REPAIR OF ACUTE DISTAL BICEPS TENDON

RUPTURES
FREDERICK M. AZAR, MD, and MICHAEL D. LOEB, MD

Distal biceps tendon ruptures are most common in men between the ages of 40 and 60 years and usually are
caused by an unexpected extension force applied to the flexed arm. The most successful treatment of complete
rupture of the distal biceps tendon is anatomical repair. The two-incision technique consistently restores flexion
and supination strength. We have not found heterotopic ossification or synostosis to compromise results.
KEY WORDS: distal biceps tendon, acute rupture, repair.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Although ruptures of the distal biceps tendon have been

considered relatively rare injuries, they are being reported
with increasing frequency. Perhaps participation in athletic and fitness activities into later years is at least partly
responsible for the increase, since these injuries occur most
commonly in the dominant extremities of men between 40
and 60 years of age. Distal biceps tendon ruptures are
uncommon in younger athletes but have been reported,
especially in weightlifters, 1 and have been associated with
the use of anabolic steroids. 2 The usual mechanism of
injury is an unexpected extension force applied to the
flexed arm, such as lifting a heavy object, which generally
results in an avulsion of the tendon from its insertion into
the radial tuberosity, although ruptures within the tendon
substance and at the musculotendinous junction have
been reported.
Degenerative and mechanical processes have been implicated as the cause of rupture. Age-related degenerative
changes may compromise the structural integrity of the
tendon but remain unrecognized until sufficient trauma
causes complete rupture of the tendon. Morrey 3 suggested
that chronic inflammation of the deep bicipital radial bursae at the radial tuberosity may contribute to degeneration
of the biceps tendon. Repetitive impingement of the tendon by hypertrophic bone on the anterior margin of the
radial tuberosity also has been suggested as a cause of
biceps tendon rupture. 4

PREOPERATIVE EVALUATION
Patients with complete distal biceps tendon ruptures usually report feeling a sudden, sharp, painful tearing sensation in the antecubital region of the elbow when an unexpected extension force was applied to the flexed arm.

From the Department of Orthopaedic Surgery, University of Tennessee-Campbell Clinic, Memphis, TN.
Address reprint requests to Frederick M. Azar, MD, Campbell Foundation, Editorial Department, 1211 Union Ave., Suite 510, Memphis, TN
38104.
Copyright 2003, Elsevier Science (USA). All rights reserved.
1060-1872/03/1101-0009535.00/0
doi:10.1053/otsm.2003.35889

32

Occasionally, pain also is present in the posterolateral

aspect of the elbow. The acute pain subsides in a few hours
and is replaced by a dull ache; with chronic ruptures,
weakness and fatigue occur with repetitive flexion and
supination activities. Physical examination reveals tenderness in the antecubital fossa, and a defect usually can be
palpated there. Active flexion of the elbow causes the
biceps muscle belly to retract proximally, accentuating the
defect in the antecubital fossa (Fig 1). In addition to local
swelling, ecchymosis, and a palpable tendinous defect, the
supination test is helpful in making the diagnosis. With
the elbow flexed and the forearm held in pronation, the
patient is asked to actively supinate against resistance.
When a complete tear is present, the distal biceps tendon
can be seen bobbing beneath the skin with each attempt to
supinate. If the biceps tendon can be palpated in the
antecubital fossa, a partial rupture of the distal biceps
tendon should be considered. Ecchymosis and swelling
usually are evident in the antecubital fossa and along the
medial aspect of the arm and proximal forearm.
Plain radiographs generally do not show any bony
changes, although irregularity and enlargement of the radial tuberosity and avulsion of a portion of the radial
tuberosity have been reported with complete ruptures of
the distal biceps tendon. Magnetic resonance imaging
(MRI) can be helpful to distinguish complete from partial
ruptures and to differentiate partial rupture from tendinosis, tenosynovitis, hematoma, and brachialis contusion
(Fig 2).

TREATMENT
The most successful treatment of complete ruptures of the
distal biceps tendon is anatomical repair. Nonoperative
treatment can be considered for elderly, sedentary patients
who do not require strength and endurance in flexion and
supination and for patients with medical problems that
increase surgical risks. However, activity-related pain often persists with nonoperative treatment, as well as decreased strength and endurance in flexion and supination.
The two most commonly used techniques for reattachment of the tendon to the radial tuberosity use either a
single incision or two incisions. The original single-inci-

