How should a chronic complete biceps tendon rupture (more than 4–6 weeks old) be treated in an otherwise healthy, active adult?

Treatment of Chronic Complete Biceps Tendon Rupture

For an otherwise healthy, active adult with a chronic complete biceps tendon rupture (>4-6 weeks old), surgical reconstruction is the treatment of choice to restore strength and function, using either direct repair when sufficient tendon quality and excursion exist, or graft reconstruction when the native tendon has retracted excessively. 1, 2, 3

Surgical Decision Algorithm

When Direct Repair Is Feasible

• Direct anatomical repair without graft augmentation should be performed when adequate residual tendon length and quality are present, even in chronic tears delayed up to 121 days (mean across studies). 2
• Direct repair of chronic tears yields acceptable patient satisfaction, functional outcomes, and range of motion comparable to acute repairs. 2
• The rerupture rate after direct repair of chronic tears is low at 3.19%. 2

When Graft Reconstruction Is Required

• Graft reconstruction using semitendinosus autograft or Achilles tendon allograft is indicated when native tendon retraction and extensive scar formation preclude anatomical repair. 1, 4
• Successful reconstruction has been documented even 4 years post-injury using single-incision technique with free semitendinosus autograft and EndoButton fixation. 1
• Chronic injuries (defined as ≤18 months in the literature) are routinely managed with surgical tendon reconstruction. 1, 4

Surgical Technique Considerations

Multiple fixation methods are available including:

• Transosseous tunnels
• Suture anchors
• Interference screws
• EndoButton fixation 1, 4

The literature shows no consensus on superiority of one technique over another; all demonstrate excellent functional restoration. 1, 4

Postoperative Management

Early Phase (0-2 weeks)

• Use a protective device that limits excessive strain but avoid complete immobilization to prevent muscular atrophy. 5
• Patient compliance with weight restrictions is essential, as documented reruptures occur with protocol non-compliance. 5

Protected Activity Phase (2-6 weeks)

• Mobilization should begin by 2-4 weeks postoperatively using a protective device. 5
• Active motion is encouraged while maintaining weight restrictions. 5

Return to Activity

• Plan return to sports between 3-6 months post-surgery for surgically treated tendon repairs. 5

Conservative Management: Limited Role

Conservative treatment is restricted to:

• Elderly patients
• Individuals with very low physical activity levels
• Patients with absolute contraindications to surgery
• Mild partial tears only 4

While two case reports document strength recovery with structured physical therapy alone 6, this contradicts the established evidence that nonoperative management results in 40% loss of supination strength, 47% loss of supination endurance, and 21-30% loss of flexion strength. 1 These isolated cases should not guide standard practice for active adults.

Critical Pitfalls to Avoid

• Do not delay surgical consultation beyond 4-6 weeks, as progressive tendon retraction may necessitate more complex graft reconstruction rather than simpler direct repair. 1, 2
• Avoid complete immobilization postoperatively, which leads to muscular atrophy, but equally avoid premature heavy loading that risks rerupture. 5
• Be aware that transient lateral antebrachial cutaneous nerve (LABCN) palsy occurs in 12.1% of chronic repairs versus 7.9% in acute repairs, though this complication is overwhelmingly temporary. 2
• Major complications including posterior interosseous nerve palsy and radioulnar synostosis are rare but require meticulous surgical technique. 3

Diagnostic Confirmation Before Surgery

MRI in the flexion-abduction-supination (FABS) position is the gold standard, achieving 86% accuracy for distal biceps pathology, and is particularly helpful for chronic ruptures to assess tendon quality and retraction. 7, 3