What is a distal biceps rupture?The biceps is the large muscle at the front of the upper arm. It is attached to the shoulder blade at the top of the arm and to the radius bone of the forearm. At the elbow the tendon is known as the distal biceps. The distal biceps tendon can rupture or tear from the radius bone in the forearm when the muscle is suddenly loaded while it is lengthening (known as eccentric loading). There is often a story of suddenly catching or saving something heavy from falling, with a tearing sensation felt at the front of the elbow. Ruptures may also occur in contact sports such as rugby.
What are the symptoms and signs?The history above may be familiar and classically there is bruising on the front and inside of the elbow with an absence of the tendon. There is often asymmetry of the biceps, which is more noticeable when contracting the muscle. If you bend your elbow and look at the palm of your hand and tense your biceps you should be able to feel the tendon at the front of the elbow by hooking a finger behind the tight structure. If the hook is not achievable, the biceps tendon may be ruptured. A surgeon should be able to diagnose a rupture, but sometimes scans can be helpful if there is doubt or there are partial tears of the tendon. Either an ultrasound or magnetic resonance (MRI) scan will be performed (Figures).
Hook Test for Distal Biceps Rupture
How is it treated?Less active patients can live with a ruptured biceps tendon but more active people benefit from surgical repair. If the tear is not repaired surgically there is some loss of strength of the elbow. There is around 20-30% loss of bending strength but up to 50% of forearm rotation (supination) strength loss. Some patients who do not undergo surgery will complain of chronic cramping sensation in the biceps; this is an indication for considering late repair of a biceps rupture. There are many techniques described to repair distal biceps ruptures. The aim of surgery is to re-attach the torn tendon to the bone and to protect the repair while healing takes place. Either one or two incisions (cuts) are made at the front of the elbow to both find and repair the tendon. One of the strongest fixations is to use a button and thick suture to hold the tendon in the bone; this may be supplemented with a screw (Figure).
What are the potential complications?The risks of surgery are low, with very low risks of infection, bleeding and nerve injury. There are major nerves to the hand around the elbow and injury to a major nerve is rare. There is, however, a slightly higher risk of injury to smaller nerves that supply sensation to the forearm (lateral antebrachial cutaneous nerve of the forearm) or the back of the thumb (lateral branch of the superficial radial nerve). These nerves are rarely cut, but if they are bruised or stretched they can take some time to settle back to normal. Re-ruptures are not common and are most likely in the early stages after repair if the rehabilitation is not followed.
What rehabilitation is necessary after surgery?The repair is generally strong enough for immediate mobilisation of the elbow within the confines of a sling. Initial rehab aims to restore elbow range of motion while the tendon heals. A sling will be required for four weeks. During the first two weeks the sling is placed to prevent straightening (extension). At two weeks the sling is lengthened to allow more straightening and it is discarded from four weeks. A physiotherapist can guide patients through a post-operative rehabilitation. Driving can be resumed at four to six weeks, when safe to do so, and return to contact sports at three months.
FABS Distal Biceps Rupture MRI
Distal Biceps Button Fixation
A big thank you to Simon and his team for their care, patience and perseverence looking after me through all stages of both shoulder and elbow surgery.
Since the shoulder stabilisation I have continued my sailing and fitness training without the worry that my shoulder might dislocate; and I don’t have to think twice whether my ulnar nerve will hinder any progression in my sports.
With their amazing help, I’ve been able to get back to sailing competatively and am now a double National champion.
After multiple shoulder dislocations Charlie helped me set a route for recovery, which has been nothing but smooth sailing. Surgery went successfully and I am well on my way to playing the sports I was previously. Would highly recommend.
Simon successfully operated on my frozen left shoulder in 2012 with fantastic results. This year he has overseen and advised treatment for my frozen right shoulder (via hydrodilation injection). His unrivalled experience in orthopaedic shoulder treatments, coupled with his reassuring bedside manner and excellent results, gave me huge confidence throughout. I’m hugely grateful to have my quality of life back and wouldn’t hesitate to recommend his services. Thank you Simon.
I had suffered with a painful shoulder and pins and needles for three years following a right shoulder fracture and failed half joint replacement prior to meeting Mr Pennington. He explained the situation in a way I could relate to and I’m delighted to say my revision shoulder replacement has gone well and for the first time in years I can use my arm and am pain free. I was even able to walk my daughter down the aisle 3 months after surgery! Many thanks.
I would like to thank Charlie Talbot and his team for the operations performed on both my shoulders and also the aftercare put in place after my operations. I have played golf since I was 12 years of age and thought at one point that I would never get back to playing again. Charlie was always very positive and told me that he would get me playing golf again. Well, I have now been playing golf for nearly 2 years. Before surgery I had a handicap of 12 and I am now down to 9, not bad at the age of 68. So many many thanks.
I had PRP injections into my right elbow last year and within 3 months I was pain free, a year on it is more or less 100% better. Fabulous I would recommend it to anyone with Tennis Elbow, in fact I have gone back again this year to get my left elbow done. Thanks Simon.
Mr Pennington I really wanted you to know how very thankful I am for the excellent care & treatment you and your staff gave me. It really meant a lot that you were so clear, friendly & professional and listened to me – so thank you again.
After more than four decades of shoulder problems with a total of three surgeries the full shoulder replacement surgery by Mr. Talbot has changed my life beyond expectations. I am now able bodied for the first time in years and pain free.
Thank you to Mr Boyle and team for the excellent care and attention both before and after Replacement Shoulder surgery, using the Tornier Simpliciti procedure. After very many months of severe pain and lack of movement I was pain free from day one. Now, after nine weeks, the shoulder and arm movement continues to improve, beyond expectation, with physiotherapy and exercise. I am extremely grateful for all the continuing care.
Following two years of recurrent problems with my left shoulder I was recommendedto Consult Mr Neil Pennington. I had the opportunity to have my surgery quickly and at my convenience, this fitted well around my professional and home commitments. The surgery was carried out as a day case procedure and Mr Pennington visited me following the surgery to explain everything. My operation was a minimally invasive procedure so my recovery was straightforward with only a few restrictions; in fact I was encouraged to keep my shoulder moving. I was driving and back to work after 2 weeks – after 2 years of pain and sleep disturbance I found this operation to be life changing! I found Mr Pennington to be a very professional and compassionate surgeon and he is surrounded by a whole team of professionals that gave me the utmost confidence in the care and treatment I received.
I would like to thank Mr. Talbot and the amazing team of nurses, physiotherapists and support staff for their care and support during my recent visit to the Duchy Hospital, Harrogate, for a replacement shoulder. The care and attention I received was unparalleled. The pain free movement I now have has changed my life.