Ruptures of the biceps tendon in the elbow are not very common. Most often they are caused by sudden trauma and result in greater dysfunction of the arm than rupture of the long biceps tendon.
Other arm muscles can accomplish elbow flexion quite well in the context of biceps tendon rupture. However, they cannot perform all the functions of the elbow, especially forearm rotation (supination).
In order for the strength of the arm to return close to normal, surgery to reattach the tendon to the radius is recommended. However, conservative treatment is a reasonable option for patients who do not perform demanding hand movements.

ANATOMY

The biceps muscle has two tendons at the shoulder and a tendon that attaches to the elbow. The tendon that attaches to the radius is called the distal biceps tendon. It attaches to a part of the radius called the radial tuberosity.
The biceps muscle helps flex and rotate the forearm.

DESCRIPTION

Biceps tendon tears can be partial or complete.
Partial tears. These tears affect the tendon but do not completely disrupt it.
Complete tears. In a complete rupture, the tendon detaches from the radius.
In most cases, distal biceps tendon tears are complete. This means that the entire muscle is detached from the bone and ascending toward the shoulder.
Other arm muscles can supply the affected tendon resulting in full movement and reasonable functionality. Without surgical reattachment, the affected arm will have a decrease in strength of 30% – 40%, mainly in supination.
Rupture of the distal biceps tendon is uncommon. It occurs in only 3-5 people per 100,000 per year, rarely in women.

WHAT CAUSES DISTAL BICEPS TENDON RUPTURE?

The main cause of distal biceps tendon rupture is a sudden trauma.

WHAT ARE THE INJURIES?

Injuries to the distal biceps tendon usually occur when the elbow is in extension and flexing against resistance.
An example is lifting a heavy box. You may lift it without realizing how much it weighs. You strain your biceps muscles and tendons trying to keep your arms bent, but the weight is too heavy, forcing you to stretch your arms out. As you make this effort, the stress on the biceps increases and the tendon may detach from its insertion on the radius.

WHAT ARE THE RISK FACTORS?

Men over 30 are more likely to rupture their distal biceps tendon.
Other risk factors for distal biceps tendon rupture:
-Smoking. Nicotine use can affect the strength and quality of the tendon;
-Corticosteroid medication. Long-term use of corticosteroids can affect tendon strength.

WHAT ARE THE SYMPTOMS?

You may hear a ‘pop’ in your elbow when the tendon ruptures. At first the pain is severe, but may improve after a week or two. Other symptoms include:
– Swelling on the anterior aspect of the elbow;
– Visible tenderness of the elbow and forearm;
– Weakness when flexing the elbow;
– Weakness when supinating (turning);
– A bulge at the top of the upper arm created by shortening of the biceps muscle;
– A depression in the front of the elbow created by the absence of the tendon.

EXAMINATION BY THE DOCTOR

Physical examination
During the physical examination, the doctor will palpate the anterior aspect of the elbow looking for a depression where the tendon has ruptured. He will then test the supination motion of the affected forearm compared to the healthy one.

IMAGING TESTS

In addition to a physical examination, the doctor may recommend imaging tests to confirm the diagnosis.
Radiography. Although radiography cannot reveal soft tissue, it can be useful in ruling out other problems that can cause elbow pain.
Ultrasound. This imaging technique can show the loose end of the biceps tendon that has retracted into the arm.
MRI. These scans give better images of the soft tissue.

WHAT IS THE TREATMENT?

In order to regain full strength and function of the arm, surgery to reattach the tendon to the radius tendon is necessary.
Non-surgical treatment may be considered in elderly and less active patients, or if the condition is in the non-dominant arm and you can tolerate decreased forearm function.
Non-surgical treatment may also be an option for people who have medical problems that may increase the risk of complications during surgery.

CONSERVATIVE TREATMENT

Conservative treatment options focus on relieving pain and maintaining upper limb function. Treatment recommendations may include:
– Rest. Avoid activities that involve lifting heavy objects; your doctor may recommend using a support sling.
– Non-steroidal anti-inflammatory drugs. Medications such as ibuprofen and naproxen reduce pain and swelling.
– Physiotherapy. After the pain has subsided, the doctor may recommend rehabilitation exercises to increase muscle tone and restore functionality as close to normal as possible.

SURGICAL TREATMENT

Tendon repair surgery should be performed within the first 2-3 weeks after the injury. After this period the tendon and biceps muscle begin to heal and retract and it will no longer be possible to reattach the tendon to the radius.
Procedure
There are several types of procedures to repair the distal biceps tendon on the radial tuberosity. Some doctors prefer to make a single incision on the anterior aspect of the elbow, while others make small incisions on the anterior and posterior aspect of the elbow.
One of the indicated surgical options is to attach the tendon with sutures made through holes drilled in the radius. Another method is to attach the tendon to the bone using small metal implants (called suture anchors).

COMPLICATIONS

Surgical complications are generally rare and temporary.
– There may be numbness and/or weakness in the forearm, which usually disappears over time;
– Elbow calcifications that limit movement, especially supination;
– Although less common, the tendon may rupture again after complete healing.

RECOVERY

Immediately after surgery, the arm must be immobilized in a sling.
After immobilization for about 4 weeks, medical recovery is necessary with passive movements until mobility is restored and then active movements.
Endurance exercises such as light biceps curls or the use of elastic bands can be gradually added to the recovery plan.
Because it takes more than 3 months for the distal biceps tendon to heal completely, it is important to protect the arm and not overuse it.