eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity

Bicipital Tendon Injuries

Updated: Nov 2, 2009

Introduction

Bicipital tendon injuries of the elbow most commonly occur in the dominant extremity of men aged 40-60 years. Injuries range from tendonitis to partial tears to complete ruptures. A rupture usually occurs at the insertion of the tendon to the radial tuberosity, resulting in pain and deformity about the elbow, as well as weakness, especially with supination. Most surgeons agree that the best results are obtained with early surgical intervention and reattachment of the tendon to the radial tuberosity.^{1,2,3,4,5,6,7}

Biceps muscle and tendons.

Recent studies

Freeman et al retrospectively compared the outcome of 18 patients with 20 distal biceps tendon ruptures managed nonoperatively with historical controls from 6 published series of operatively treated patients. The median supination and elbow flexion strengths for the injured arm in the nonoperative group were 63% and 93% of those for the contralateral arm, compared with values of 92% and 95% for the historical controls that had been treated surgically. Patients had satisfactory outcomes overall, with median scores on the Broberg and Morrey Functional Rating Index, the Mayo Elbow Performance Index, and the Disabilities of the Arm, Shoulder and Hand questionnaire of 85, 95, and 9, respectively. The authors concluded that nonoperative treatment of distal biceps tendon ruptures may yield acceptable outcomes with modestly reduced strength, especially supination.⁸

Nesterenko et al measured isokinetic strength and endurance in elbow flexion and forearm supination in both arms of 9 patients with an untreated unilateral complete distal biceps tendon rupture; 1 additional patient underwent isokinetic testing only. Peak torque was found to be significantly lower in involved limbs regarding both flexion and supination, but no significant differences were found in the fatigue index between involved and uninvolved limbs for flexion or supination. The authors noted that although nonoperative treatment is rarely recommended for complete distal biceps tendon ruptures, when it is selected, rehabilitation should concentrate on improving strength, not endurance.⁹

Schneider et al performed a retrospective study of 10 patients who sustained non-simultaneous bilateral distal biceps brachii tendon ruptures repaired surgically. They found that bilateral distal biceps tendon ruptures tended to occur in middle-aged men who commonly participated in weightlifting, manual labor, or sports and had higher rates of nicotine use (50%) and anabolic steroid use (20%) than the general population. The mean time from the first tendon rupture to the contralateral tendon rupture was 2.7 years (range, 0.5 - 6.3 y).¹⁰

Cil et al studied an immediate active range-of-motion protocol after modified 2-incision distal biceps tendon repair in 21 patients with acute ruptures. After repair, the arms were placed in a sling for 1-2 days, followed by immediate active range of motion. For the first 6 weeks, the elbow was allowed activities of daily living, with a 1-lb weightlifting restriction. Mean follow-up extension was 0º, and mean follow-up flexion was 141º on the operated arm, with supination of 74º and pronation of 75º. Mean DASH score was 3.6 ± 3.6; mean follow-up isometric flexion strength was 5%; and the power (dynamic strength) of flexion was 12% greater on the operated side. However, on the operated arm, follow-up isometric supination strength was 9% less and the power of supination was 11% less. According to the authors, the modified 2-incision distal biceps repair allows a safe immediate active range-of-motion protocol with early return of nearly full range of motion and strength.¹¹

History of the Procedure

Boyd and Anderson first described a modified 2-incision approach for repair of a distal biceps tendon in 1961.¹² The original approach involved subperiosteal dissection on the ulna. This led to an increased incidence of synostosis and heterotopic bone formation.

A modified approach with muscle splitting rather than subperiosteal dissection decreases the incidence of synostosis and heterotopic bone formation. The biceps tendon is secured after the tuberosity is excavated. The tendon is fixed through 3 drill holes in the tuberosity.

The advent of suture anchors has increased the popularity of the single-incision approach. This approach has the theoretical advantage of a low risk of synostosis. The originally described anterior single-incision extensile approach was associated with radial nerve injury. Today's limited anterior approach has been associated with neurapraxic injuries only.

Problem

The biceps brachii is the most powerful supinator of the forearm, and along with the brachialis, it provides elbow flexion. Rupture of the distal biceps tendon results in loss of supination power and deformity, as well as pain in the elbow. Without early surgical repair, chronic weakness and deformity persist. Pain typically resolves in time. Because this injury is most common in the dominant extremity of active middle-aged men, it may lead to significant impairment of their daily activities.

