Lesson

Tendon rupture

Distal biceps tendon rupture is relatively common in a young athletic population. The peak incidence though is in men in their 40s and 50s.9 Triceps tendon ruptures and avulsions are also possible, although rare.

 

History

Acute injuries to the tendons about the elbow typically involve an acute incident with a sudden forced eccentric contraction. Patients often report a popping sensation and then develop significant bruising.

 

Examination

Patients who rupture their distal biceps develop characteristic bruising in the cubital fossa and forearm; this is a key to recognising this injury. The biceps muscle may appear retracted and the tendon may not be palpable. The patient will generally have weakness of supination (with their elbow flexed). Flexion may be relatively unaffected. Patients with a triceps tendon rupture will have marked weakness of elbow extension, particularly against gravity.

 

Investigations

It can sometimes be hard to determine how much of the tendon is involved. MRI is the best single modality. The biceps tendon runs obliquely and can be hard to visualise. Ultrasound can also be useful.

 

Treatment

Surgical repair of the ruptured distal biceps tendon is generally required to maintain supination and flexion strength. A systematic review of repair options concluded that the best results are seen when surgery occurs within two weeks.10 Patients are typically immobilised for a short period and return to sport after three to four months. Conservative treatment is possible, but generally results in permanent weakness of forearm supination while elbow flexion strength generally returns to normal.11 Partial tears can also occur. Tears involving less than 50% of the tendon can be managed conservatively.

Click on the following links to view images of tendon ruptures.

  • Distal biceps rupture

    Note the retracted looking distal biceps muscle belly.

  • Distal biceps tendon rupture

    Observe the wavy-looking retracted distal biceps tendon on this sagittal MRI sequence.

  • Triceps tendon avulsion fracture

    X-rays can still be useful for the assessment of tendon injuries.