Hand SurgeryHand & WristSurgery Center

Distal Biceps Tendon Repair (Elbow)

Peter Fitzgibbons, MD, is a fellowship-trained hand and upper extremity surgeon at Maryland Orthopedic Specialists who performs primary and reconstruction distal biceps tendon repair at the elbow using both single-incision and two-incision techniques.

Duration: 45–75 minutesAnesthesia: Regional or general

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What is distal biceps tendon repair (elbow)?

Distal biceps tendon repair is surgery to reattach the biceps tendon to the radial tuberosity at the elbow after it has ruptured from the bone. This is a tear at the elbow, not the shoulder. Acute ruptures (within 3 weeks) are repaired primarily; delayed or chronic ruptures may require tendon reconstruction. The surgery restores elbow flexion strength and forearm supination power.

Why this approach — at MOS

The most important factor in distal biceps repair is timing. The native tendon can be repaired to the radial tuberosity within approximately 3 weeks of rupture — within this window, the tendon is pliable, the tissue is healthy, and fixation is reliable. After this window, the tendon retracts and scars in a shortened position, and a reconstruction using tendon graft (allograft or autograft) becomes necessary. Patients who present promptly after the injury and are advised to proceed with surgery — rather than delaying "to see if it gets better" — have the most predictable outcomes.

At Maryland Orthopedic Specialists in Germantown, Dr. Fitzgibbons uses the single-incision technique with suture anchors or EndoButton cortical fixation for most acute repairs. The EndoButton technique distributes fixation forces along the cortical surface of the radius rather than at a single anchor point, which provides biomechanical advantages in cortical bone. The approach is individualized based on bone quality, patient anatomy, and the chronicity of the tear.

For chronic or reconstructed cases — where the native tendon is not usable — Achilles tendon allograft or semitendinosus allograft is used to bridge the gap. These cases are technically more demanding, have a longer recovery, and require a pre-operative MRI or ultrasound to assess tendon retraction and tissue quality.

Who is a candidate?

Indications

Complete distal biceps tendon rupture confirmed by clinical examination and MRI in an active patient
Acute rupture (within 3 weeks of injury) in any patient who uses the arm for manual work, sports, or overhead activities
Partial rupture that fails conservative management and causes persistent pain and weakness at the radial tuberosity
Chronic rupture (over 3 weeks) in a patient who cannot accept the functional deficit — requires more complex reconstruction

Contraindications

Complete rupture in a very sedentary, elderly patient whose functional expectations can be met without surgery
Significant medical comorbidities elevating surgical risk beyond the expected functional benefit
Active elbow infection
Partial rupture with acceptable strength and minimal symptoms — can be managed conservatively

Conservative Treatment First

Complete distal biceps tendon ruptures in active patients are generally recommended for surgical repair without a prolonged conservative trial, because the window for primary repair (re-attaching the native tendon directly to the bone without grafting) closes at approximately 3–4 weeks after rupture. After this point, the tendon retracts and scars in a shortened position, making primary repair technically impossible or requiring complex reconstruction.

Non-surgical management is appropriate for very sedentary, elderly patients or those with significant comorbidities. Conservative treatment preserves some elbow flexion strength (roughly 70–80% of normal) but supination strength is reduced to approximately 50–60% of the opposite side — a deficit that is noticeable in daily tasks like opening jars or doors and significant in manual labor and sports. For partial ruptures with intact function, a supervised rehabilitation program with progressive strengthening is the initial approach.

The procedure

What Is Distal Biceps Tendon Repair?

The biceps muscle has two heads at the shoulder (long head and short head), both of which converge into a single tendon that attaches at the elbow to the radial tuberosity — a bony prominence on the radius, approximately 3 cm below the radial head. The distal biceps tendon is the primary supinator of the forearm (rotating the palm from face-down to face-up) and a secondary elbow flexor. When this tendon ruptures — typically in men aged 40–60 who sustain a sudden eccentric load on the flexed elbow, such as lifting a heavy object with an unexpected release — it avulses from the radial tuberosity.

The moment of rupture is typically described as an audible or felt pop, followed by sudden weakness and a bulge of the biceps muscle toward the shoulder (the "reverse Popeye" sign — the opposite of the long head biceps rupture at the shoulder, which causes the muscle to move downward). Bruising over the antecubital fossa (inner elbow crease) develops within 24–48 hours. A "Hook test" — attempting to hook a finger under the biceps tendon in the antecubital fossa — is the most specific physical examination finding for distal biceps rupture.

Untreated, a distal biceps rupture results in approximately 40–50% loss of supination strength and 20–30% loss of flexion strength — a significant functional deficit for manual workers and active patients. This is why surgical repair is generally recommended for the complete rupture in active individuals.

What Happens During Distal Biceps Tendon Repair?

Setting and anesthesia: Performed at an ambulatory surgery center under regional anesthesia (brachial plexus block) or general anesthesia. The procedure takes 45–75 minutes.