Frequency

The overall frequency of bicipital tendon injuries is not truly known but has been reported to occur in 1.2 patients per 100,000 population. It has been reported with increasing frequency, but generally is considered to represent only 3% of biceps tendon injuries as a whole. This injury is more common in men and rarely reported in women.

Etiology

Bicipital tendon injuries most commonly occur when an extension force is applied with the elbow in flexed position. This force overpowers the tendon and causes its rupture. It is believed that a degenerative process occurs in the tendon prior to the rupture. This process is evident clinically at the time of surgery with the finding of a bulbous, degenerated end of the tendon. Histologic studies have confirmed the degenerative process. Exactly how partial ruptures are related to this process is unknown. In addition, mechanical and vascular issues contribute.

Presentation

Bicipital tendon ruptures most commonly occur in the dominant extremity in men aged 40-60 years, with an average patient age of about 50 years. Patients often have a history of acute pain in the antecubital fossa, and typically give a history of either lifting or holding something heavy with the elbow flexed immediately prior to the injury. Patients may or may not have a history of previous elbow pain. This pain, if present, may be related to tendon degeneration or a previous partial tear.

The acute pain is accompanied by deformity in the antecubital fossa due to tendon retraction. An obvious deformity indicates rupture of the tendon and the lacertus fibrosis. Some patients have swelling and/or ecchymosis in the antecubital fossa as well, typically over the medial proximal forearm. Initially, they may have weakness with flexion due to pain. This symptom may subside in a few days as the swelling decreases, but weakness with supination does not subside. If the tendon is completely ruptured but the lacertus fibrosis is intact, little deformity may be present.

On examination, tenderness may be noted in the antecubital fossa, as well as deformity due to the tendon retraction. If the lacertus fibrosis is not ruptured, the deformity is not as pronounced, but it can still be appreciated on comparison with the opposite extremity. The deformity is accentuated with resisted supination with the elbow in flexion.

Indications

Most surgeons agree that the vast majority of bicipital tendon ruptures benefit from early surgical repair. Indications for surgical intervention include a complete tendon rupture, with or without lacertus fibrosis rupture, in an otherwise healthy, cooperative, and active individual.

Acute ruptures are best treated early, within 8 weeks of the injury. Chronic injuries may require reconstruction or augmentation of the tendon, a much more complicated procedure.²

Relevant Anatomy

The biceps brachii travels in the anterior compartment of the arm and is innervated by the musculocutaneous nerve. It is the most powerful supinator of the forearm and also acts as a flexor of the elbow. It has 2 separate proximal origins: the coracoid process and the bicipital tuberosity of the superior glenoid. Distally, a single tendon inserts on the radial tuberosity after passing through the antecubital fossa. The lacertus fibrosis, an aponeurotic expansion, originates at the musculotendinous junction medially, blends distally with the fascia of the superficial flexor mass, and inserts on the proximal ulna.

The lateral antebrachial cutaneous nerve travels between the brachialis and biceps brachii and exits the arm in the subcutaneous tissue laterally. It supplies sensation to the lateral aspect of the forearm.

The median nerve courses with the brachial artery and vein medial to the biceps tendon in the antecubital fossa. The artery bifurcates into the radial and ulnar arteries at the level of the radial head. A recurrent branch from the radial artery travels lateral and proximal across the antecubital fossa.

The radial nerve travels laterally between the brachialis and brachioradialis to enter the antecubital fossa. The superficial branch travels deep to the brachioradialis in the forearm. The deep branch enters the supinator muscle lateral to the radius and becomes the posterior interosseous nerve.

Contraindications

Surgical repair of a bicipital tendon rupture has few contraindications. Contraindications include the presence of little functional impairment from the injury, medical contraindications to a surgical procedure, and a sedentary or uncooperative patient.

A relative contraindication is chronic disruption. Because of tendon retraction and muscle contraction, it is difficult or impossible to anatomically reattach the tendon to the radial tuberosity. In these situations, delayed reconstruction using autograft or allograft tissue is required and the outcome is less dependable.

Workup

Imaging Studies

Plain radiography is a necessary part of a complete evaluation. Radiographs can reveal a bony avulsion from the radial tuberosity, but they are often negative. Mild to moderate underlying degenerative changes are not a contraindication to reconstruction of acute tears.
MRI can be helpful in cases of partial rupture of the tendon or in cases of chronic disruption or when the diagnosis is uncertain, but it is otherwise is unnecessary for the diagnosis and treatment of acute injuries.

