Elbow Pain: Distal Biceps Ruptures

The “biceps muscle” and is a combination of two muscles in the front part of the arm.  It is important in helping movement of the elbow and forearm.  Its primary function is to supinate (turn palm upwards) the forearm and secondarily aids in elbow flexion.  Supination is very important in daily tasks/activities, such as lifting and carrying objects, turning door knobs, shaking hands, and turning a screwdriver.

The biceps muscle is attached at the top (proximal) of the arm by two tendons (one inside the shoulder joint called the long head and one outside the shoulder joint called the short head) and at the bottom (distal) by one tendon to a forearm bone (the radius).

Injuries of the biceps muscle are uncommon and most biceps injuries are to the tendons.  Patients may often feel pain in the biceps area (to the front and side of the arm) however this may be referred pain from a shoulder condition.  Careful evaluation by a shoulder and elbow physician can easily determine the location and cause.  Tears of the biceps tendons can occur at either the distal or proximal tendon.  Treatments markedly vary depending on the location of the injury with most distal biceps tendon injuries benefiting with surgical repair to alleviate pain and optimize daily functioning.

Most distal biceps injuries occur in males and are usually a result of a lifting or contraction of the biceps muscle while the elbow is being extended or prevented from flexing.  These injuries can be sports related but more often occur with normal lifting activity. The tear occurs when the muscle undergoes an eccentric contraction, which means that the biceps muscle was contracting, such as trying to lift a heavy object, but the force acting on the muscle was pulling in the opposite direction.

The most common description is feeling and even hearing a “pop” at the elbow when they are lifting an object.  Typical symptoms of a torn biceps may include pain and swelling at the front of the elbow and forearm, bruising at the elbow and forearm, and a visible defect of the biceps muscle with retraction up the arm.  A physician specializing in shoulder and elbow injuries is usually able to determine if there is a rupture by physical examination alone.

Imaging studies (x-ray) are often obtained to exclude any other underlying condition or fracture.  An MRI may be obtained if the physical exam alone does not fully make the determination of a tendon rupture.

Distal biceps tendon are usually complete tears and the tendon tears directly off of the bone (radius) in the forearm.  Partial tears to the biceps tendon attachment may occur, however these usually require surgery to eliminate the symptoms.

Most distal biceps tendon tears benefit from surgery and it is best to undertake surgical repair within a few weeks from the injury as prolonged delay may make the repair harder (as the tendon and muscle retracts more away from the insertion point).  Nonsurgical treatment is an option for the management of a distal biceps tendon rupture but is usually reserved for patients with a low demand of use for the elbow and arm and more so for the non-dominant arm.  Initial pain will improve but there will be a noticeable weakness of the elbow and forearm particularly with twisting activities and lifting as well as decreased endurance with repetitive activities. 

Most people who sustain a distal biceps tendon rupture benefit from surgical repair.  The procedure is usually performed through a small incision in the front of the elbow and occasionally a second small incision is needed.  The surgeon will then re-attach the tendon to the bone.  Different surgeons have different preferences regarding how to best repair the damage to the biceps tendon with ultimate outcomes being similar.

Rehab protocols following surgical treatment vary however most include a period immobilization for a few weeks and then gentle range of motion followed by strengthening.