Distal Biceps Tendon Rupture



Dominant arm of middle aged men

- between 40 and 60




Sudden dramatic event

- sporting / weightlifting injury

- resisting heavy extension load




Degenerative changes seen on histology





- retracted / rupture of lacertus fibrosis

- minimally retracted



- small - partial tears of some fibres

- large - near complete avulsion of biceps tendon from radial tuberosity




Complete tears / non operative management

- 30% loss of flexion strength

- 50% loss of supination strength




Distal Biceps Rupture


Acute onset pain / distal swelling / bruising


Biceps muscle may bulge proximally

- not always seen as lacertus fibrosis may be intact


Hook test

- attempt to hook finger about biceps tendon

- unable to palpate biceps tendon


O'Driscoll et al Am J Sports Med 2007

- Hook test negative in partial tears

- but 9/12 painful with this test


Biceps Tendon Hook Test



- supination > flexion


Distal Biceps Rupture 1Distal Biceps Rupture 2Distal Biceps Rupture 3




May see bony avulsion from radial tuberosity




Confirm diagnosis


A.  Complete tear / retracted

- relatively easy to diagnose


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 oedema


MRI Biceps Partial TearBiceps Partial tear


Festa et al J Hand Surg Am 2010

- MRI 100% sensitive for full thickness tears

- MRI only 59.1% sensitive for partial tears






Indication for complete tears


Elderly patients who do not require full strength and endurance


Usually lose one grade power with distal avulsion

- decreased strength and endurance 

- supination and flexion

- i.e. labourer might have difficult with inserting screws






Young active patients with recent rupture 

- may be more difficult with chronic tears




Two incision Boyd and Anderson

- anterior incision to retrieve tendon

- posterior incision to attach tendon to radial tuberosity

- associated with radioulnar synostosis

- less risk of inadvertant PIN injury


One incision

- single anterior incision

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

- theoretical higher risk PIN injury

- endobutton fixation 2 - 3 x higher strength than suture anchors


Operative Technique:  One incision technique with endobutton


Set up

- supine, arm board, tourniquet



- longitudinal medially / transverse across cubital fossa / longitudinal mobile wad

- S shaped


Find biceps tendon

- proximally above brachialis

- Allis clamp

- mobilise by blunt dissection

- deliver into wound


Distal Biceps Repair IncisionDistal Biceps Tendon with EndobuttonDistal Biceps Repair Final


Fixation with no 2 Ethibond / Fibre wire

- Krackow suture

- enter lateral aspect tendon proximally

- 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


Insert passing sutures and flipping sutures in lateral holes

- no 2 ethibond to pull through

- 1 vicryl to flip

- different colours to help you tell which is which


Dissect down to radial tuberosity

- find and protect LCNFA

- under cephalic vein

- mobile wad laterally with radial nerve

- blunt dissect down to radial tuberosity


Prepare radial tuberosity

- forearm fully supinated

- make trough for tendon with burr

- avoid lateral retractors which can inadvertantly injure PIN


Pass guide wire through dorsal cortex 

- aim distal and medial

- pass cannulated 4.5 endobutton reamer

- pass beath needle with sutures

- pass and flip endobutton

- check II


Distal Biceps Endobutton RepairDistal Biceps Endobutton Repair


Post op

- splint for 2 weeks

- then active assist ROM

- no heavy lifting for 8/52




Greenberg et al J Should Elbow Surg 2003

- endobutton technique

- patients had 97% flexion strength

- 82% supination strength


Khan et al Arthroscopy 2008

- suture anchor repair in 17 patients

- 5 degee loss of extension and rotation

- strength 80% other side


John et al JSES 2007

- suture anchor repair in 53 patients

- 46 excellent results, 7 good

- HO in 2 patients


Chavan et al Am J Sports Med 2008

- systematic review

- endobutton strongest

- increased complications in two-incision techniques


Mazzocca et al Am J Sports Med 2007

- biomechanical study

- endobutton (440N) stronger than suture anchors (380N) or bone tunnel (300)


Lo et al Arthroscopy 2011

- 11 mm to PIN if aim directly across long axis of radius

- increases to 16 mm if aim 30 degrees to the ulna side

- aiming distally 45 degrees and radially decreased this to 2 mm


2 incision Boyd and Anderson Technique




Anterior Henry approach as before


Passed curved haemostat 

- maximally pronate forearm

- hug border of radius

- 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 ECRB

- expose supinator

- find and protect PIN

- subperiosteally detach supinator



- performed through bone tunnels




Greewal et al JBJS Am 2012

- single incision (anchors) v double incision (drill holes)

- RCT 91 patients

- double incision 10% stronger flexion strength

- increased transient neuropraxis LCNF in single incision

- ASES / DASH scores same in each group

- 4 re-ruptures due to lack of complicance


Partial Tears


Management Options


Bain et al Sports Med Arthrosc 2008

- non operative treatment < 50%

- operative treatment for > 50%


Surgical Treatment of a Partial Tear


Biceps ApproachBiceps Partial TearBiceps Partial Tear 2


Repair with suture anchors


Biceps Suture Anchor Repair


Chronic Tears


> 3 weeks old

- harder to repair

- associated with higher complication rates

- have to repair in significant position of flexion


Typically run into problems > 6 - 8 weeks

- tendon involutes into biceps

- need either hamstring autograft or allograft reconstruction

- secure to radial tuberosity with endobutton first

- then weave through distal biceps stump

- pulve taft weave through tendon


Hamstring autograft biceps reconstruction


Biceps reconstruction with tendoachilles allograftDistal biceps reconstruction with allograft






Injury LCNFA


Injury PIN


Loss of extension

- more common with chronic injuries


Rerupture / failure fixation


Distal biceps fixation failure