Treatment

Surgical Therapy

Early surgical intervention for complete ruptures provides the best results. Two techniques are commonly used: the 2-incision (modified Boyd-Anderson) technique and the single-incision technique.^3,13

The 2-incision technique, which Boyd and Anderson described in 1961, is the more common technique. However, with the advent of suture anchors, the single-incision technique is becoming more popular. An advantage of the 2-incision technique is potentially stronger fixation to the radial tuberosity. The most common complication is heterotopic bone, which can create a mechanical block to motion. As a result, this bone may need to be removed surgically. Another reported complication is injury to the posterior interosseous branch of the radial nerve.¹⁴

The single-incision technique has the obvious advantage of 1 incision versus 2 incisions. Fixation usually is achieved with suture anchors placed into the radial tuberosity. The most common complication with the current single-incision technique is lateral antebrachial nerve neurapraxia.

Preoperative Details

A thorough history, physical examination, and radiographic workup should be completed prior to surgery. Range of motion (ROM) and stability of the elbow should be assessed.

Intraoperative Details

Examination with the patient under anesthesia is essential to surgery in any extremity. Surgery should be performed by using a tourniquet placed as high on the arm as possible. After standard sterile preparation and draping, the limb is exsanguinated and the tourniquet inflated.

With the 2-incision technique, a small incision in the antecubital fossa (approximately 3-4 cm) is made in the flexion crease. Dissection is taken through the fascia, and the biceps tendon is easily identified. Sometimes, a "milking" maneuver must be performed to deliver the tendon into the wound. Once the tendon is identified, it is prepared for fixation. The tendon invariably has bulbous degeneration at the rupture site. Once the bulbous degeneration is resected, 2 nonabsorbable braided 5-0 sutures are placed in a Bunnell or Krakow fashion to secure the tendon.

A curved Kocher or Kelly clamp is used to mark the second incision. The clamp is placed through the sheath of the biceps tendon and curved toward the radius with the forearm in supination. Great care is taken not to disturb the periosteum of the ulna to prevent synostosis. The clamp is used to tent the skin dorsally after it passes by the radial tuberosity. Once the clamp is past the tuberosity, the forearm is placed in pronation. Pronation of the forearm protects the radial nerve.

A 4- to 6-cm incision is made over the tip of the clamp. The dissection is taken down through the fascia of the common extensor and supinator and down to the radial tuberosity, which is cleared of overlying soft tissue. The tuberosity can be excavated with a high-speed burr. D'Arco et al described a better technique in 1998.⁴ In their method, the radial tuberosity is prepared with multiple drill holes in an oval fashion and then excavated with small, curved curettes. This approach avoids creating the bone dust from the burr that may lead to synostosis.

After the tuberosity is prepared, 3 drill holes are made along the lateral margin of the tuberosity. The tendon is then delivered from the anterior wound to the tuberosity. This step can be expedited by placing a passing stitch when the curved clamp is removed from the biceps tendon sheath. The tendon is delivered into the tuberosity and the sutures are tied, securing the tendon. Last, the wound is closed in layers.

Postoperative Details

Whether the 2-incision or the 1-incision technique is used, the elbow should be immobilized in 90° of flexion and slight supination for 7-10 days for the patient's comfort. Outpatient physical therapy begins with gentle ROM. A hinged ROM brace can help initially block the terminal 30° of flexion to protect the repair. This angle is gradually increased to full extension. Pronation and supination should be initiated early in therapy.

Follow-up

Unrestricted motion can usually be achieved by 6-8 weeks after surgery. Full, unrestricted resistance activities should be delayed at least 4 months.

Complications

The most common complication from a 2-incision approach is heterotopic bone formation. This complication can be minimized by avoiding use of a burr to excavate the radial tuberosity, decreasing the amount of bone dust created. In addition, by avoiding disruption of the ulnar periosteum, the risk of synostosis can be minimized.

The most common complication from a 1-incision approach is nerve palsy. Most of these palsies are transient in nature and completely resolve. They are best avoided by minimizing traction on the nerve.

Outcome and Prognosis

Excellent results can be obtained with early surgical intervention. Early direct repair of the tendon to the radial tuberosity gives the best opportunity for full functional recovery. Both the 2-incision and the 1-incision techniques provide excellent results. The choice of technique depends on the surgeon's preference.

Delayed repair or reconstruction is more difficult than early treatment. Late repair may result in long-term weakness and loss of motion due to the chronicity of the injury.

Future and Controversies

With early repair, success rates with either the 2-incision or the 1-incision technique are great. The 1-incision technique will continue to advance with the development of better suture anchors. The use of multiple drill holes instead of a high-speed burr to excavate the radial tuberosity should also improve outcomes by decreasing the incidence of synostosis.

