Distal Biceps Tendon Rupture Management
Surgical repair is recommended for complete distal biceps tendon ruptures in active patients to optimize functional outcomes, but non-operative management may be appropriate for select patients with limited functional demands. 1, 2
Diagnosis
- MRI without contrast is the most accurate imaging modality for diagnosing distal biceps tendon tears, with superior accuracy (86.4%) compared to ultrasound (45.5%) 3, 4
- The FABS (flexion-abduction-supination) MRI view provides optimal visualization of the distal biceps tendon by imaging the patient in prone position with elbow flexed at 90°, shoulder abducted, and forearm supinated 3, 4
- Plain radiographs should be obtained first to rule out associated fractures or bony abnormalities 4
- Physical examination typically reveals palpable and visible deformity of the distal biceps muscle belly with weakness in flexion and supination 1
Treatment Algorithm
Complete Ruptures in Active Patients
- Early surgical reattachment to the radial tuberosity is recommended for optimal results in active patients 1, 5
- Surgical repair provides improved strength in forearm supination and elbow flexion compared to non-operative management 5
- Without surgical repair, patients may experience up to 40% loss of supination strength, 47% loss of supination endurance, and 21-30% loss of flexion strength 6
- The re-rupture rate following surgical repair is low at approximately 1.5%, with most re-ruptures occurring within 3 weeks of surgery 7
Surgical Techniques
- Modified two-incision technique is widely used, but anterior single-incision techniques may be equally effective if the radial nerve is protected 1
- Biomechanical studies show that suspensory cortical button technique exhibits maximum peak load to failure 5
- Postoperative rehabilitation should emphasize protected return of motion for the first 8 weeks after repair 1
Non-operative Management Considerations
- Non-operative management may be appropriate for patients with limited functional demands 2
- Case reports suggest that some patients can regain normal strength and function through structured rehabilitation focusing on strengthening and stretching elbow flexors and supinators 2
- Initial strength deficits of 17-21% in flexion and 13-19% in supination have been shown to return to normal limits with appropriate rehabilitation in select cases 2
Special Considerations
- Chronic ruptures (>4 weeks) may require reconstructive techniques due to tendon retraction and scar formation 1, 6
- Options for chronic rupture reconstruction include semitendinosus autograft and Achilles tendon allograft 6
- Partial tears are statistically more common than complete ruptures in women 7
- Surgical complications may include sensory and motor neurapraxia, infection, and heterotopic ossification 5
Common Pitfalls to Avoid
- Failing to distinguish between partial and complete tears, which requires accurate imaging (preferably MRI) 4
- Relying solely on ultrasound for diagnosis, which has limitations in detecting partial tears and tendinopathy 3, 4
- Delaying treatment decision, as early surgical repair provides better outcomes for complete ruptures in active patients 1
- Inadequate protection during early rehabilitation, as most re-ruptures occur within 3 weeks of surgery 7