Distal Biceps Tendon Repair Surgery

Elbow and forearm tendon injury is common for overhead throwing athletes, such as baseball and softball players and those who play tennis. Acute tendon rupture can occur with repetitive, forceful overhead throwing. The biceps muscle is in the front portion of the upper arm, and it helps you rotate your forearm and bend your elbow. This structure is also necessary for shoulder stability.

The biceps tendons attach the biceps muscle to the bones of the shoulder and elbow. If you tear this tendon at the elbow, you lose strength in your arm and have significant weakness in supination (turning hand from palm down to palm up). Unless the biceps tendon is surgically repaired, there will be significant loss of arm function. The biceps tendon at the elbow region is the distal biceps tendon. The biceps tendon that attaches to the shoulder is the proximal biceps tendon.

Rupture of the proximal portion of the biceps tendon occurs often when there is a degenerative change within the tendon leading to structure failure. However, this tendon region could rupture during trivial activity. The primary cause of a distal biceps tendon tear is sudden injury.

Risk Factors

Those at risk for distal biceps tendon tears include men, age 30 or older. Smoking and the use of corticosteroids also increase the risk of these tears.


A distal biceps tendon tear causes the muscle to ball up near the shoulder, sometimes called the “popeye deformity”. Oftentimes, there is bruising at the elbow. If you tear this tendon, you may hear a “pop” at the elbow region. Pain is usually severe at first, but subsides after a couple of weeks. Other symptoms include weakness in twisting the forearm, swelling in the front of the elbow, and a gap in the front of the elbow.

Usually patients will have sudden pain associated with an audible snap in the area of their shoulder. The pain is usually not significant, and, as mentioned previously, some patients may experience pain relief after the rupture. After the ruptured tendon retracts, patients may notice a bulge in their arm at the biceps muscle. This is the retracted muscle bunched up in the arm, and is sometime referred to as a “Popeye Muscle,” because the muscle is more pronounced than normal.

Distal biceps tendon rupture is characterized by sudden pain over the front of the elbow after a forceful effort against a flexed elbow. Usually the patient will hear a snap and have pain where the tendon rupture occurs. Swelling and bruising around the elbow are also common symptoms of distal biceps tendon rupture.


Medical History and Physical Examination

After discussing your symptoms, your doctor will review the events of the injury to determine how it occurred. During the physical examination, your doctor will feel the front of your elbow, looking for a gap in the tendon. He or she will test the supination strength of your forearm by asking you to rotate your forearm against resistance.

Your doctor will compare the supination strength to the strength of your opposite, uninjured forearm. In addition to the examination, your doctor may recommend imaging tests to help confirm a diagnosis.

Imaging Tests

X-rays. Although X-rays cannot show soft tissues like the biceps tendon, they can be useful in ruling out other problems that can cause elbow pain.
Magnetic resonance imaging (MRI). These scans create better images of soft tissues. They can show both partial and complete tears.


Patients usually do not notice any loss of arm or shoulder function following a proximal biceps tendon rupture. A slight bulge in the arm, and some twitching of the retracted muscle are usually the most significant symptoms. Surgical repair of the proximal biceps tendon is usually only considered in the case of a younger patient who is more active.

The reason there is little functional loss following a proximal biceps tendon rupture is that there are actually two tendinous attachments of the biceps at the shoulder joint (that is why the muscle is named “bi-ceps,” meaning two heads). When the rupture occurs at the distal biceps tendon at the elbow, where there is only one attachment, surgical repair is much more commonly needed.

If pain persists following a proximal biceps tendon rupture, other causes of shoulder pain should be considered. These include impingement syndrome (rotator cuff bursitis), rotator cuff tears, or fractures around the shoulder.

Rupture of the distal biceps tendon at the elbow joint is much less common and accounts for less than 5% of biceps tendon ruptures. This injury is also usually found in middle-aged patients, although not always. There is usually some degree of tendinosus, or degenerative changes within the tendon, that predisposes the patient to rupture of the tendon.

The significance of a distal biceps tendon rupture is that without surgical repair, patients who experience complete rupture of the distal biceps tendon will notice loss of strength at the elbow. The strength will affect both the ability to bend the elbow against resistance, and the ability to turn the forearm to the palm-up position against resistance (for example, turning a doorknob or screwdriver).

Nonsurgical Treatment

Nonsurgical treatment may be considered for patients who are elderly and inactive, or who have medical problems that make them high-risk for modest surgery.

Patients must weigh the decision to proceed with nonsurgical treatment carefully, because restoring arm function with later surgery may not be possible.

The tendon should be repaired during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten.
While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.

Surgical Treatment

If you and your doctor decide upon elbow surgery,the surgery is performed as an outpatient procedure under either regional or general anesthesia. Your procedure will most likely take between one and two hours. Following surgery, your arm will be placed in a splint for several days to immobilize the elbow and allow the wound to heal. During this time gentle wrist, hand and shoulder exercises are performed.

Early range of motion is begun within three to seven days after surgery depending on the type and extent of the reconstruction. You will be able to remove the splint and use a range of motion brace in order to avoid elbow stiffness. It is particularly important to achieve elbow extension (that is to be able to straighten the elbow fully).


Doctors use several procedures to reattach the distal biceps tendon to the forearm bone. Some doctors prefer to use two incisions, while others only one incision. There are pros and cons to each approach.
Sometimes the tendon is attached with stitches through holes drilled in the bone. Other times, small metal implants are used to attach the tendon to the bone.

Be sure to carefully discuss the options available with your doctor.
X-rays showing metal implants called suture anchors that have been used to secure the biceps tendon to the bone.


Right after surgery, your arm may be immobilized in a cast or splint.
Your doctor will soon begin having you move your arm, often with the protection of a brace. He or she may prescribe physical therapy to help you regain range of motion and strength.

Resistance exercises, such as lightly contracting the biceps or using elastic bands, may be gradually added to your rehabilitation plan.
Be sure to follow your doctor’s treatment plan. Since the biceps tendon takes 2 to 3 months to fully heal, it is important to protect the repair by restricting your activities.

Light work activities can begin soon after surgery. But heavy lifting and vigorous activity should be avoided for several months.

Although it is a slow process, your commitment to your rehabilitation plan is the most important factor in returning to all the activities you enjoy.

The physical therapy team at Hoag is orthopedic specialized, and they will work closely with your surgeon to establish a personalized rehabilitation plan for you. About six weeks after your surgery, elbow strengthening exercises may begin. For patients who remain dedicated to physical therapy the chances of complete recovery are very high, at above 90 percent.


About Wayne Weil

Wayne Weil, MD Dr. Weil is a board-certified orthopedic surgeon who is well known in the community for his expertise in hand surgery. He sees patients with a wide variety of hand ailments, including carpal tunnel syndrome, cubital tunnel syndrome, dupuytren’s syndrome, thumb arthritis, wrist fractures, and more.