What is the first line treatment for a patient with a bicep tendon tear?

First-Line Treatment for Bicep Tendon Tear

Conservative management with physical therapy and anti-inflammatory medications (NSAIDs) should be the initial treatment approach for bicep tendon tears, regardless of whether the tear is proximal or distal, complete or partial. 1

Treatment Algorithm by Location and Tear Type

Proximal Long Head Biceps Tendon Tears

For complete proximal long head biceps tendon tears, conservative management is the definitive first-line treatment. 1

• The intact short head of the biceps maintains adequate elbow flexion and supination strength, making surgery unnecessary in most cases 1
• This injury does not pose an immediate threat to life, limb, or long-term function 1, 2
• Isolated complete ruptures of the long head are actually the least common biceps injury pattern 2
• Conservative treatment typically results in good outcomes without surgery 1

Initial conservative regimen includes:

• Physical therapy focused on maintaining range of motion and strengthening the remaining functional biceps components 1
• NSAIDs for pain and inflammation control 1
• Activity modification during the acute phase 3

Distal Biceps Tendon Tears

For distal biceps tendon tears, initial conservative treatment should still be attempted first, though surgical intervention becomes more likely after failed conservative management. 4, 5

• Conservative treatment is appropriate for elderly patients, those with very low physical activity levels, patients with contraindications to surgery, and cases of mild partial tendon tears 4
• At least 65 out of 86 patients in systematic review data received a trial of conservative treatment before proceeding to surgery 6
• Of the 14 patients who underwent surgery for partial distal tears, all had failed nonsurgical treatment first 5

Conservative management includes:

• Exercise therapy and NSAIDs as the foundation 3
• Physical therapy focusing on maintaining elbow and forearm function 4
• Activity modification to avoid eccentric loading 7

When to Consider Surgical Referral

Surgery becomes an option after failed conservative treatment, particularly for:

• Healthy, active individuals with distal biceps tendon ruptures who fail 6-12 weeks of conservative management 7, 6
• Complete distal tears in patients requiring full supination and flexion strength for occupational or athletic demands 7
• Partial tears causing persistent symptoms despite adequate conservative trial (typically at least 65 patients required failed conservative treatment before surgery) 6

Early surgical repair after acute injury is only a weak recommendation and should not supersede the initial conservative approach. 3

Critical Pitfalls to Avoid

• Do not rush to surgery: Even for complete tears, conservative management should be the initial approach unless the patient is a high-demand individual who has failed conservative treatment 1, 4
• Avoid serial surgical revisions: Repeated procedures lead to deteriorating outcomes with increased morbidity 1
• Do not assume all tears require surgery: The intact short head (in proximal tears) or the potential for functional adaptation (in distal tears) often provides adequate function 1

Expected Outcomes with Conservative Management

• Proximal tears: Good functional outcomes due to intact short head maintaining elbow flexion and supination 1
• Distal tears: Variable outcomes, with some patients achieving acceptable function and others requiring delayed surgical intervention 4, 6
• Surgical outcomes when needed: 94% satisfactory clinical outcomes after failed conservative treatment 6

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with:

• Plain radiographs first to exclude fractures or bony abnormalities 8, 2
• MRI without contrast as the gold standard (86.4% accuracy vs 45.5% for ultrasound) 8, 2
• FABS view on MRI for optimal distal biceps visualization 8, 2