Sports MedicineHand & WristSurgery Center

Distal Biceps Tendon Repair

Performed by Drs. Raffo and Fitzgibbons, fellowship-trained orthopedic surgeons who repair distal biceps tendon ruptures at the elbow through a single or two-incision technique.

Duration: 45–75 minutesAnesthesia: General

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What is distal biceps tendon repair?

Distal biceps tendon repair surgically reattaches the biceps tendon at the elbow after it ruptures from the radial tuberosity. The injury typically occurs when a middle-aged man suddenly feels a 'pop' lifting a heavy object. Surgery restores full elbow flexion strength and forearm rotation and is most effective within the first 2–4 weeks after rupture.

Why this approach — at MOS

Timing is the most critical variable in distal biceps repair. Repairs performed within 2 weeks of rupture routinely achieve anatomic restoration with minimal dissection. By 4–6 weeks, the tendon stump has retracted and is embedded in scar, requiring extensive mobilization and occasionally a graft. We encourage early evaluation — patients who present to us promptly after the injury can typically be scheduled for repair within 7–10 days.

Our fixation preference for acute tears is a cortical button or suture anchor construct at the radial tuberosity, using a single-incision approach. This minimizes the risk to the posterior interosseous nerve compared to a traditional two-incision technique, while providing robust fixation that allows early protected motion.

Who is a candidate?

Indications

Complete distal biceps tendon rupture in an active patient with functional demands on elbow flexion and forearm supination
Partial tear with significant weakness or pain not responding to conservative management
Acute rupture (within 4 weeks) — the ideal timing window for straightforward repair
Chronic rupture causing functional deficits in a patient who wishes to restore strength

Contraindications

Complete rupture in an elderly, sedentary patient with minimal functional demands who accepts residual weakness (non-operative management is reasonable)
Active elbow infection
Severe medical comorbidities precluding surgery
Chronic rupture with severe proximal retraction and scarring in a patient unwilling to accept graft augmentation

Conservative Treatment First

Partial distal biceps tears — which occur on a spectrum from partial thickness to full rupture — can be managed conservatively with activity modification, anti-inflammatory medication, and physical therapy in patients who remain functional and whose demands are limited. A brief period of elbow rest and avoidance of heavy lifting allows the remaining tendon to settle.

Complete ruptures in active patients are different. Non-operative management is rarely optimal when the patient is physically active and relies on forearm rotation for work or sport, because the strength deficits (particularly supination) are permanent and progressive muscle changes develop. The conversation is about timing: in younger, active patients, surgery should be discussed promptly after rupture, as the repair is significantly easier and outcomes better within the first 3 weeks. Patients presenting to Maryland Orthopedic Specialists in the Rockville area for evaluation should be seen as soon as possible after the injury to allow timely decision-making.

The procedure

What Is Distal Biceps Tendon Repair?

Distal biceps tendon repair surgically reattaches the biceps tendon at the elbow after it ruptures from the radial tuberosity. The injury typically occurs when a middle-aged man suddenly feels a "pop" lifting a heavy object. Surgery restores full elbow flexion strength and forearm rotation and is most effective within the first 2–4 weeks after rupture.

This procedure is entirely at the elbow — not the shoulder. This is an important distinction from proximal biceps tenodesis, which addresses the shoulder end of the same muscle. The biceps muscle attaches distally (at the forearm end) to the radial tuberosity, a rough bony prominence on the inner aspect of the radius just below the elbow. When this attachment ruptures, the tendon retracts and the muscle belly bunches visibly in the upper arm.

The distal biceps is not merely an elbow flexor. It is the primary supinator of the forearm — the motion that turns the palm upward. Loss of supination strength (turning a screwdriver, opening a jar) is clinically significant and is the most impaired function after rupture. Elbow flexion is partially maintained by the brachialis, but forearm supination is almost entirely dependent on the biceps. Without surgical repair, patients lose roughly 40–50% of supination strength and 20–30% of flexion strength permanently.

The typical patient is a man in his 40s or 50s who experiences a sudden sharp pain and pop at the elbow while lifting a heavy object — often an exercise-related injury or a heavy work task. The forearm may show a visible deformity. MRI or ultrasound confirms the rupture.

