Partial rupture of the distal biceps tendon
Dimitris G. Vardakas, MD, Douglas S. Musgrave, MD, Sokratis E. Varitimidis, MD, Felix Goebel, MD,
and Dean G. Sotereanos, MD, Pittsburgh, Pa
We report on 7 cases of partial rupture of the distal biceps
tendon. The mean patient age was 52 years (range, 38-58
years). There were 5 men and 2 women. The dominant arm
was affected in all 7 patients. Pain was the chief complaint in
all patients. Immobilization and physiotherapy were attempt-
ed in all patients, and 4 had at least 1 local steroid injection.
No patient improved from the conservative treatment. All
patients eventually underwent surgical debridement and reat-
tachment of the biceps tendon with use of a 1-incision tech-
nique with suture anchors. After a mean follow-up of 31
months (range, 25-44 months), all patients reported a signifi-
cant decrease in their pain. No complications were noted. (J
Shoulder Elbow Surg 2001;10:377-9.)
INTRODUCTION
Partial rupture of the distal biceps tendon has rarely
been reported. Only 20 cases have been reported in
the literature, and for 10 of them, no details were avail-
able regarding treatment.2,5-8,12,13 The lack of a trau-
matic event in many of these patients and the difficulty
in diagnosing such a lesion may be reasons for the
small number. Since the advent of magnetic resonance
imaging (MRI), more accurate diagnosis is possible.
Pain in the antecubital fossa with resisted supination
is the most common finding. Active flexion and supina-
tion strength is usually limited by pain, but swelling is
not always present. MRI is capable of quantifying the
extent of the tear, as well as tenosynovitis, tendinitis, or
bursitis, which may accompany the tear.6,7 The treat-
ment is initially conservative and includes nonsteroidal
anti-inflammatory drugs, splinting, and physiotherapy.
Some physicians have used and have recommended
local corticosteroid injections. Surgical treatment is
reserved only for refractory cases.2,6
MATERIALS AND METHODS
Seven right hand–dominant patients, 5 men and 2
women, presented with symptoms and clinical signs of dis-
From the Department of Orthopaedics, University of Pittsburgh.
Reprint requests: Dean G. Sotereanos, MD, Chief, Hand and
Upper Extremity Surgery, Department of Orthopaedics, Univer-
sity of Pittsburgh, Kaufmann Building, Suite 1010, 3471 Fifth
Ave, Pittsburgh, PA 15213 (E-mail: dsoterea@uoi.upmc.edu).
Copyright © 2001 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2001/$35.00 + 0 32/1/116518
doi:10.1067/mse.2001.116518
tal biceps tendinitis. The mean age of these patients was 52
years (range, 38-58 years). The dominant extremity was
involved in all. Five reported no history of an acute event
and did not recall when the symptoms began. One patient
reported an unexpected large load applied to the flexed
arm, and one was injured while attempting to prevent a fall.
On presentation, all of the patients complained of pain in
the antecubital fossa and 4 of them had limited active range
of motion in flexion and supination due to painful inhibition.
Two patients had slight swelling in the antecubital fossa. On
physical examination, tenderness with palpation of the dis-
tal biceps tendon was present in all patients, as well as pain
with resisted flexion and supination. Plain radiographs
showed no abnormalities. All patients underwent MRI scans.
Varying degrees of partial rupture on the undersurface of the
biceps tendon insertion were noted in all 7 (Figure 1). Soft
tissue swelling, tendon degeneration, and tenosynovitis
were present in all patients. Two patients had MRI evidence
of an enlarged bicipital bursa and edema in the tissues sur-
rounding the tendon. Conservative treatment with immobi-
lization, anti-inflammatory drugs, and physiotherapy was
unsuccessful in all 7. Four of them had at least 1 local injec-
tion of steroid. Operative treatment was performed after a
mean symptom and conservative treatment duration of 9.5
months (range, 7-14 months). The mean follow-up after sur-
gery was 31 months (range, 25-44 months).
At the final follow-up, patients were questioned about
their activity level, job status, and pain relief. Elbow range
of motion was compared with that of the uninjured arm. Sta-
tic muscle testing was performed with use of a BTE Work
Simulator (Baltimore Therapeutic Equipment, Hanover, Md),
and each value was expressed as a percentage of the unin-
jured side.
Operative technique
A single, S-shaped, anterior incision was centered over
the antecubital fossa, facilitating a modified Henry’s
approach. The proximal limb of the incision is lateral to the
biceps tendon, and the distal limb is just medial to Henry’s
mobile wad. The lateral antebrachial cutaneous nerve was
identified and retracted laterally. The biceps tendon was
exposed and traced distally to the insertion at the radial
tuberosity. The lacertus fibrosus was found to be intact in
all cases. The radial attachment of the supinator was not
released. The radial nerve and posterior interosseous
nerve were not exposed; instead, they were protected by
gentle retraction and, most important, by keeping the fore-
arm supinated at all times. The radial recurrent vessels
were ligated to facilitate retraction, which allowed safe dis-
tal exposure of the tuberosity. In all cases the tendon had
significant degeneration and softening at the insertion site,
but was in partial continuity with the radial tuberosity. The
affected portion of the tendon varied between 60% and
377
378 Vardakas et al
B the repaired stump with an absorbable suture for reinforce-
Figure 1 A, T1-weighted magnetic resonance image of a partial
distal biceps tendon rupture. Note replacement of normal low signal-
intensity (black) biceps tendon with intermediate signal-intensity
(gray) edema and scar (arrow). B, T2-weighted magnetic resonance
fat suppression image of a partial distal biceps tendon rupture.
