This 48-year-old male goalkeeper coach presents following an acute injury to his dominant right elbow. He describes reaching out to stop a shot with his right hand. He felt acute pain and a popping sensation in his anterior elbow. The following day he developed quite extensive bruising over his antecubital fossa. In addition to the bruising he was also found to have weakness of forearm supination and tenderness in the antecubital fossa.
X-rays of the right elbow were normal. MRI confirmed the clinical diagnosis of a distal biceps tendon rupture. The tendon is retracted with a fluid signal filled gap.
A decision was made to surgically repair the ruptured distal biceps tendon. He was able to return to all normal activities within four months.
The distal biceps tendon has an extended insertion and also has a fibrous covering (the lacertus fibrosus). This can mean that it can feel intact to palpation – even when it has been ruptured. Key points to the clinical examination are characteristic bruising (which can be missed when the patient is not seen acutely) and weakness of forearm supination. Patients who rupture their distal biceps tendon typically develop characteristic bruising over the antecubital fossa. This is an important clue to establishing this diagnosis. Bruising can be an important clinical sign, also seen in other regions following active tendon injuries. Other examples are of posterior thigh bruising after rupture of the proximal hamstring tendon and anterior shoulder and arm bruising following rupture of the pectoralis major tendon.
Most patients who rupture their distal biceps tendon elect to have this surgically repaired. Non-surgical treatment is an option; however, most patients are aware of weakness with elbow and forearm supination. Younger and more active patients generally do not tolerate this well. Elbow flexion strength is less affected.
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