Surgery is recommended within 2–4 weeks of acute rupture for the best outcomes. Chronic repairs (after 4–6 weeks) are more complex, as the tendon retracts and scars into surrounding tissue and may require graft augmentation.

What Happens During Distal Biceps Tendon Repair?

Before Surgery

You arrive at the ambulatory surgery center approximately 90 minutes before surgery. General anesthesia is administered. The procedure does not use an interscalene block — this is an elbow procedure, not a shoulder procedure. A tourniquet is applied to the upper arm to minimize bleeding during the repair.

Single-Incision Approach

The most common technique uses a single transverse or oblique incision (3–5 cm) in the antecubital fossa (the crease of the elbow). Careful dissection protects the lateral antebrachial cutaneous nerve and the radial nerve. The retracted tendon is located and mobilized from the surrounding scar tissue. The radial tuberosity is exposed by rotating the forearm into supination. Two suture anchors or a cortical button-and-interference screw construct are placed into the tuberosity. High-strength sutures are woven through the end of the tendon and secured to the fixation device, pulling the tendon snugly against the tuberosity. The elbow is flexed to about 90 degrees during fixation to optimize tendon tension.

Closure and Splinting

The wound is closed in layers. The arm is placed in a posterior splint with the elbow at 90 degrees and the forearm in neutral rotation for the first 1–2 weeks, to protect the repair.

Recovery timeline

Days 0–10

Posterior elbow splint at 90 degrees. Wrist and hand exercises begin immediately.

Weeks 2–6

Splint/brace transitioned to a hinged elbow brace allowing progressive extension. Light elbow range of motion.

Weeks 6–10

Full active motion. Progressive elbow flexion and supination strengthening begins. Sling and brace discontinued.

Months 3–4

Return to full activity, gym, and manual work. Supination strength typically fully restored by month 4.

Distal biceps repair recovery is measured primarily by return of supination strength, which is the functional hallmark of a successful repair. Most patients regain over 95% of supination strength compared to the opposite side at 6 months. Elbow flexion strength recovery is similarly excellent. Full range of motion — both flexion and full supination/pronation — is expected by 8–10 weeks.

The nerve most at risk during this procedure is the posterior interosseous nerve (the motor branch of the radial nerve). An experienced surgeon with careful technique has a very low rate of this complication. Transient numbness from lateral antebrachial cutaneous nerve irritation is more common and resolves in most patients over 4–8 weeks.

Frequently Asked Questions

How do I know if I've ruptured my distal biceps tendon?

The classic presentation is sudden sharp pain and a "pop" at the front of the elbow during forceful lifting. Many patients notice a visible bulge of the biceps muscle belly in the upper arm (Popeye sign). Weakness turning the palm upward (supination) and elbow flexion weakness develop. Your surgeon can confirm the rupture with a physical exam (hook test) and MRI or ultrasound.

What happens if I don't have surgery?

Without repair, the tendon heals in a retracted position with scar tissue — not to the radial tuberosity. The biceps muscle remains functional as an elbow flexor (supplemented by the brachialis), but supination strength — turning the palm up — is permanently reduced by roughly 40–50%. For active individuals, this is a meaningful functional loss. Fatigue and cramping in the forearm during sustained rotation tasks are common.

How soon should I have surgery after the rupture?

As soon as possible — within 2–3 weeks of injury if surgery is the plan. Acute repairs (under 3 weeks) are technically straightforward and have excellent outcomes. Chronic repairs (4+ weeks) require extensive dissection and often graft augmentation, carry higher complication rates, and achieve slightly less predictable strength restoration.

Is this the same as biceps tenodesis at the shoulder?

No. Biceps tenodesis is a procedure at the shoulder (proximal) end of the biceps tendon — it addresses pathology at the shoulder socket. Distal biceps tendon repair is at the elbow end — it addresses a rupture where the biceps attaches to the radius. These are different injuries in different locations of the same muscle.

Will I have numbness or weakness in my hand after surgery?

Temporary numbness on the outer (lateral) aspect of the forearm is common after distal biceps repair — from stretching of the lateral antebrachial cutaneous nerve during surgery. This typically resolves over 4–8 weeks. Posterior interosseous nerve injury causing finger extension weakness is a rare but recognized risk that an experienced surgeon minimizes with careful technique.