New News on the Treatment of Distal Biceps Tendon Ruptures

The biceps muscle of the upper arm is the muscle the cartoon character Popeye was always flexing to show his strength after eating a can of spinach. This muscle has an important role in bending the elbow. Ruptures of the biceps tendon at the elbow can be very disabling and often require surgical repair or reconstruction.

In this review article, hand surgeons from the University of Pittsburg Department of Upper Extremity Reconstructive Surgery provide an update on this problem. The “new news” about distal biceps tendon injuries has come about for three reasons:

1) Technology has made it possible to discover new understanding about the biceps tendon anatomic form and function.

2) Thirty years of improvements have been made on surgical techniques to reduce complications following surgery and to improve strength of the repair (referred to as tendon-to-bone fixation).

3) Studies over the last 30 years (since the mid-1980s) have given us enough data to see long-term results of both conservative (nonoperative) care and surgical management.

Form and function (mentioned in number one above) refers to the structure of the biceps tendon, “footprint” (where and how it attaches to the bone), and biomechanics (how it contracts and relaxes to create movement). Data mentioned in number three above has been collected on both acute and chronic injuries as well as partial and complete tears of the distal biceps tendon.

Through a series of illustrations, photos, and imaging studies (MRIs, X-rays), the authors bring us up-to-date on the basic science of biceps tendon, repair biology (how it heals), and the diagnosis of partial versus complete tears. The same approach is used to describe current methods of treatment. Here are a few highlights of new findings that may be of interest to surgeons:

  • The distal biceps tendon is two unique and separate units. This understanding replaces the former belief that there were two units that blended together to form one at the insertion point to the bone.
  • Accurate reattachment of the two tendon subunits to the bone must be done carefully. Anterior placement (forward of the original footprint) is no longer preferred. To gain the best results, the tendon must be reattached at its original anatomic site.
  • A posterior surgical approach is recommended. This technique gives the surgeon access to the footprint and allows for placement of the anchor or button (a fixation device used to hold the tendon in place) in an anatomic position.
  • Many patients heal with additional bone forming in the soft tissue. This effect called intrasubstance heterotopic bone does not seem to adversely affect final outcomes.
  • Partial tears are still treated conservatively at first; surgical repair can be saved for later if the nonoperative approach fails to give the desired results. Patients can expect some loss of strength and motion of the forearm/elbow with conservative care.
  • Chronically torn distal biceps tendons should be repaired with the elbow fully flexed (bent); this technique has been shown to decrease the need for a tendon graft.

    In addition to the details listed above, the reader will find information in this article about complications, complication rates, advice regarding surgical techniques, and pros and cons of conservative care versus surgical intervention. Summaries of treatment results from past studies on this topic of distal biceps tendon injuries and treatment are also provided.