Single-incision technique: An anterior (S-shaped or transverse) incision is made in the antecubital fossa. The tendon is identified, retrieved, and prepared by passing heavy non-absorbable sutures through its end using a Krackow or Bunnell locking stitch. The forearm is supinated fully to expose the radial tuberosity. The tuberosity is prepared to create a bone socket or fresh cortical surface for tendon healing. The tendon is reattached using one of several fixation methods: suture anchors threaded into the tuberosity, an EndoButton (cortical button and loop) that passes the sutures through a tunnel in the radius, or bone tunnel fixation with sutures passed through the bone. The fixation is confirmed to be secure through passive range of motion. The wound is closed and a posterior splint is applied with the elbow at 90 degrees and the forearm in neutral rotation.

Two-incision technique (Henry approach): A small anterior incision retrieves the tendon, and a second incision is made posterolaterally over the tuberosity to create bone tunnels under direct vision without the need for specialized devices. The tendon is passed through a window in the muscle and secured in the tunnels. This approach reduces the risk of posterior interosseous nerve injury from instruments near the radial head but is associated with a small risk of radioulnar synostosis (unwanted bone growth between the radius and ulna) if the bone graft bed contacts the ulna.

Recovery timeline

Week 1–2

Posterior splint at 90 degrees of elbow flexion. Gentle finger and shoulder motion. No active elbow motion.

Weeks 2–6

Transition to a hinged elbow brace with progressive extension allowed. Active elbow flexion begins at 3–4 weeks. Forearm rotation exercises begin at 4 weeks.

Weeks 6–10

Progressive strengthening. Return to light daily activities. No lifting over 5 pounds.

Months 3–4

Return to manual work, lifting, and sports progressively. Supination strength typically reaches 85–90% of normal by 4–6 months.

6 months

Most patients achieve 90–100% of pre-injury strength. Grip, flexion, and supination fully restored in most cases.

Elbow flexion strength recovers relatively quickly after distal biceps repair — most patients recover near-symmetric flexion by 3 months. Supination strength — the most functionally critical deficit — recovers more slowly, typically reaching 80–90% of the opposite side by 4–6 months. The repair is protected from resisted supination loads during the first 6–8 weeks to allow the tendon-to-bone healing to consolidate.

Physical therapy beginning at 3–4 weeks is essential for restoring forearm rotation and elbow range of motion. MOS coordinates therapy for all distal biceps repair patients. Lateral antebrachial cutaneous nerve (a sensory branch near the anterior incision) irritation causing forearm tingling is common in the first 4–8 weeks and resolves without treatment in most cases.

Frequently Asked Questions

How do I know if my biceps tendon ruptured at the elbow or the shoulder?

A proximal biceps rupture at the shoulder typically causes the muscle to migrate toward the elbow (a "Popeye" deformity — the muscle belly bulges toward the forearm). A distal biceps rupture at the elbow causes the muscle to retract toward the shoulder (a "reverse Popeye" — the belly bulges toward the upper arm) and causes pain and weakness specifically in the antecubital fossa (elbow crease). The Hook test — hooking a finger under the biceps cord in the elbow crease — is negative when the distal tendon is torn. MRI confirms the diagnosis.

Is surgery necessary for a ruptured distal biceps tendon?

For complete ruptures in active patients, surgery is generally recommended because untreated rupture results in approximately 40–50% permanent loss of supination strength and 20–30% loss of flexion strength. For sedentary patients with minimal physical demands, non-surgical management is acceptable. For partial ruptures, conservative management with a supervised rehabilitation trial is appropriate before considering surgery.

How long do I have to decide about surgery after a distal biceps tendon rupture?

The window for primary repair — reattaching the native tendon directly to the bone — is approximately 3 weeks from the time of injury. After this point, the tendon retracts and scars, and reconstruction using a graft becomes necessary. Graft reconstructions have longer recoveries and slightly less predictable outcomes than primary repairs. Early consultation after a suspected biceps rupture is important to preserve the primary repair option.

What is the difference between single-incision and two-incision techniques?

Single-incision repair uses one anterior incision in the elbow crease to retrieve the tendon and reattach it using specialized anchor or button devices without a second incision. Two-incision repair uses a small anterior incision plus a second posterolateral incision over the radial tuberosity for bone tunnel creation under direct vision. Single-incision techniques carry a lower risk of radioulnar synostosis; two-incision techniques avoid specialized implants and allow direct visualization of the tuberosity. Both produce excellent outcomes in experienced hands.

When can I lift heavy objects or return to manual labor after repair?

Progressive lifting begins at 6–8 weeks. Return to full manual labor — including heavy lifting, tool use, and forceful supination — typically occurs at 3–4 months. Complete strength recovery continues until 6 months. Rushing return to heavy loading before the tendon-to-bone interface has consolidated significantly increases the risk of re-rupture.

Related conditions

Distal Biceps Tendon Rupture

Medically reviewed by Peter G. Fitzgibbons, MD, MD

Last reviewed May 20, 2026