Distal Biceps

Tendon Ruptures

MICHELLE WOLCOTT, M.D.

ASSOCIATE PROFESSOR

CU SPORTS MEDICINE

No disclosures

Biceps Tendon Anatomy

Two indistinct insertions

Short head inserts distally on the

radial tuberosity

Long head inserts proximally on the

radial tuberosity

Lacertus Fibrosis

Aponeurosis that comes off of the

medial tendon

Can be mistaken for intact tendon

Biceps Tendon Anatomy

Biceps Biomechanics

Radial Tuberosity

Anterior protuberance acts as a

supination cam

Biceps Biomechanics

Short head medial to the long

head at myotendinous junction

Tendon externally rotates 90 deg

to place the short head distal to

the long head on the radial

footprint

Short head exerts 15% greater

flexion torque due to distal

attachment

Long head exerts greater

supination moment due to

posterior insertion

Presentation

Males, 40s (93%)

Dominant arm (86%)

Risk factors

Smoking

Hypovascularity

Mechanical impingement?

Presentation

Eccentric load on a flexed elbow

Often accompanied by a ”pop”

Pain in antecubital fossa

Pain or weakness in supination

and/or elbow flexion

”Hook” sign/deformity

Presentation

Hook Test

MRI

May be helpful to determine

complete vs partial rupture

Helpful to determine tendon

retraction

Muscle vs tendon tear

Treatment

Non operative repair

Generally reserved for low-

demand or high-risk patients

Results in up to 30% elbow flexion

weakness, 40-50% supination

weakness

Partial tears < 50%

Treatment

Operative Repair

One Incision

Suture anchors

Cortical button

Interference screw

Two Incision

Bone tunnels

Treatment

Treatment

Operative Treatment

Anatomic Repair

Complications

Transient Neuropraxia

LACN

PIN palsy

Heterotopic ossification

Results

Overall results are excellent

regardless of technique

Clinical results

Avg 85-90% return of flexion and supination strength

Slightly decreased ROM and increased incidence of HO with 2-incision technique

Mazzocca, et.al. AJSM 2007

Biomechanical testing

Bone tunnel, suture anchor, cortical button, interference screw

Evaluated load to failure and cyclic loading

No significant difference in displacement of repair

Greater load to failure with Endobutton

Results

Anatomic Repair

Partial Biceps Ruptures

Presentation

Chronic pain and weakness with

elbow flexion and supination

Following an acute injury (usually

remote)

Physical exam findings are most

often normal

Treatment

Nonoperative

Same indications as complete

rupture

Low demand

Operative

Chronic symptoms

Antecubital pain

Supination, occasional flexion

weakness

Chronic Biceps Ruptures

Typically presents with stiff,

proximally contracted, shortened,

atrophic tendon

Bosman, et.al. JSES 2012

6 patients

FROM

Mild supination weakness

No reruptures

Morrey, et.al. JSES 2014

Retrospective study

Fixed in 60-90 deg flexion

No difference in clinical strength,

rerupture rates, range of motion, or

complications

Chronic Biceps Ruptures

Allograft or autograft

augmentation

Musculotendinous junction tears

Poor tendon quality

Flexion greater than 90 deg?

References

Cheung, E. V., Lazarus, M., & Taranta, M. (2005). Immediate range of motion after distal biceps tendon repair. Journal of Shoulder and Elbow Surgery, 14(5), 516-518. doi:10.1016/j.jse.2004.12.003

El-Hawary, R., MacDermid, J. C., Faber, K. J., Patterson, S. D., & King, G. J. (2003). Distal biceps tendon repair: Comparison of surgical techniques. The Journal of Hand Surgery, 28(3), 496-502. doi:10.1053/jhsu.2003.50081

Kettler, M., Lunger, J., Kuhn, V., Mutschler, W., & Tingart, M. J. (2007). Failure Strengths in Distal Biceps Tendon Repair. The American Journal of Sports Medicine, 35(9), 1544-1548. doi:10.1177/0363546507300690

Mazzocca, A. D., Burton, K. J., Romeo, A. A., Santangelo, S., Adams, D. A., & Arciero, R. A. (2006). Biomechanical Evaluation of 4 Techniques of Distal Biceps Brachii Tendon Repair. The American Journal of Sports Medicine, 35(2), 252-258. doi:10.1177/0363546506294854

Panagopoulos, A., Tatani, I., Tsoumpos, P., Ntourantonis, D., Pantazis, K., & Triantafyllopoulos, I. K. (2016). Clinical Outcomes and Complications of Cortical Button Distal Biceps Repair: A Systematic Review of the Literature. Journal of Sports Medicine, 2016, 1-11. doi:10.1155/2016/3498403

Schmidt, C. C., Savoie, F. H., Steinmann, S. P., Hausman, M., Voloshin, I., Morrey, B. F., … Brown, B. T. (2016). Distal biceps tendon history, updates, and controversies: from the closed American Shoulder and Elbow Surgeons meeting—2015. Journal of Shoulder and Elbow Surgery, 25(10), 1717-1730. doi:10.1016/j.jse.2016.05.025

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