What is it?
The biceps muscle helps to flex the elbow and rotate the forearm palm up. The muscle runs from the shoulder, down the front of the arm, and attaches just below the elbow. Tendons help attach muscle to bone. The biceps tendon can tear both in the shoulder and more rarely at the attachment just below the elbow. When the biceps tendon tears just below the elbow, the injury is known as a “distal biceps” tendon tear. The injury typically occurs when a force is applied to a flexed elbow in activities like weight lifting, a ball being ripped out of an athlete’s hand in sports like football or rugby, and even doing something simple, such as lifting a heavy item off the floor.

Symptoms

• A sudden, sharp pain and tearing sensation in the arm
• A defect felt where the biceps used to run in front of the elbow
• A bulge or swelling in the upper arm, where the torn biceps muscle has retracted
• Swelling and bruising in the arm, especially in and around the front of the elbow
• Weakness and limited flexion of the elbow, and rotation of the forearm

Sports Evaluation and Treatment
If a distal biceps rupture is suspected, the athlete should be seen by a physician for evaluation. A sports medicine physician will perform a history of the injury and a thorough physical exam. The physical exam will help to test movement, strength, and sensation of the arm. Further testing may include imaging like x-rays, ultrasound, or magnetic resonance imaging (MRI).

Initially, treatment may include ice, compression, and pain management. Imaging can help to clarify the extent of the injury. Ultimately, surgery will be considered to reattach the biceps tendon, especially for younger or more active patients. If surgery is chosen as treatment, it will likely be done within a few weeks, as scarring and shortening of the biceps muscle can occur quickly. Regardless of whether surgery is done or not, rehabilitation will be an important part of the athlete’s recovery.

There are no specific recommendations to prevent a biceps tear, but maintaining equal and adequate strength and flexibility for sports participation is recommended. Using proper technique during lifting or when playing certain sports can also help to prevent biceps injuries. Smoking and steroids can weaken tendons, and they should be avoided for optimal tendon health.

Return to Play
Return to play for most distal biceps ruptures, especially those that undergo surgical repair, will take several months. Rehabilitation will be required before athletes return to full sport activities.

AMSSM Member Authors: Kyle V. Goerl, MD; Cindy J. Chang, MD

References
Baratz M, King GJW, Steinmann S. Repair of distal biceps ruptures. J Hand Surg Am. 2012;37(7):1462–6. doi:10.1016/j.jhsa.2012.02.008.
Dillon MT, King JC. Treatment of chronic biceps tendon ruptures. Hand (N Y). 2013;8(4):401–409. doi:10.1007/s11552-013-9551-4.
Miyamoto RG, Elser F, Millett PJ. Distal biceps tendon injuries. J Bone Joint Surg Am. 2010;92(11):2128–38. doi:10.2106/JBJS.I.01213.
Sarda P, Qaddori A, Nauschutz F, Boulton L, Nanda R, Bayliss N. Distal biceps tendon rupture: current concepts. Injury. 2013;44(4):417–20. doi:10.1016/j. injury.2012.10.029. Stevens K, Kwak A, Poplawski S. The biceps muscle from shoulder to elbow. Semin Musculoskelet Radiol. 2012;16(4):296–315. doi:10.1055/s-0032-1327004.