Distal Biceps Rupture
Biceps Tendon Tear at the Elbow
Expert diagnosis and surgical repair for optimal strength recovery
Understanding Distal Biceps Rupture
Distal biceps ruptures account for approximately 3% of all biceps tendon injuries, with the vast majority occurring at the proximal (shoulder) end. However, when the distal tendon ruptures, surgical repair is usually recommended to restore strength.
Demographics & Risk Factors
- • Age: 40-60 years (peak incidence)
- • Sex: Males almost exclusively (ratio 100:1)
- • Arm: Dominant arm in 85% of cases
- • Risk factors: Smoking, anabolic steroids, heavy lifting
- • Associated with tendon degeneration
Functional Loss Without Repair
Untreated distal biceps ruptures result in approximately 40% loss of supination strength (turning palm up) and 30% loss of flexion strength. Supination power is more affected because the biceps is the primary supinator.
Presentation & Diagnosis
Typical History
Clinical Tests
Hook Test
Attempt to hook finger under biceps tendon with elbow at 90°. Absent tendon = positive test (most reliable)
Biceps Squeeze Test
Squeeze biceps belly - should produce forearm supination if tendon intact
Ruland Test
Patient flexes elbow against resistance - examiner palpates tendon. Absent cord-like structure = rupture
MRI
Confirms diagnosis, shows tendon retraction distance (surgical planning)
Treatment Options
May be considered for:
- • Elderly, sedentary patients with low functional demands
- • Significant medical comorbidities making surgery high-risk
- • Partial tears that don't limit function
Outcome: Will lose ~40% supination strength and ~30% flexion strength. Acceptable for some sedentary patients.
Optimal timing: Within 2-3 weeks of injury
Single Incision Technique
- • Anterior approach only
- • Lower risk of synostosis
- • Suture anchors or cortical button
- • Adequate for most cases
Two Incision Technique
- • Anterior + posterolateral incisions
- • Better anatomic footprint exposure
- • Bone tunnel or suture anchor fixation
- • Historical risk of synostosis (modified technique safer)
Fixation Methods
- • Cortical Button (Endobutton): Highest fixation strength, single incision possible
- • Suture Anchors: Good fixation, familiar technique
- • Interference Screws: Good compression at footprint
- • Bone Tunnels: Traditional technique, two incision
After 4-6 weeks, the tendon retracts and direct repair may not be possible:
- • Tendon graft reconstruction: Achilles allograft, semitendinosus autograft
- • More extensive surgery with longer recovery
- • Good results possible but less predictable than acute repair
Recovery & Rehabilitation
Sling or splint for comfort
Gentle passive ROM
Avoid active flexion and supination
Begin active ROM exercises
Light resistance at 10-12 weeks
Progressive strengthening
Full strengthening program
Return to heavy lifting 4-6 months
Full sports at 6 months
Expected Outcome: 90-95% of patients recover full strength with surgical repair
Evidence & References
• Morrey BF, et al. Rupture of the distal tendon of the biceps brachii: A biomechanical study. JBJS Am 1985
• O'Driscoll SW, et al. The hook test for distal biceps tendon avulsion. Am J Sports Med 2007
• Grewal R, et al. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures. JBJS Am 2012
• Watson JN, et al. Repair techniques for acute distal biceps tendon ruptures: a systematic review. JBJS Am 2014
Last Updated: January 2025 | Content reviewed by Dr. Deepthi Nandan Reddy, FRCS (Ortho)