Distal Biceps Tendon Rupture

Distal Biceps Rupture




Dominant arm of middle aged men between 40 and 60


Kelly et al Am J Sports Med 2015

- national database study

- mean age 46

- 95% male

- increased with smoking and increased BMI




Usually trauma related

- sporting / weightlifting injury

- resisting heavy extension load




Degenerative changes seen on histology






Retracted proximally - rupture of lacertus fibrosis

Minimally retracted



- low grade - partial tears of some fibres

- high grade - near complete avulsion of biceps tendon from radial tuberosity




Feel pop / tear at elbow

Lifting heavy object

May be prodromal symptoms of elbow pain




Acute onset pain / distal swelling / bruising

Reverse popeye - biceps muscle bulge proximally


Distal Biceps RuptureDistal bicep rupture


Distal biceps rupture


Distal Biceps Rupture 2


Distal biceps 1Distal biceps 2

Bilateral distal biceps rupture


Hook test

- attempt to hook finger about biceps tendon, from a lateral to medial direction

- can get a false positive from the lacertus if hook from medial to lateral

- unable to palpate biceps tendon


Biceps Tendon Hook Test


Luokkala et al, Shoulder Elbow 2020

- sensitivity in acute complete tears: 78%

- much lower in partial tears: 30%




Usually normal

Rarely see bony avulsion from radial tuberosity





Can be used to confirm full thickness tears

Less reliable in partial tears


Lobo et al AJR Am J Roentgenol 2013

- ultrasound diagnosis distal biceps injury

- complete tear: sensitivity 97%, specificity 100%, accuracy 98%




Confirm diagnosis


A.  Complete tear / retracted


Best seen on sagittal MRI


Distal biceps rupture MRIDistal biceps rupture MRI


Distal Biceps Rupture MRI


B.  Partial tear


Best evaluated on the axial view

- absence of low signal intensity biceps tendon insertion onto tuberosity

- present of soft tissue edema


MRI Biceps Partial TearBiceps Partial tear






Indication for complete tears


Elderly patients who do not require full strength and endurance

Chronic tears





Morrey et al JBJS Am 1985

 - 40% loss of supination strength

 - 30% loss of flexion strength


Looney et al JSES 2022

- systematic review of operative versus nonoperative management

- 62 studies with 2481 cases

- improved flexion and supination strength with operative management

- improved flexion and supination endurance with operative management

- improved outcome scores with operative management






Young active patients with recent rupture 

- may be more difficult with chronic tears




One incision

- single anterior incision

- use suture anchors / endobutton to fix to tuberosity through this incision


Biceps Suture Anchor Repair


Two incision Boyd and Anderson

- anterior incision to retrieve tendon

- posterior incision to attach tendon to radial tuberosity




Single versus double incision


Grewal et al JBJS Am 2012

- RCT single incision with 2 suture anchors versus 2 incision with drill holes

- no difference in outcomes except 10% increased flexion strength with 2 incision

- increased injury to lateral cutaneous nerve of the forearm with single incision


Dunphy et al Am J Sports Med 2017

- retrospective cohort of 784 repairs

- higher posterior interosseous nerve palsy with two incision (3.4% vs 0.8%)

- higher heterotopic bone formation with two incision (7.6% vs 2.7%)

- higher reoperation with two incision (8.3% vs 2.3%)

