What is the appropriate treatment and management for a patient with a torn bicep?

Management of Biceps Tendon Tear

For a torn bicep, immediately obtain plain radiographs followed by MRI to distinguish between partial versus complete tears and proximal versus distal location, as this determines whether surgical repair is indicated—complete distal biceps tears in active patients warrant early surgical repair to restore supination and flexion strength, while proximal tears and partial tears may be managed conservatively initially.

Initial Diagnostic Approach

Imaging Protocol

• Obtain plain radiographs first with minimum 3 views (AP in internal/external rotation plus axillary or scapular-Y view) to exclude associated fractures, glenohumeral dislocation, or bony abnormalities 1, 2, 3
• MRI without contrast is the definitive next step, with 86.4% accuracy for biceps tendon tears compared to only 45.5% for ultrasound 1, 2, 3
• Use the FABS view (flexion-abduction-supination) on MRI for optimal visualization—patient positioned prone with elbow flexed 90°, shoulder abducted, and forearm supinated to visualize the entire tendon on a single image 1, 2, 3
• Ultrasound is only acceptable when MRI is contraindicated, but has significant limitations in detecting partial tears and tendinopathy 1, 2, 3

Critical Clinical Examination Findings

• Inspect for the "Popeye" deformity (visible bulge in the upper arm from retracted muscle belly), which indicates complete proximal long head biceps rupture 4
• Palpate for well-localized tenderness in the antecubital fossa (distal tears) or anterior shoulder (proximal tears) that reproduces the patient's pain 2
• Assess for muscle atrophy, asymmetry, swelling, and erythema 2
• Perform physical maneuvers that simulate tendon loading to reproduce pain 2
• Complete neurovascular examination is mandatory to rule out associated nerve injuries 4

Treatment Algorithm Based on Tear Location and Completeness

Complete Distal Biceps Tendon Rupture

Surgical repair is strongly recommended for healthy, active patients:

• Early surgical repair (within weeks, not months) provides improved supination strength restoration and, to a lesser degree, elbow flexion strength 5
• Rupture causes an average 40% loss of supination strength, 47% loss of supination endurance, and 21-30% loss of flexion strength if left untreated 6
• Surgical techniques include suspensory cortical button (maximum peak load to failure), suture anchors, or interosseous screws 5
• Delay in surgical intervention increases complication risk including heterotopic ossification, nerve injury, and rerupture 7
• Chronic cases (>18 months) may require reconstructive techniques using semitendinosus autograft or Achilles allograft when native tendon has retracted extensively 6

Partial Distal Biceps Tendon Tears

Initial conservative management is appropriate, but has high failure rate:

• 55.7% of patients attempting nonoperative management ultimately require surgery 8
• MRI-diagnosed tears >50% are predictive of failing conservative treatment (odds ratio 3.0) and should prompt earlier surgical consideration 8
• High-need patients (defined by occupational demands) are significantly more likely to report ideal recovery with surgery compared to conservative management (odds ratio 11.58) 8
• Conservative treatment does not negatively affect outcomes if subsequent surgery becomes necessary 8

Conservative Management Protocol for Partial Tears

• Relative rest to decrease repetitive loading of the damaged tendon 2
• Oral NSAIDs for pain and inflammation control 2
• Monitor closely for progression or persistent symptoms warranting surgical intervention 8

Proximal Long Head Biceps Tendon Tears

Conservative management is often successful:

• Most proximal tears can be managed nonoperatively, especially in older or less active patients 4
• Functional deficits are typically less severe than distal tears 5
• Surgical options (tenotomy or tenodesis) exist but evidence for superiority is insufficient 3

Surgical Complications to Counsel Patients About

• Sensory and motor neurapraxia (particularly posterior interosseous nerve with single-incision anterior approach) 5, 7
• Heterotopic ossification (more common with two-incision technique, can limit forearm rotation) 5, 7
• Infection 5
• Rerupture (uncommon but risk increases with delayed repair) 7
• Heterotopic ossification requiring surgical resection can be performed once mature on radiographs, with good functional restoration possible 7

Common Pitfalls to Avoid

• Failing to distinguish between partial and complete tears—this requires MRI, not clinical examination alone 2, 3
• Relying solely on ultrasound when MRI is available, as ultrasound misses many partial tears 1, 2, 3
• Delaying surgical referral for complete distal tears in active patients, as delay increases complications and may necessitate complex reconstruction rather than primary repair 7, 6
• Missing associated pathologies including rotator cuff tears, SLAP lesions, or pulley lesions that may require concurrent treatment 1
• Underestimating functional deficits in patients with high occupational demands who attempt conservative management of partial tears 8

Postoperative Rehabilitation

• Early return to motion and activities of daily living is the current trend 5
• Most patients regain near-normal upper extremity motion and function and can return to preinjury activities 7