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Biceps Tendon Rupture at the Elbow

Rupture or tear of the distal biceps tendon at the elbow, although uncommon, is one of the most commonly injured tendons of the elbow, whereas triceps tendon tears occur much less frequently. Most often ruptures of the biceps tendon occur as a sudden injury which forces the elbow straight from a flexed position such as trying to catch a very heavy object that is falling. The biceps tendon can also tear when the elbow is forcibly flexed against excessive resistance as in attempting to lift something extremely heavy. An overload to the biceps tendon causes the tendon to rupture or tear away from its attachment to bone, which can be a complete tear or partial tear. These injuries are generally associated with chronic degeneration of the biceps tendon insertion into bone which becomes more susceptible to an overload injury. Biceps tendon ruptures are more frequently seen in men over 40 years of age and very rarely seen in women.

When a distal biceps tendon ruptures at the elbow, patients often describe hearing a “pop” followed by swelling, pain, and bruising at the elbow and forearm. With complete tendon rupture, the biceps muscle may appear balled up towards the shoulder. After initial injury, sharp pain may last for several hours, but generally a dull achiness persists for weeks. Full elbow motion is still possible since other muscles of the arm also function to bend the elbow. However, if the distal biceps tendon injury is left untreated, a reduction in strength, particularly with rotation and twisting of the forearm to a palm up position (supination), can be expected. Persistent pain or achiness can occur with heavier demands or activities on the injured arm, particularly with a partial tear of the tendon.

Treatment

Biceps tendon ruptures at the elbow are not always obvious on clinical examination. MRI of the elbow may be done to help confirm the presence of a tear, whether partial or complete. Non-operative treatment may be considered for very elderly patients who are inactive or have significant medical problems. Otherwise, surgery is recommended for distal biceps tendon repair by reinsertion of the tendon into bone. The literature has shown that surgical repair of the tendon affords functional superiority over non-surgical treatment for these injuries, and excellent results can be expected with early surgical repair. Large partial tears or high grade tears of the biceps tendon generally fail non-operative treatment and are typically treated in the same manner as a complete tendon rupture. With partial tears of the biceps tendon that are small or low grade, surgery may not be necessary, but if chronic pain develops, surgery is recommended.

For complete tear of the distal biceps tendon, early evaluation and treatment is important as tendon repair is best performed within the first 2 to 3 weeks from injury. Further delay leads to shortening of the biceps muscle and scarring of the tendon which only complicates the surgery, and if too delayed, reconstruction with a tendon graft (using tendon from another source in the body) may be necessary to restore functional use of the biceps. It should be understood that late reconstruction of the biceps tendon can be more difficult to perform and results are typically less successful as compared to early primary repair.

Once repaired, complete healing of the biceps tendon to bone takes about 12 weeks. Light activities soon after surgery are allowed during recovery with restrictions guided by your elbow surgeon. Full unrestricted activities, including manual labor and heavy lifting, are typically expected after 4 months from surgery following sufficient restoration of strength.

Several repair techniques for reattachment of the distal biceps tendon to the forearm bone are described in the literature. Some surgeons prefer to perform these techniques using a single incision, while others use a two incision technique. There are pros and cons to each method, and Dr. Katz will discuss these in detail with you.

Dr. Katz also evaluates and treats elbow triceps tendon tears or ruptures.