- higher LCNF and superficial radial nerve with single incision


One incision suture anchor versus cortical button


Return to sport


McGinniss et al JSES 2021

- 35 NFL players with distal biceps repairs

- high rate of return to play at previous performance level


One incision technique with endobutton


Vumedi Arthrex Adjustable button technique


Vumedi Endobutton technique


Set up

- supine, arm board, tourniquet



- proximal Henry approach to proximal radius

- protect lateral cutaneous nerve of the forearm

- divide fascia

- mobile wad medially

- divide recurrent leash if needed

- supinate forearm

- reflect supinator muscle laterally

- identify bicipital tuberosity

- can place hohmann retractors medially but not laterally as they can injure PIN


Prepare radial tuberosity

- forearm fully supinated to protect PIN

- pass guide wire through both cortices centred in tuberosity

- pass cannulated 4.5 endobutton drill

- use burr or ACL drill 8 mm to open volar cortex only to take biceps tendon


Find biceps tendon

- an additional proximal incision can help with retracted biceps

- divide fascia

- blunt dissect and deliver tendon into proximal wound

- whip stitch with high strength suture to endobutton

- enter lateral aspect tendon proximally and suture down to distal aspect

- pass around middle two holes of endobutton

- back up medial aspect and tie

- leave 2 mm space between endobutton and distal end of tendon

- allows space for dorsal cortex of radius


Distal Biceps Repair IncisionDistal Biceps Tendon with Endobutton


Tunnel distal biceps tendon to radial tuberosity

- find pathway with blunt dissection

- pass beath pin through tuberosity and skin with endobutton passing sutures

- pass and flip endobutton

- can check using image intensifier


Distal Biceps Endobutton RepairDistal Biceps Endobutton RepairDistal Biceps Repair Final


Two incision Technique


Vumedi Two Incision technique


AO surgery foundation technique





- Henry approach

- maximally pronate forearm

- hug border of radius with curved hemostat

- avoid periosteum of ulna to prevent synostosis

- palpate tip dorsally in extensor mass

- dissect down to radius



- Thompson's approach

- line from lateral epicondyle to lister's tubercle

- between EDC and ECU

- expose and split supinator



- performed through bone tunnels


Post operative management


Bergman et al JBJS AM 2021

- RCT of early mobilization versus 6 weeks immobilization

- 83 patients treated with suture button followed for 12 months

- trend towards better ROM with early mobilization

- better QuickDASH scores over time with early mobilization


Partial Tears


Bauer et al JSES 2018

- 74 patients with partial distal biceps tears

- 34/61 (55%) treated nonoperatively went on to have surgery

- high grade partial tears (>50%) on MRI more likely to need surgery


Biceps Partial TearBiceps Partial Tear 2


Chronic Tears




> 3 weeks old

- harder to repair

- associated with higher complication rates

- have to repair in significant position of flexion


> 6 - 8 weeks

- tendon involutes into biceps

- need either hamstring autograft or allograft reconstruction




Vumedi allograft distal biceps reconstruction



- S shaped, proximal medial and lateral distal

- identify and protect the brachial artery and medial nerve in the proximal approach

- identify the radial tuberosity through the lateral distal approach


Biceps Approach


Graft options


Hamstring allograft

Tibialis anterior or posterior allograft

Tendoachilles allograft with bone block removed




Secure to radial tuberosity with endobutton first

- approach and mobilize biceps muscle

- brachial artery is directly medial

- then weave graft through distal biceps muscle belly

- pulvertaft


Single incision allograft reconstructionTwo incision allograft reconstruction




Hendy et al JSES Int 2020

- compared 46 allograft distal biceps reconstructions to primary repair

- no difference in functional outcome at mean 5 years


Complications of distal biceps repair


Amarasooriya et al Am J Sports Med 2020

- systematic review of complications after distal biceps repair

- 1.6% PIN injury

- 1.4% median nerve injury

- 1.4% re-rupture

- 9.2% lateral cutaneous nerve injury

- 0.1% synostosis / brachial artery injury / compartment syndrome / radial fracture


PIN Palsy


Nigro et al JSES 2013

- 230 patients

- 3.2% developed postoperative PIN palsy

- all 9 resolved at average of 86 days (range, 41 - 145)


Reichert et al Med Sci Monit 2018

- 7 cases of PIN palsy with no recovery after 3 months

- 5 demonstrated nerve entrapment by scar or by biceps

- 2 demonstrated PIN division secondary to drill


Failure fixation


Distal biceps fixation failure