Multimedia

Media file 1: Biceps muscle and tendons.

References

Mazzocca AD, Spang JT, Arciero RA. Distal biceps rupture. Orthop Clin North Am. Apr 2008;39(2):237-49, vii. [Medline].
Hamer MJ, Caputo AE. Operative treatment of chronic distal biceps tendon ruptures. Sports Med Arthrosc. Sep 2008;16(3):143-7. [Medline].
Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: a systematic review. Am J Sports Med. Aug 2008;36(8):1618-24. [Medline].
D'Arco P, Sitler M, Kelly J, et al. Clinical, functional, and radiographic assessments of the conventional and modified Boyd-Anderson surgical procedures for repair of distal biceps tendon ruptures. Am J Sports Med. Mar-Apr 1998;26(2):254-61. [Medline].
Churgay CA. Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. Sep 1 2009;80(5):470-6. [Medline].
D'Alessandro DF, Shields CL, Tibone JE, Chandler RW. Repair of distal biceps tendon ruptures in athletes. Am J Sports Med. Jan-Feb 1993;21(1):114-9. [Medline].
Gaskin CM, Anderson MW, Choudhri A, Diduch DR. Focal partial tears of the long head of the biceps brachii tendon at the entrance to the bicipital groove: MR imaging findings, surgical correlation, and clinical significance. Skeletal Radiol. Oct 2009;38(10):959-65. [Medline].
Freeman CR, McCormick KR, Mahoney D, Baratz M, Lubahn JD. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Joint Surg Am. Oct 2009;91(10):2329-34. [Medline].
Nesterenko S, Domire ZJ, Morrey BF, Sanchez-Sotelo J. Elbow strength and endurance in patients with a ruptured distal biceps tendon. J Shoulder Elbow Surg. Aug 5 2009;[Medline].
Schneider A, Bennett JM, O'Connor DP, Mehlhoff T, Bennett JB. Bilateral ruptures of the distal biceps brachii tendon. J Shoulder Elbow Surg. Sep-Oct 2009;18(5):804-7. [Medline].
Cil A, Merten S, Steinmann SP. Immediate active range of motion after modified 2-incision repair in acute distal biceps tendon rupture. Am J Sports Med. Jan 2009;37(1):130-5. [Medline].
Boyd HB, Anderson LD. A method for reinsertion of the distal biceps brachii tendon. J Bone Joint Surg. 1961;43:1041-3.
Checo FJ, Rodner CM. Bone tunnel and suture anchor fixation of distal biceps tendon ruptures. Sports Med Arthrosc. Sep 2008;16(3):124-9. [Medline].
Cohen MS. Complications of distal biceps tendon repairs. Sports Med Arthrosc. Sep 2008;16(3):148-53. [Medline].
Lintner S, Fischer T. Repair of the distal biceps tendon using suture anchors and an anterior approach. Clin Orthop. Jan 1996;116-9. [Medline].
Morrey BF. Tendon injuries about the elbow. In: The Elbow and its Disorders. 2nd ed. Philadelphia, Pa: WB Saunders; 1993:. 492-504.
Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii. A biomechanical study. J Bone Joint Surg Am. Mar 1985;67(3):418-21. [Medline].
Ramsey ML. Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg. May-Jun 1999;7(3):199-207. [Medline].

Keywords

biceps tendon, biceps tendon injury, distal biceps tendon, elbow tendon, bicipital tendonitis, bicipital tear, bicipital injury, elbow pain, elbow deformity, modified Boyd-Anderson incision

Contributor Information and Disclosures

Author

John P Salvo Jr, MD, Assistant Director of Sports Medicine, Cooper Bone and Joint Institute, Cooper University Hospital; Assistant Professor of Surgery, University of Medicine and Dentistry of New Jersey
John P Salvo Jr, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Pennsylvania Medical Society, and Pennsylvania Orthopaedic Society
Disclosure: Nothing to disclose.

Medical Editor

Michael S Clarke, MD, Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine
Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Thomas R Hunt III, MD, John D Sherrill Professor and Director of Orthopaedic Surgery, Surgeon in Chief of UAB Highlands Hospital, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham
Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association
Disclosure: Tornier Consulting fee Review panel membership; Tornier Royalty None; Tornier Ownership interest None

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD, Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine
Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society
Disclosure: Nothing to disclose.

Further Reading

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Clinical guidelines

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ACR Appropriateness Criteria® chronic elbow pain.