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Distal Biceps Tendon

The biceps muscles are situated at the front of the upper arm and connect to the shoulder and elbow bones through tendons. Tendons are strong, fibrous cords that link muscles and bones together.

Tears or injuries in the distal biceps tendon near the elbow are relatively rare, affecting only 3 to 5 individuals out of 100,000 annually. These occurrences are even less common in women. Injuries are usually the result of sudden trauma and often lead to more significant arm weakness compared to biceps tendon injuries at the shoulder.

Distal biceps tendon tears can be classified as:

  • Partial: These involve soft tissue damage without fully severing the tendon.
  • Complete: In this case, the tendon is entirely detached from its connection to the bone.

Most distal biceps tendon tears are complete, meaning the muscle entirely separates from the bone and retracts toward the shoulder.

Symptoms

When the biceps tendon ruptures, a popping sound is often heard at the elbow. The initial pain can be intense but usually decreases within one or two weeks. Additional common symptoms are:

  • Swelling at the facade of the elbow
  • Noticeable bruising on the elbow and forearm
  • Weakness when bending the elbow
  • Supination (difficulty twisting the forearm)
  • A visible bulge in the upper arm due to the recoiled or shortened biceps muscle
  • Space at the front of the elbow where the tendon is missing

Causes

Distal biceps tendon injuries typically occur due to a forceful, unusual elbow contraction. This is when the biceps muscle contracts while the elbow extends, causing the muscle-tendon unit to lengthen. It can happen, for instance, when someone tries to lift a heavy object by bending their elbow, and instead, the weight forcefully straightens the elbow.

Biceps tendon ruptures may result from a sudden injury or an “acute-on-chronic” condition, where the tendon has already been weakened by degeneration (tendinosis).

In addition, certain risk factors, including diabetes, use of anabolic steroids, smoking, and a higher body mass index (BMI), can increase the likelihood of injury.

Diagnosis

Physical examination:

During the diagnosis of the distal biceps tendon injury, the doctor will review your symptoms and ask how the tear occurred. Your elbow will also be thoroughly examined by:

  • Palpating the front of the elbow to check for a gap where the tendon is absent.
  • Assessing forearm supination strength by asking you to turn your forearm in opposition to resistance.
  • Comparing the strength of the affected arm to the unharmed arm.

Imaging tests:

To confirm the diagnosis, these imaging tests may be ordered:

  • X-rays – While they do not reveal soft tissues such as the biceps tendon, X-rays can help rule out other reasons for elbow pain.
  • Ultrasound – This can detect the tendon’s free end that has retracted into the arm.
  • Magnetic resonance imaging (MRI) – Provides detailed pictures of soft tissues and can distinguish between partial and complete bicep tendon tears.

If the diagnosis is clear from the physical examination, additional imaging, such as an ultrasound or MRI, may not be necessary.

Treatment

Non-surgical options:

The goal of non-surgical treatment is to relieve pain and maintain arm function. These treatments may be suitable particularly if:

  • You are older and less physically active.
  • The injury is in your non-dominant arm, and you can manage it with reduced function.
  • You have medical conditions that increase surgical risks.
  • You are unable to commit to the rehabilitation process after surgery.

Non-surgical options may involve:

  • Rest: Do not lift heavy items and do overhead movements in order to minimise pain and swelling. A sling may be recommended for short-term support.
  • NSAIDs: Medications such as ibuprofen or naproxen can help ease pain and inflammation.
  • Physical therapy: Once pain subsides, rehabilitation exercises can help strengthen nearby muscles and improve mobility.

Surgical options:

Surgery may be required to reconnect the tendon to the bone and restore total arm strength as well as function.

Surgery should ideally be conducted within 2–3 weeks of injury for the best outcome. After this period, scarring and tendon shortening may make the procedure more complex and less effective. While delayed surgery is possible, it often involves more complicated techniques with lower success rates.

There are different surgical techniques for reattaching the distal biceps tendon to the forearm bone. Surgeons often use a single cut at the front of the elbow, while others may prefer two small incisions at the front and back. The tendon can be secured using:

  • Stitches through holes pierced in the radius bone
  • Small metal implants (suture anchors or buttons) to connect the tendon and the bone

Rehabilitation after surgery:

Immediately after surgery, your arm remains restrained in a splint or cast. Gradual movement begins soon under medical supervision, often with the use of a brace. Physical therapy helps restore mobility and strength, with progressive resistance exercises introduced over time.

Full tendon healing takes 3–4 months, so activity restrictions are essential to safeguard the repair. Light activities can resume early, though you should avoid heavy lifting and strenuous movement for several months.

While recovery is gradual, staying committed to your rehabilitation plan is key to regaining full function and returning to normal activities.

Bottom Line

A distal biceps tendon tear and injury can significantly impact your arm strength and function. Luckily, surgical or non-surgical treatments can help you regain mobility and minimise discomfort. Early diagnosis and prompt medical attention are important for the best recovery outcomes.

Book an appointment with our experts today to discuss your treatment options.