Elbow: Rupture of distal biceps tendon

Distal biceps tendon ruptures usually occur in muscular, young or middle aged males. Oftentimes the injury occurs while working out. Sometimes the injury occurs while lifting a heavy package. A pop is felt, with severe pain, tenderness, swelling, and bruising in front of the elbow.

How is the diagnosis made?

A physical exam can be difficult due to pain and swelling. It can be impossible to feel the biceps tendon with fingers when the front of the elbow is swollen, filled with blood, and painful to touch. An MRI is usually necessary to confirm the diagnosis with certainty.

Who needs surgery for this injury?

Faced with a distal biceps tendon rupture, a patient often thinks that the injury must be fixed with surgery in order to have acceptable function. This is not necessarily so.

  1. Contrary to popular belief, the rupture of the distal biceps tendon affects the supination strength more than the strength of flexion of the elbow. Even without surgery, 75% of the elbow flexion strength will be preserved.
  2. The loss of strength in supination is approximately 40-50%. This means that about one half of the strength of supination will be preserved, even without surgery.

Nonsurgical treatment is therefore a reasonable option. The caveat here is that if you decide to seek surgery at a later time, past about 6 weeks it becomes technically difficult or impossible to repair the torn biceps tendon. The tendon becomes scarred, the muscle atrophies, etc. If you are thinking of having the biceps tendon repaired, do it quickly. It will be an easier surgery, it will be a better surgery compared to the same procedure 1 month later.

For young, healthy patients I typically recommend surgical treatment of biceps tendon ruptures. Like every other surgical operation, this one is not without risks.

How is this surgery done?

The skin in front of the elbow is incised, the bicipital fascia is opened next, and the ruptured tendon is found, delivered out of the wound, and stitched. One of several reattachment methods can be used next. I personally use a one incision endobutton technique.

With this technique, the sutures are passed through a small rectangular metal button. A power drill is used to drill a tunnel in the radius, which will serve as "a new home" for the tendon. The rectangular button is then passed into this tunnel, flipped, and anchored to the bone. This results in secure repair of the tendon to the bone.

An alternative repair method is the two incision technique.

The advantages and disadvantages of each technique are debated at professional orthopedic meetings every year. As far as I can tell there is no real difference in outcomes.

What are the risks of this surgery?

  1. Death, as with any other surgery
  2. Infection, as with any other surgery
  3. Neurovascular injury
    1. The front of the elbow contains major structures that can be damaged from this surgery, including large arteries and the median nerve.
    2. The posterior interosseous goes through the supinator muscle and is vulnerable during this operation. PIN injury can occur during exposure of the radial tuberosity. The nerve can be stretched from the surgical retractors. Injury to the PIN would cause inability to extend the wrist and fingers.
    3. The termination of the musculocutaneous nerve is adjacent to the biceps tendon. This nerve, known as the LCNF, is oftentimes stretched and pulled by the biceps tendon rupture, during the initial injury. The stretching of this nerve would cause some numbness in the forearm, but no major problems.
  4. Fracture of the radius has been described as a possible complication of this surgery.

What is the recovery like?

  1. The patient goes home the same day after this surgery.
  2. A sling is used in the first 2 weeks.
  3. A proper physical therapy program is initiated from the first week.
  4. The patient usually is able to move the elbow comfortably by 4 weeks.
  5. The repaired tendon achieves its full strength in about 6 months.

Case study

A 48 year old male, who felt a pop while lifting a heavy box. He presented with pain, swelling, and a bruise in front of his elbow.

He sought surgical repair in order to regain maximum strength. He understood the risk of complications and he was willing to take the risk.

The one incision repair technique was carried out, as described briefly above.

Patient was discharged home in the same day. He participated in physical therapy, and recovered fully.