Distal biceps rupture
What is distal biceps rupture?
Bicep muscle is a muscle located on the front of the upper arm that attaches to the bones of shoulder and elbow joint. It plays an important role in bending of elbow and rotation of the forearm (Supination – palm facing up). It is attached to the forearm (Radial tuberosity) by a tendon (a strong cord of fibrous tissue that attaches muscles to the bones). Distal Biceps rupture or distal biceps avulsion is a tear of the tendon of biceps muscle at its insertion in the forearm. It is caused by a sudden injury to the tendon during lifting heavy load beyond one’s capacity or sudden straightening of the elbow to reach out something.
Distal biceps rupture accounts for 10 % of all biceps ruptures. It is common in weightlifters. It occurs usually in the dominant elbow of men (86%) and of age 40-49 years (93%). The risk factors of biceps tendon tears are smoking, anabolic steroids and corticosteroid injections that weaken the tendon of the body. The rupture can be partial or complete.
What are the symptoms of distal biceps rupture?
When bicep tendon is torn, the muscle will roll and pop up proximal to elbow crease. You will feel severe pain immediately after rupture which may subside after two weeks of injury. Swelling and bruising can be seen in the front of the elbow. Weakness will be the only symptom after few weeks, most patients feel 30% loss of flexion strength and around 50% loss of supination strength. A cosmetic deformity can also be seen, which is called “reverse popeye sign” as the muscle bulk moves towards shoulder. A gap is also felt in the front of the elbow.
How is it diagnosed?
After listening to your symptoms and your medical history, your orthopaedic surgeon will examine your elbow for the biceps tendon and check its strength. He may recommend an X-ray to rule out fractures in the bones in this area. Your surgeon usually asks for MRI/ultrasound scan to confirm the diagnosis.
What happens if nothing is done?
If it is left untreated, pain vanishes after 2 to 4 weeks of the rupture. There will be a significant loss of function of the elbow while bending or twisting the forearm. In some patients the retracted end of tendon becomes inflamed and could cause pain with movement and tender to touch. A chronic cosmetic deformity is also seen. The surgery becomes complicated in patients who opt for late treatment.
How is it treated?
Distal biceps rupture needs surgical treatment. Conservative treatment is recommended for old aged people with fewer requirements, in some cases where non-dominant elbow is injured or in whom surgery is contradicted. It involves rest, immobilization by a sling, anti-inflammatory medicines and physical therapy.
Surgery is indicated in
- Complete rupture
- Partial rupture more than 50%
- The partial rupture that does not respond to conservative treatment
- Young adults who are involved in contact sports/weight lifters/cage fighters
What are the non-operative treatments?
The non-operative treatment is indicated in old people who have a sedentary lifestyle.
- Rest- your surgeon will advise you take rest and avoid lifting weights to manage your pain and swelling. Polysling is applied on your arm for a couple of weeks.
- Cold packs- ice packs or crushed ice in a cloth or a bag of frozen peas can be applied on the affected site for 15- 20 minutes twice or thrice a day to help with pain and swelling.
- Medicines-painkillers like paracetamol or codeine are prescribed to manage pain. Anti-inflammatory medicines like aspirin or ibuprofen are given to control pain and swelling for few days.
- Physical therapy– after the pain reduces, your surgeon will advise you to see a physiotherapist to strengthen your muscles in this area and regain the range of motion and function.
What does the operation involve?
The main goal of surgery is to repair/reconstruct the tendon to the forearm bone and restore the function of the arm. Surgery should be performed in 2- 3 weeks after the injury to have better results.
- The operation is conducted as a day-case procedure under general anaesthesia; an incision is made at the front of the elbow to reattach the tendon to the forearm bone.
- Sutures are used to knit the tendon in an interlocking manner to attach the tendon on the bone. Suture anchor or endobutton is used to fix the tendon to the bone.
- In chronic ruptures to bridge the gap between retracted tendon and bone, tendon graft is used.
- The skin is then stitched with absorbable sutures, a hinged elbow brace is applied to the elbow. The operation takes 1- 2 hours and most patients are discharged on the same day of operation.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- Before discharge, your physiotherapist will teach you gentle exercises of fingers, wrist, elbow and the shoulder. This is necessary to prevent stiffness and to maintain the strength of the muscles.
- The bulky bandage could be removed in 48hrs and dressings over the wound kept clean and dry for 2 weeks.
- The patient is reviewed at 2 weeks and referred for physiotherapy.
- The wound should be massaged (typically after 2 weeks) using the moisturizing cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications and helps the scar to mature.
The physical therapy after distal biceps repair begins immediately after surgery. The sling is worn for 2 weeks and the brace is worn for 4-6 weeks. Rehabilitation starts with gentle exercises at 2 weeks and is progressed to strengthening exercises around 6-8 weeks. It is advisable to avoid contact sports or any injury to the affected area for 4-6 months. This will be guided by your surgeon and the duration may increase or decrease based on severity/chronicity of injury and method of reconstruction.
Are there any risks?
- Lateral cutaneous nerve of forearm injury – Numbness of the outer forearm (usually resolve in 3-6months)
- Posterior interosseous nerve injury – finger drop (usually resolve in 3-6months)
- Damage to blood vessels
- New bone formation
- Repair failure (uncommon)
What are the results of the operation?
The outcome of the surgery is excellent with minimal serious complications (<1%). The outcome following this surgery depends on severity/chronicity of the injury, treatment involved and adherence to physiotherapy. However is more predictable in the author’s experience.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 4-6 months and you should be able to resume driving in 6-12 weeks. The above time line could vary based on the severity of injury and the treatment modality. Your physician will be able to advise you.
30 year old gentleman, ruptured his left distal biceps in Gym (red arrow) and presented with weakness in elbow flexion and supination. He underwent distal biceps repair using endobutton/fibrewire and returned back to his preinjury level of activities in 6 months.