Operative Techniques in Sports Medicine, Vol 11, No 1 (January), 2003: pp 32-35

Fig 1. (A and B) Clinical appearance of acute rupture of distal biceps tendon,

sion technique required an extensive anterior approach

that often resulted in injury to the radial nerve. More
recently, the use of suture anchors has allowed a safer, less
extensive approach. 5,6 This technique is attractive because
it limits the amount of stripping necessary and obviates
the need for a second incision. However, the strength of
suture anchor fixation and long-term healing of tendons
reattached with this method have not been clearly defined.
A recent biomechanical cadaver study by Pereira and coworkers 7 compared the strength of suture anchor repair to
bone-tunnel repair and found that bone-tunnel repair with
a two-incision technique produced a stronger and stiffer
repair in nonosteoporotic bone. Berlet and coworkers 8 also
found the two-incision repair to be stiffer and to have a
higher tensile strength to failure than repair with suture
anchors.
To minimize the risk of neurologic injury associated
with the single-incision technique, Boyd and Anderson 9
developed a two-incision technique using a limited anterior approach to identify and retrieve the ruptured tendon
and a posterolateral approach to reattach the tendon
through holes drilled in the radial tuberosity. This technique consistently restores the power of flexion and supination and avoids the dangers of deep dissection in the
antecubital fossa. Reports in the literature indicate that,
compared with the uninvolved extremity, 97 to 99% of
flexion strength and 95 to 99% of supination strength is
restored with this technique. 1~12
The primary concern with the two-incision technique
has been the development of heterotopic ossification and
radioulnar synostosis. Most often, however, the heterotopic ossification is minimal, and even synostosis usually
imposes no significant limitations of motion. In 21 twoincision repairs reported b y Bell and coworkers, 13 only one
synostosis required surgical excision, and Moosmayer and
coworkers 14 reported that neither heterotopic ossification
nor radioulnar synostosis caused significant problems in
their 9 patients. In a meta-analysis of the literature Rantanen and Orava 15 found 4 synostoses in 45 two-incision
repairs (9%). In 33 patients treated with this technique at
our institution, we have not found heterotopic ossification
to be a problem. Failla and coworkers 16 suggested several
possible causes of heterotopic ossification after the t w o ACUTE DISTAL BICEPS TENDON RUPTURES

incision technique: (1) damage to the proximal portion of

the interosseous membrane, (2) hematoma formation between the radius and ulna, (3) bone debris, and (4) stimulation of the ulnar periosteum.
To prevent the disbursement of bone particles into the
interosseous space, we use an osteotome rather than a drill
to create a trough in the radial tuberosity rather than a
trapdoor, as described in the original technique. We also
irrigate frequently to remove all bony debris. Instead of
the curvilinear anterior incision, we use a small transverse
incision. ~7 We pass the torn end of the biceps through the
interosseous space using a curved Kelly clamp and try to
accomplish this with a single attempt.

OPERATIVE TECHNIQUE
A transverse 3- to 4-cm incision is made over the anterior
aspect of the elbow. The deep fascia is incised and the
distal biceps tendon is located, with care taken to identify
and protect the lateral antebrachial cutaneous nerve. Usually it is retracted 5 to 7.5 cm proximal to the elbow. A
heavy, no. 5 nonabsorbable locking suture is passed
through the tendon so that its ends emerge on the avulsed
surface (Fig 3). Then a curved Kelly clamp is used to locate
the tunnel between the radius and ulna through which the
tendon originally passed, taking care not to violate the
periosteum. The elbow is flexed and a second incision is
made on the posterolateral aspect of the elbow for the
Boyd approach. The interval is developed between the
lateral border of the ulna and the anconeus and extensor
carpi ulnaris (Fig 4). The anconeus is stripped from the
bone subperiosteally. The dissection is deepened to the
interosseous membrane, and the supinator muscle overlying the radial tuberosity is sharply incised, exposing the
radial tuberosity. Pronation of the forearm protects the
deep branch of the radial nerve as it enters the forearm in
the substance of the supinator muscle and brings the radial tuberosity into view. A 1/4-inch osteotome is used to
create a trough in the radial tuberosity and two holes are
drilled in the margin. With a curved Kelly clamp, the ends
of the sutures in the tendon are passed between the radius
and ulna and are brought out through the second incision.
Traction on the sutures will advance the tendon into the
33

Fig 3, Suture passed through tendon end through anterior

approach at antecubital crease. (Reprinted with permissionJ a)

Radial nerve

~ . ~

Supinator
m.c,
Incision
Extensor carpi
Anconeus muscle ulnaris muscle
Fig 4. Transverse cut of proximal forearm at level of radial
tuberosity demonstrating interval in posterolateral Boyd approach, (Reprinted with permission. TM)

posterolateral incision. The ends of the sutures are brought

out through the holes in the tuberosity and, with the elbow
flexed, are securely tied over the b o n y bridge between the
holes (Fig 5). Reinforcing sutures can be placed through
the tendon into the adjacent soft tissues if necessary. The
two incisions are closed in routine fashion and the elbow
is immobilized in a posterior plaster splint with the elbow
flexed to 100 and the forearm supinated 45 .

POSTOPERATIVE REHABILITATION
At 2 weeks, the splint is removed and a removable hinged
brace locked at 90 of flexion is applied. This brace is w o r n
for an additional 4 weeks. Passive flexion exercises are
initiated and extension is advanced 15 to 20 each week

Fig 2. MRI appearance of acute rupture of distal biceps

tendon, (A) Sagittal view. (B) Transverse cut at mid-arm level,
(C) Transverse cut at distal arm.

34

AZAR AND LOEB

Fig 5. Sutures in tendon tied over bony bridge through

posterolateral approach as described by Boyd and Anderson. (Reprinted with permission. 18)
u n t i l full e x t e n s i o n is r e a c h e d at 6 to 8 w e e k s after s u r g e r y .
S u p i n a t i o n a n d p r o n a t i o n r a n g e - o f - m o t i o n exercises are
b e g u n at 4 w e e k s . A c t i v e - a s s i s t e d f l e x i o n a n d s u p i n a t i o n
exercises are s t a r t e d at 8 w e e k s a n d are a d v a n c e d o v e r the
n e x t 2 m o n t h s . S t r e n g t h e n i n g exercises are p r o g r e s s e d a n d
r e t u r n to full a c t i v i t y c a n b e e x p e c t e d b y 16 w e e k s .

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