Distal Biceps Tendon Rupture
Distal biceps tendon rupture is a significant upper extremity injury that results in substantial weakness of forearm supination and, to a lesser degree, elbow flexion. It is far less common than proximal biceps ruptures but carries greater functional consequence. Surgical repair within 2–4 weeks of injury restores near-normal strength and function in active patients, making prompt diagnosis and referral essential. At Maryland Orthopedic Specialists, our fellowship-trained surgeons perform distal biceps repair using proven techniques with consistently excellent outcomes.
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What is distal biceps tendon rupture?
The distal biceps tendon inserts on the radial tuberosity, the rough posteromedial prominence of the proximal radius. This insertion provides the mechanical advantage for forearm supination (supination strength decreases approximately 40–50% after rupture) and contributes to elbow flexion strength (~20–30% loss).
The distal biceps tendon inserts on the radial tuberosity, the rough posteromedial prominence of the proximal radius. This insertion provides the mechanical advantage for forearm supination (supination strength decreases approximately 40–50% after rupture) and contributes to elbow flexion strength (~20–30% loss).
Mechanism of injury: The classic mechanism is a sudden eccentric load applied to a partially flexed, supinated elbow. This occurs most commonly while lifting heavy objects, catching a falling load, or during weightlifting (deadlifts, curls). The tendon fails at its insertion on the radial tuberosity, where vascularity is poorest.
Epidemiology: Distal biceps ruptures occur almost exclusively in men aged 40–60 years. Risk factors include smoking, anabolic steroid use (associated with tendon degeneration), and prior local corticosteroid injection. Complete ruptures are far more common than partial tears.
Anatomy of weakness: The biceps is the primary supinator of the forearm (ahead of the supinator muscle itself) and a secondary elbow flexor. Because the brachialis and brachioradialis compensate for flexion, supination weakness is the dominant functional deficit after rupture.
Symptoms — do you recognize these?
- Sudden sharp pop or tearing sensation at the antecubital fossa with acute injury
- Immediate pain in the anterior elbow and proximal forearm
- Swelling and bruising in the antecubital fossa and distal arm
- Proximal retraction of the biceps muscle belly — the "Popeye deformity" — may be visible or palpable, though it is less dramatic than with proximal biceps ruptures
- Supination weakness — the dominant functional complaint; difficulty turning doorknobs, screwdrivers, or using tools
- Elbow flexion weakness (less prominent due to brachialis compensation)
- A palpable defect or absence of the distal tendon in the antecubital fossa
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How we diagnose it
Clinical Examination
Hook test (most sensitive clinical test): The patient actively supinates the forearm to 90° and flexes the elbow to 90°. The examiner hooks an index finger into the antecubital fossa from the lateral side, attempting to "hook" under the distal biceps tendon. If the tendon is intact, a distinct cord is palpable. If the tendon is ruptured, the finger slides medially through soft tissue without engaging a tendon cord. Sensitivity approximately 81–100%; specificity ~100%. This is the single most reliable physical examination maneuver for distal biceps rupture.
Biceps squeeze test: Squeezing the biceps muscle belly with the elbow at 90° should produce passive supination if the tendon is intact; failure to supinate suggests rupture (analogous to the Thompson test for Achilles).
Supination fatigue test: Resisted supination against examiner resistance. Weakness is expected but the test is less specific.
Imaging
Ultrasound: A readily available, cost-effective first-line imaging study. Real-time dynamic ultrasound can confirm complete tendon retraction, localize the tendon stump, and assess for partial tears. Operator-dependent.
MRI: The gold standard imaging study. Confirms diagnosis, differentiates complete from partial rupture, identifies the degree of tendon retraction, and evaluates for associated pathology (brachialis injury, lateral ligament involvement). Axial and sagittal sequences at the level of the radial tuberosity are key.
Treatment options
Non-Operative Management
Non-operative treatment (supervised rehabilitation, activity modification) is an acceptable option for: Low-demand, elderly patients with limited physical requirements. Medical comorbidities making surgery high-risk. Patients who decline surgery. Outcomes include permanent supination weakness (~40–50%), reduced elbow flexion strength, and early fatigue with repetitive overhead activities. Patients must be counseled that non-operative management will not restore full strength.
Distal Biceps Tendon Repair
Surgical repair of a completely ruptured distal biceps tendon at the radial tuberosity using a single-incision or two-incision technique. Restores full supination strength and the approximately 30% of elbow flexion power lost at rupture.
Click for more Surgical ProcedureDistal Biceps Tendon Repair (Elbow)
Primary and reconstructive repair of distal biceps tendon ruptures at the radial tuberosity, using a single-incision anterior approach or two-incision technique based on anatomy and chronicity of the rupture.
Click for moreRecovery & rehabilitation
- Post-operative immobilization: Posterior splint at 90° of elbow flexion for 1–2 weeks.
- Range of motion: Active-assisted ROM begins at 1–2 weeks; passive extension is restricted initially to protect the repair.
- Strengthening: Progressive strengthening begins at 6–8 weeks.
- Return to unrestricted activity: Most patients return to full activity at 4–6 months post-operatively.
- Return to heavy labor/sport: 5–6 months for most patients; timing individualized by surgeon.
Frequently Asked Questions
Does distal biceps rupture need to be fixed urgently?
Will I need a graft?
How much strength will I recover?
What is the "Popeye" sign?
Can partial tears of the distal biceps be treated without surgery?
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Related conditions
References
- Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal tendon of the biceps brachii: a biomechanical study. Journal of Bone and Joint Surgery (JBJS). 1985;67(3):418–421. https://doi.org/10.2106/00004623-198567030-00013
- Chavan PR, Duquin TR, Bisson LJ. Repair of the ruptured distal biceps tendon: a systematic review. American Journal of Sports Medicine (AJSM). 2008;36(8):1618–1624. https://doi.org/10.1177/0363546508315045
- Citak M, Backhaus M, Seybold D, et al. Surgical repair of the distal biceps brachii tendon: a comparative study of the single-incision and the modified two-incision technique. Knee Surgery, Sports Traumatology, Arthroscopy. 2011;19(10):1752–1757. https://doi.org/10.1007/s00167-011-1469-8
- American Academy of Orthopaedic Surgeons. Distal Biceps Tendon Tears. OrthoInfo. https://orthoinfo.aaos.org/en/diseases--conditions/distal-biceps-tendon-tears (accessed May 2026).
- Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of distal biceps tendon rupture: a new technique using the Endobutton. Journal of Shoulder and Elbow Surgery (JSES). 2000;9(2):120–126. https://doi.org/10.1067/mse.2000.103003