A 45 year old recreational player presented one week after an injury to his left elbow. He was playing in goal and described blocking a powerful shot with his left hand, forcibly extending his left elbow against resistance. He reported feeling a tearing sensation and immediate pain in his elbow. He developed bruising over his cubital fossa.
On examination there was prominent bruising over the medial aspect of the left elbow. He had localised tenderness in the cubital fossa and an absent distal biceps tendon to palpation. His biceps appeared to have retracted. He has good elbow flexion strength but resisted forearm supination was weak and painful.
An x-ray of the elbow was normal. MRI sequences show that there is complete discontinuity of the mid to distal biceps tendon. The proximal portion of the tendon is thickened with intermediate to high T2 signal and has a wavy redundant appearance, lying 4.5cm from its insertion. The inter-tendinous gap measures approximately 2.3cm . There is a large amount of surrounding oedema extending into the musculotendinous junction and distal muscle belly.
The player underwent surgery to repair his ruptured distal biceps tendon using a 2-incision technique. This was done 20 days after his injury. Following the surgery he was managed in a ROM of brace for six weeks and was advised against lifting or carrying with the injured arm. The brace was locked at 90 degrees flexion for the first two weeks. At this point the player was gradually allowed to extend their elbow further under clinician supervision. A progressive biceps strengthening programme was started at approximately 9 weeks post-surgery starting with isometric and light isotonic exercise. He was cleared to return to football training at approximately five months post-surgery. At this time he had a full and painless range of motion, near symmetric elbow flexion/supination strength and was able to complete football-specific activities like throwing, catching and diving.
Distal biceps tendon injuries are relatively rare. They generally occur after an eccentric load on a flexed elbow. As this case illustrates, patients typically present with bruising and swelling about the antecubital fossa and tenderness about the biceps tuberosity. This is a key finding and should prompt consideration of this diagnosis. The majority of patients have a loss of biceps strength, especially supination, if they pursue non-surgical treatment. As a result, most patients elect to pursue surgical repair. A range of repair techniques have been described in the literature and are largely associated with good outcomes. Where possible this repair should ideally be done as soon as possible. This is to try to prevent complications that might occur due to tendon retraction, scarring and the need for a more extensive dissection. Delayed repairs are however possible and good results from this treatment have been reported in the literature.
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