The distal biceps is important for flexing (or bending) your elbow and also for rotating your forearm outwards (supination).
Biceps Tendon (Anatomy)
The biceps tendon starts in the shoulder and attaches down around the elbow joint. In the shoulder it has 2 different origins, one from inside the shoulder joint and the other from a bone outside the joint. These 2 tendons then join and form the main muscle mass in the front of your arm which you can easily palpate. This muscle mass then becomes one single thick tendon (the distal biceps tendon) and attaches to the radial tuberosity which is a bone found around your elbow joint.
When you contract or flex your elbow you can easily palpate this tendon. The distal biceps is important for flexing (or bending) your elbow and also for rotating your forearm outwards (supination). Therefore when this tendon ruptures you lose strength of flexion and supination.
How do patients present?
The overwhelming majority of patients that rupture their biceps tendons are male. The injury usually occurs after a sudden lift or when your elbow is loaded in an unusual way (can be forced into extension). The patients are generally aged between 25 and 65 years of age and often the dominant arm is affected. When the tear occurs you often hear or feel a snap and a tearing sensation. A lump can often be palpated in the lower arm as the tendon retracts around your elbow.
Tenderness is then felt in your elbow crease and bruising can occur within 24 hours. The pain slowly settles but you are generally left with weakness of elbow flexion and weakness of rotating your forearm outwards (the motion used for a screwdriver). When the tendon remains ruptured these actions remain permanently weak.
How is the diagnosis made for Distal Biceps Ruptures?
The diagnosis can generally be made from the patient’s history and physical examination. As mentioned above, bruising is characteristic around the elbow joint, one also finds patients have tenderness around the normal course of the biceps tendon. The biceps tendon when completely ruptured is also very difficult to palpate or feel along its normal course as it often retracts up the arm. If one is unsure of the clinical diagnosis then a more definitive diagnosis can be made with imaging such as an ultrasound or the gold standard test of a MRI scan. Once the diagnosis is confirmed then treatment options can be considered.
How are Distal Biceps Tendon Ruptures Treated?
For the majority of patients a distal biceps rupture causes significant weakness around their elbow. For these reasons surgery is generally recommended so as to restore function around the elbow. Conservative or non operative treatment is generally recommended for those that have very low demands on their elbow with the understanding that there will always be an element of weakness.
How long after I rupture my tendon have I got to have it repaired?
The sooner you are seen after you rupture your tendon the easier it is to repair. Beyond 4 weeks after the injury it is very difficult to repair and the results are not as rewarding. The tendon after the rupture starts to retract up the arm and gets to a stage after 4 to 6 weeks where it can not be brought down to its anatomical position of attachment.
The Operation for Distal Biceps Ruptures
The distal biceps tendon ruptures off the bone called the radius at its proximal end near the elbow joint.
The part of the radius it arises from is called the radial tuberosity. This part of the radius rotates around the other bone in the elbow called the ulna allowing the motion of rotation. The biceps tendon has to be surgically repaired to this anatomical part of the radius to allow full function to occur. The tendon can be repaired in 2 different ways using either one or two incisions. In my practice I prefer to use 2 small incisions to allow the most anatomical repair therefore restoring near to normal function.
The first incision is made in your elbow crease at the front of your arm. This incision is about 3 cm long and through this exposure we find your ruptured tendon.
Sutures are then woven up and down the tendon and these are then used to reattach the tendon to the bone (radial tuberosity).
A second incision is then made at the back of your elbow over the bone called the radial tuberosity. Through this incision we dissect onto the bony attachment site for the tendon, little drill holes are made in this bony prominence for reattachment of the tendon. The biceps is then pulled through the top incision and down to the second incision, the sutures are pulled through the drill holes and the tendon reduced to its normal anatomical position.
Once the tendon is reattached we put your elbow through a normal range of motion to check all is secure and functioning normally.
It is now up to the tendon to heal back to the bone and for your elbow to slowly regain function.
What happens after surgery for Distal Biceps Ruptures?
The surgery generally takes about an hour. Your elbow is placed in a bandage and also a sling to protect the repair. No plaster is necessary. This operation can be performed as a day only or sometimes an overnight procedure. I get you to start moving your elbow the next day to prevent stiffness. The movement you start doing is called passive which means you get your other hand to hold your affected wrist as you move your arm to prevent a load being placed through the repair. I start with 2 exercises which are passive flexion and passive supination during the first 6 weeks as seen in the pictures.
Unfortunately for the majority of the remaining 6 weeks you have to rest your arm in the sling to allow the tendon to heal.
During this 6 weeks you can take your arm out of the sling when sitting down or resting. One can generally do simple tasks such as using keyboards, eating and drinking. No weight heavier than a full coffee cup should be put through your elbow during this time of healing.
After 6 weeks a physiotherapy programme is started so you regain strength and function in your arm. It takes 4 to 6 months for your elbow to recover and feel reasonably normal. Heavy loads should not be put through your elbow in this time.
What is the success rate of surgery?
In my hands most patients are very happy with the operation and are very glad they have had it performed. The majority of patients recover their full range of motion and strength after a 4 to 6 month recovery period. Most patients can return to their pre-injury functional level after this period of time.
What complications can occur with this operation?
The complications after a distal biceps repair are very small but possible. Firstly, if the tendon is of poor quality it maybe irreparable. Some of the other complications include nerve damage as the tendon travels close to major nerves in your arm, blood vessel injury, and rerupture of the tendon. The other major complication that can occur is where your tendon repair heals rapidly causing extra bone to develop and subsequent loss of rotation of your forearm. If this occurs then a second operation is necessary to remove the bone so as to allow the rotation to recur.
Frequently Asked Questions
Q: How long am I in hospital for?
A: Often just one day but maybe overnight depending on how you feel after your general anaesthetic.
Q: How long do I need to wear a sling for?
A: 6 weeks
Q: When can I drive?
A: You cannot drive whilst wearing a sling so not for 6 weeks.
Q: When can I return to work?
A: It really depends on the type of work that you do. If your work is office based and desk work you could expect to be back at work within a week or 2 so long as you had some way of getting there. Any work involving heavy lifting would need to be avoided until 4-6 months after your surgery.