What is the biceps tendon?

The biceps tendon is a bipennate (two-headed) tendon that attaches the biceps muscle to the forearm. Its main function is to supinate (forcefully rotate the palm up) and secondarily to flex the elbow.

What kinds of biceps injuries are there?

There are two primary classes of biceps tendon injuries: biceps tendonitis and complete biceps rupture, both of which are likely the result of the same disorder. The tendon insertion point on the radius has a poor blood supply and therefore can become injured through repetitive use or simply from the aging process. The inflammatory response of the body, which drives tendonitis, is an attempt at healing this tendon but can ultimately cause pain.  Conversely, an acute rupture can occur without any symptoms. Sometimes there is a presenting period of pain in the anterior elbow before the tendon pops, but most of the time there is just a sudden tear of the tendon.

Who gets biceps tendon injuries?

Typically, “weekend warriors” are at the greatest risk of developing biceps tendon ruptures. They are almost always male and between the ages of 35-60. Steroids have also been implicated in biceps ruptures. Biceps tendonitis is less common than acute ruptures.  Biceps tendonitis can be present in men and women and typically causes anterior elbow pain, pain with lifting, and pain with supination. There may or may not be an inciting injury.

How are biceps tendon injuries diagnosed?

A complete rupture is usually obvious if the tendon retracts up into the arm. Oftentimes, however, a tight band of tissue in the arm prevents the tendon from retracting after the injury.   In any case, there will be significant pain, swelling and often subcutaneous bleeding.  An MRI is the most often-used diagnostic tool to get a definitive answer on whether or not the tendon is ruptured.

Tendonitis, on the other hand, is diagnosed with a physical examination. Your physician will look for things like pain with resisted supination, pain when pushing on the biceps tendon, and pain with resisted flexion to indicate biceps tendonitis.  X-rays and MRI are also essential in making a diagnosis and to rule out other problems like radial nerve irritation.

How is biceps tendonitis treated?

If it is caught early, biceps tendonitis can be treated with supervised physical therapy. More than 50% of the time, patients will fail physical therapy and require operative treatment. Surgical treatment of biceps tendonitis consists of removing the remaining biceps tendon from the radius bone and reattaching it as if it were acutely torn.  The rehabilitation protocol is the same after surgical treatment as an acute rupture.  The outcomes for surgical treatment is excellent in almost all cases.

How are biceps ruptures treated?

Biceps ruptures are usually treated surgically.  Non-surgical evaluations of patients show that not repairing a biceps tendon at the elbow can result in up to a 70% loss in supination strength and a 40% loss of elbow flexion strength. With the advent of new surgical techniques and hardware, surgeons can reattach the biceps through a drill hole in the bone with excellent results.

Complications of surgical treatment increase as time passes between the injury and surgery.  Therefore, time is of the essence in determining the success of surgical treatment for acute ruptures.

Can chronic, long-standing biceps tendon ruptures be treated surgically?

Yes; however, most orthopedic surgeons won’t treat a biceps tendon rupture after 2-3 weeks.  We have treated patients as far-removed from the date of injury as 6 years.  Ideally, we would treat a biceps tendon rupture earlier than that, but they present late for a myriad of reasons. For chronic biceps tendon ruptures, we use a tendon graft, either from the patient’s leg or more commonly from a tissue bank.  The primary indications for surgical treatment late following injury is continued pain and/or weakness. In these cases, the cosmetic deformity may persist, but strength will improve.

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