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The distal biceps tendon tear – to fix or not to fix?

distal biceps tendon tears are common in body buildersThe distal biceps tendon tear is an injury which has occurred with increased frequency over the last few years. It is common in body builders. A complete tear will not heal on its own, and may lead to certain functional and cosmetic deficits. With good rehabilitation you may overcome some of the weakness caused by the injury, but to restore the natural contour of the biceps muscle and to obtain maximum strength, surgery will be needed…

A distal biceps tendon tear is a common injury among bodybuilders. It appears to have increased in frequency in recent years. While improvements in diagnostic imaging may have played a role, I suspect that it has more to do with an increase in supplement use and lifting heavier weights as a result.

The biceps is an interesting muscle in that it attaches to bony surfaces by means of tendons on both sides of the muscle. It is possible for the biceps tendon to be torn from the upper attachment. This is a proximal biceps tendon tear and generally occurs in older individuals who have a degenerative tendon. This condition will not be discussed further here – I will focus on biceps tears involving the lower attachment to the bone in the forearm (the radius).

Contraction of the biceps muscle causes two movements of the forearm. The most obvious is bending or flexion at the elbow. The other important movement is supination. This is a rotatory movement of the forearm where the hand turns to the palm-up position, like when one is holding a bowl of soup.

What causes a distal biceps tendon tear?

A distal biceps tendon tear usually occurs because of trauma in a young, active individual. It is a common injury seen in bodybuilders who lift extremely heavy weights. It may also occur in the casual gym-goer and in people engaged in other activities. I recall one patient describing that he sustained the injury while trying to stop a small boat sliding off the roof-racks of his car. Another patient was a rock climber who sustained the injury while hanging from a rock with one hand during a climb. The common mechanism of injury is that there is a forced extension of the forearm while the biceps is contracting strongly.

Although the injury is called a tear, it is an avulsion. This means that the tendon tears away from the bone at its point of attachment. The result is that the entire length of the tendon is usually intact and can be reattached to the bone.

How is a distal biceps tendon tear diagnosed?

Distal biceps tendon tears may require surgery to restore functionIn many instances the injury is obvious, and the person will tell you that they “felt the biceps tendon go”. There is often bruising on the inside of the elbow and there is weakness with flexion and supination, especially against resistance. The “hook test” may be positive. In this test the examiner tries to hook underneath the biceps tendon with his or her index finger from the side of the elbow. If there is a complete rupture of the biceps tendon the examiner may not be able to do this. Another sign to look out for is the “Popeye deformity”. With a ruptured biceps tendon, when one tries to flex the arm the biceps rolls into a ball, causing a visible cosmetic deformity, likened to the appearance of Popeye’s bicep muscle.

Often the history of having felt a “pop” in the elbow along with a careful clinical examination will be all that is needed to diagnose a distal biceps tendon tear. If there is any doubt, an ultrasound or MRI scan may be obtained.

What are the treatment options for a distal biceps tendon tear?

A complete distal biceps tendon tear usually does not heal back to the bone. With time the tendon may become shortened and degenerate. There are two treatment options. One option is to do nothing and the second is to have the tendon repaired surgically. There are other muscles in the upper limb which can take over the functions of flexion and supination. With physiotherapy and a good strengthening and rehabilitation programme, these deficits may be overcome to some degree in those who choose not to have surgery. There will, however, usually be a degree of residual weakness in the arm. This may not be noticeable by some patients but may cause significant impairment in others who rely on full supination strength (e.g. using a screwdriver, turning a doorknob).

Distal biceps tendon tears may need surgery to restore cosmesisAnother important factor to consider is cosmesis. Some individuals will accept the Popeye cosmetic deformity. Most individuals, however, who have this injury are younger, image-conscious males who would like to have the normal contour of their biceps muscle restored.

Surgery is therefore indicated for those who require maximal restoration of strength and function in the arm and for those who wish to restore cosmesis. One of the most important factors is that if surgery is chosen it should be performed as soon as possible. Early surgery is associated with the best outcomes. The procedure does not need to be done as an emergency but should be performed within the first two weeks. After six weeks a repair may be not possible as the tendon begins to shorten and become degenerate. An attempted repair after six weeks has a high failure rate.

What does surgery for a distal biceps tendon tear involve?

Surgery may be done on an outpatient basis which means you do not have to spend the night in hospital. The procedure involves making a small incision on the upper end of the forearm, through which the end of the biceps tendon can be retrieved (one incision procedure). Not uncommonly, the tendon rolls up into a little ball or retracts slightly, in which case it must be retrieved through a separate incision higher up over the lower end of the arm (two incision procedure).

There are different techniques of fixing the tendon back to the bone. One technique involves using an interference screw to secure the tendon into the bone. My preferred technique is the suspensory technique. After tendon is retrieved a small metal button is stitched to the end of it with strong, non-dissolvable stitches. A small hole is drilled through the bone where the tendon pulled off. The surrounding bony surface is roughened a bit to encourage healing of tendon to bone. The metal button attached to the end of the tendon is then threaded through the drill hole to the other side of the bone and then flipped to anchor the tendon securely back down to its bony point of attachment.

Distal biceps tendon repair using a metal button

Intra-operative X-ray of the flipped metal button anchoring the biceps tendon through a hole drilled in the radius

After the operation, the arm is usually immobilised for a week or two and a sling is worn for a further four weeks. Thereafter one may begin to use the arm normally but lifting any weight is prohibited for at least 4 to 6 months.

Are there any risks associated with surgery?

The surgery generally successful but is not without potential risks. The main areas of concern are injury to blood vessels and nerves in the surrounding area. A branch of the radial nerve is close to the operative field and injury to this nerve may result in weakness or even paralysis of wrist extension. Fortunately, this does not occur commonly. There is a small risk of fracture, but again this is quite rare. If the repair fails, it is usually because of a delay in treatment.

In conclusion…

A distal biceps tendon tear is usually an obvious injury, but in cases where there is any doubt an assessment by a specialist orthopaedic surgeon is needed. Occasionally further investigation such as ultrasound or MRI scan are required in doubtful situations. Surgery is recommended to restore maximal strength and cosmesis. If surgery is considered it should be performed early. Delays in diagnosis and treatment can lead to disappointing results. Many patients who decide against surgery function well but are left with a cosmetic deformity and may have residual weakness of flexion and supination. For further information read: Distal Biceps Tendon Repair.

Yours in good health,

Dr Warren Matthee

MB BCh (Wits), MRCS (England), MMed (Ortho Surg), FC Orth (SA)

Orthopaedic Surgeon

(011) 304 6784

About the author…

I am an orthopaedic surgeon with a special interest in sports injuries and minimally invasive (arthroscopic) surgery of the knee and shoulder. I treat patients at Waterfall Hospital in Waterfall/Midrand and Morningside Mediclinic in Sandton. Besides these, I also treat patients from other areas as well, including Rosebank, Sunninghill and Fourways.

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    Distal biceps tendon tears are more common in men