A Pop In Your Elbow (Distal Biceps Tendon Rupture)

Summer is here, and with it are many outdoor activities, adventures, and possibly some heavy lifting.  I recently had a patient who was on a camping trip and attempted to move a heavy picnic bench; he bent at the elbows, pulled against the bench, and . . . POP!  Something seemed to explode in his elbow; that something was his biceps tendon. 

His arm looked like the photo to the left.  He had swelling and bruising in his elbow and forearm, and a bulge in the upper part of his arm caused by the recoiled biceps muscle.  He was weak with certain motions of the elbow and forearm.
The main cause of a distal (at the elbow, as opposed to the shoulder) biceps tendon rupture is sudden injury.   It occurs when the elbow is forced straight against resistance.   A "pop" is often felt at the time of injury.  Bruising, swelling, and pain are common initial symptoms, as is weakness in bending the elbow and twisting (supinating) the forearm    Diagnosis is made with a clinical exam of your elbow by your doctor, with MRI sometimes necessary for confirmation of the diagnosis.  Pain in the forearm and elbow may be very severe initially, but usually subsides after a week or two.  It is important to seek the consultation of an orthopaedic surgeon early as these injuries need to be repaired within the first two or three weeks after injury, if surgical repair is deemed necessary.

The biceps muscle helps you bend (flex) your elbow and rotate (supinate) your forearm.  The biceps attaches at the elbow to the radius bone at a location termed the radial tuberosity.  A ruptured distal biceps tendon will cause your arm to be 40% weaker in supination (rotating the forearm from palm down to palm up) strength and 30% weaker in flexion strength.  

Once torn, the biceps tendon at the elbow will not heal back to the bone on its own.  

Generally, a distal biceps rupture in a healthy, active person is treated surgically with repair. Nonsurgical treatment, however, may be the best option for patients who are elderly and inactive, or who have medical problems that make them high-risk for relatively minor surgery.

Patients must weigh the decision to proceed with nonsurgical treatment carefully, because restoring arm function with later surgery may not be possible.

The torn tendon should be repaired during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten.  While other options are available for patients requesting late surgical treatment for this injury, they are more complicated and generally less successful.

I typically use a single-incision technique to reattach the ruptured distal biceps tendon to the radius with a metal button made specifically for the procedure.  The x-ray to the left shows a repair I recently performed; the metal button provides excellent fixation of the tendon to the bone.  Some doctors prefer to use two incisions and suture anchors or screws; there are pros and cons to each approach and repair technique.  The most important considerations are a strong repair of the tendon to the bone and protection of the nearby nerves and blood vessels.

Almost all patients have full range of motion of their elbow at their final follow-up visit with their surgeon.  As with all surgery, there risk of complications exist.  For distal biceps repair, complications are generally rare (6-9% incidence) and temporary.  These include temporary numbness of the forearm and growth of new/extra bone at the site of tendon attachment.  Be sure to talk to your doctor about the surgical risks.  After time and rehabilitation, it is reasonable to expect full return of function and strength.   

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Seattle, WA 98122
(206) 386-2600

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