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Distal Biceps Tendon Tear

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Distal Biceps Tendon Tear

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Distal Biceps Tendon Tear can be avulsed partially or completely either at the musculotendinous junction or at the radial tuberosity.

Avulsions of the biceps tendon at the elbow occur almost exclusively in males, and the most common scenario is a rupture of the dominant elbow of a muscular male in his fifth decade of life.

Distal Bicep Tendon Tear ruptures are classified as being complete or partial.

Risk Factors include:

  1. Male.
  2. A history of cigarette smoking.
  3. Anabolic steroid use.
  4. Statin use.

Distal Bicep Tendon Tear Causes

Biceps ruptures typically involve a sudden contracture of the biceps against a significant load with the elbow in 90 degrees of flexion.

The incidence of rupture is 7.5 times greater in patients who smoke than in those with no history of smoking.

The tendon and its aponeurosis degrades with time, ultimately resulting in a spontaneous rupture of the tendon, often occurring in the hypovascular zone between the proximal and distal blood supply.

Distal Bicep Tendon insertion
Distal Bicep Tendon insertion

Distal Bicep Tendon Blood Supply

The distal tendon of biceps brachii is a paratenon-covered extrasynovial tendon with three zones of blood supply as described by Seiler et al.

  1. The proximal zone receives its blood supply from the brachial artery by branches that extend across the musculotendinous junction and continue distally within the paratenon covered portion of the tendon. These branches supply the main part of the tendon.
  2. The distal zone receives a separate blood supply by branches from the posterior interosseous recurrent artery and is limited to the tendon enthesis on the bicipital tuberosity.
  3. The middle zone is covered in a thinner paratenon and receives vessels from both sources, but only through its paratenon cover.
See Also: Elbow Anatomy
Distal Bicep Tendon Blood Supply
Distal Bicep Tendon Blood Supply Zones

Clinical Evaluation

Clinical findings vary depending on the extent of the rupture; whether it is partial or complete, these include:

  1. The typical history includes a report of a sharp, tearing pain concurrent with an acute injury in the antecubital fossa and the sensation of a “pop” within the elbow.
  2. The objective findings may include ecchymosis in the antecubital fossa, a palpable defect of the distal biceps, loss of strength of elbow flexion and grip, but especially a loss of forearm supination strength.
  3. Active and passive ROM may remain within normal limits, but a definitive decrease in strength during Manual Muscle Test for elbow flexion and supination is present.

Distal biceps tendon tear can be identified using the hook test.

The Ruland biceps squeeze test, similar to the Thompson test for the Achilles tendon, may be used to assess for a distal biceps tendon rupture and has a high sensitivity. With the patient’s elbow flexed to 60-80 degrees, squeeze the biceps and observe for forearm supination.

Most biceps tendon ruptures involve the avulsion of the bicipital (radial) tuberosity, a diagnosis made using radiographs, magnetic resonance imaging (MRI), or computed tomography (CT) scans.

See Also: Hook Test
distal bicep tendon tear on MRI

Distal Biceps Tendon Repair

Although distal bicep tendon tear treatment may be non-operative, distal bicep tendon tear surgery repair is the preferred method of treatment for both complete and partial bicep tears.

Postoperatively, the elbow is protected for 6–8 weeks, after which unrestricted range of motion and gentle strengthening exercises are initiated. Return to unrestricted activity is usually not allowed until nearly 6 months of healing has passed.

Postsurgical rehabilitation consists of a progressive return of elbow extension combined with passive elbow flexion with minimal immobilization. Full ROM is expected after 8 weeks, after which strengthening exercises are integrated.

distal bicep tendon surgery
Distal biceps tear surgery


  1. McReynolds IS: Avulsion of the insertion of the biceps brachii tendon and its surgical treatment. J Bone Joint Surg 45A:1780–1781, 1963.
  2. Hempel K, Schwencke K: About avulsions of the distal insertion of the biceps brachii tendon. Arch Orthop Unfallchir 79:313–319, 1974
  3. Kandemir U, Fu FH, McMahon PJ: Elbow injuries. Curr Opin Rheumatol 14:160–167, 2002.
  4. D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW. Repair of distal biceps tendon ruptures in athletes. Am J Sports Med. 1993 Jan-Feb;21(1):114-9. doi: 10.1177/036354659302100119. PMID: 8427351.
  5. Morrey BF, Askew LJ, An KN, et al: Rupture of the distal tendon of the biceps brachii: a biomechanical study. J Bone Joint Surg 67A:418–421, 1985.
  6. Ramsey, ML: Distal biceps tendon injuries: diagnosis and management. J Am Acad Orthop Surg, 7:199, 1999.
  7. Safran, MR, Graham, SM: Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res, 404:275, 2002
  8. O’Driscoll, SW, Goncalves, LBJ, and Dietz, P: The hook test for distal biceps tendon avulsion. Am J Sports Med, 35:1865, 2007.
  9. Sawidou, C, and Moreno, R: Spontaneous distal biceps tendon ruptures: are they related to statin administration? Hand Surg, 17:167, 2012.
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