeo will provide specific instructions to manage any post-op pain.
Distal Biceps Tendon Repair Physical Therapy Protocol
Results
After six weeks, you will begin physical therapy that includes range-of-motion and isometric exercises to strengthen the biceps muscle and prevent contracture (when the joint becomes too stiff). Light work duties may often be resumed around three months.
The good news about surgical repair of the distal biceps tendon is that you can expect to reclaim full strength, range of motion, and rotational function in your arm, elbow, and wrist once healing is complete. Full recovery typically takes about four to six months. Fortunately, in most cases, the elbow will recover to full or very close to pre-injury level of function.
FAQs
How will I know if I need biceps tendon repair surgery?
Since biceps tendon injuries are often very painful and bring a significant change in the appearance of the muscle, they are difficult to ignore. Referral to an orthopaedic surgeon for prompt medical evaluation is important. From there, the surgeon will do an exam and order special tests like x-rays, ultrasounds, and MRIs. Most of the more significant biceps tendon tears will require surgery, while minor partial tears can be treated at home without surgery.
How can I prevent biceps tears?
You can prevent biceps tears by working to maintain strength in your biceps muscles through a full range of motion. Deadlifting heavy loads can be a risk factor for tearing the distal biceps tendon. Proper form and technique are key. Anabolic steroid use can also put weight lifters at risk for tendon rupture since their tendons have not had enough time to strengthen relative to their muscles.
Similarly, when bending over to pick up a heavy object, it’s important to make sure the arms are fully straightened. Do not try to lift the heavy object with your arms alone; focus on lifting with your legs and glutes.
Last, smoking cigarettes can also make tendons more susceptible to tearing, so quitting or cutting back may help protect you from tears.