Image demonstrates high signal-intensity edema (arrow) surrounding
the distal biceps tendon and its insertion.
90% of the tendon diameter. In 2 cases a synovial cyst
found attached to the tendon was excised. The tendon was
released from the insertion, and the degenerated portion
J Shoulder Elbow Surg
July/August 2001
Figure 2 Two anchors are placed with number 2 nonabsorbable
sutures attached. Two pairs of sutures are passed through the dis-
tal 3 cm of normal tendon substance. A sliding Kessler stitch is
used to allow sliding of tendon down to radial tuberosity.
trimmed to normal tendon substance. Approximately 1 cm of
tendon was excised in all cases. Thick bursal tissue was pre-
served to reinforce the repair after tendon reattachment. The
tuberosity was then decorticated with a small, motorized
burr. Two 5.2-mm Fastin (Mitek/Ethicon/Johnson and John-
son Inc, Norwood, Mass) suture anchors with number 2 non-
absorbable sutures were inserted into the tuberosity. The
suture tails were placed into the distal 3 cm of the tendon
with a sliding Kessler stitch (Figure 2). The tendon was
advanced to bone with the arm flexed 90°. The remaining
periosteum, tendon sheath, and bursal tissue were sutured to
ment. After wound closure, the arm was placed in a well-
padded posterior plaster splint that maintained the elbow in
90° of flexion and the forearm in 20° of supination. A
dynamic, hinged extension block brace was applied at the
first postoperative visit, approximately 10 days postopera-
tively, in 45° of extension. This dynamic extension block
brace uses elastic bands to allow assisted flexion of the
elbow. It was kept in place for 6 weeks. Range of motion
was advanced to full extension progressively starting at the
third week. Resisted supination and flexion were not
allowed for 12 weeks after the procedure, but light daily
activities were allowed 2 months postoperatively. Strength-
ening exercises were begun at the fourth month.
J Shoulder Elbow Surg
Volume 10, Number 4
RESULTS
The distal biceps tendon was successfully reattached
to the radial tuberosity in all 7 patients. All returned to
their preinjury level of activity and employment by 6
months after surgery. Two of the patients were employed
as heavy laborers. All patients completed a subjective
questionnaire and were pleased with the result. All
reported that they would undergo the surgery again.
Range of motion was normal in 6. One patient
lacked 10° of extension and 10° of pronation com-
pared with the uninjured side.
All of the repaired arms were found to be stronger
in flexion and supination than the uninjured side by
BTE Work Simulator (Baltimore Therapeutic Equip-
ment) testing at the final follow-up. The entire group
averaged 8.1% more flexion strength and 1.9% more
supination strength for the repaired elbow than for the
uninvolved elbow. There were no late complications,
and serial radiographs showed no evidence of het-
erotopic ossification or change in the position of the
suture anchors.
DISCUSSION
Partial ruptures of the distal biceps tendon are gen-
erally not associated with a traumatic event. Four of 10
reported cases in the literature had a history of trau-
ma.2,12,13 In the current study only 2 patients had a
traumatic event. The mean age of patients with a par-
tial rupture of the distal biceps tendon is 54 years in the
literature and 52 years in the current study. This may be
consistent with a degenerative etiology.2,4,8,9 Further-
more, a hypovascular zone in the distal biceps tendon
just proximal to its insertion into the radial tuberosity
and an impingement mechanism between radius and
ulna during pronation have recently been proposed as
causative factors.14 Before the advent of MRI, partial
distal biceps tendon tears went undiagnosed radi-
ographically. MRI is capable of showing the extent of
the tear, as well as tenosynovitis, tendinitis, or bursitis,
which may accompany the tear.6,7
The most common clinical presentation is pain in the
antecubital fossa, which may or may not be attribut-
able to a specific traumatic event. Flexion and supina-
tion strength is usually limited by pain, and swelling
may not be present. Physical examination demonstrates
tenderness at the distal biceps tendon and pain with
resisted flexion and supination. Conservative treatment
was successful in 4 of 10 cases previously reported.5,8
In our study, after an average period of 9.5 months
(range, 7-14 months) of conservative treatment, surgi-
cal treatment was undertaken because conservative
treatment failed in all of the patients. We used a 1-
incision technique with excision of necrotic tendon to
normal tendon substance. We believe good debride-
ment and strong insertion are obtained by detaching
the tendon and then reattaching it with use of bone
suture anchors. This technique has proved successful in
Vardakas et al 379
treating acute and chronic complete ruptures of the dis-
tal biceps.15 The repaired elbows demonstrated 8.1%
more flexion strength and 1.9% more supination
strength in comparison with the uninvolved, nondomi-
nant arm. In 2 previous studies in normal individuals
the difference between dominant and nondominant
strength was 3% and 6%, respectively, for elbow flex-
ion and 8% and 10%, respectively, for supination.1,11
In other studies, after operative repair of complete dis-
tal biceps tendon ruptures, the average flexion strength
and supination strength for the dominant repaired
elbow were 96% to 110.9% and 94.7% to 105%,
respectively, compared with the uninvolved nondomi-
nant elbow.3,10,15 Furthermore, no complications were
encountered in this series.
We believe that surgical excision of degenerative
tendon through a single incision with reattachment
using bone suture anchors is an excellent method of
treatment for painful partial distal biceps rupture.
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