If you have a distal biceps tendon rupture, how long can you wait to have surgery? What can be done for your elbow injury if the injury occurred months or years earlier?

Storm in Denver, Colorado asks:

Dr. Geier,

I am a 39-year-old male. I have a distal biceps tendon rupture that occurred on May 13th while arm wrestling. It bruised at the elbow and forearm. I thought it was just a muscle strain, and a week later I continued to work out with weights. I started noticing that my biceps was moving up towards the shoulder like Popeye. I did the “hook method” in which there is no tendon to hook on the right arm from the bicep to the forearm. It has been 3 months since the injury. Is it possible to repair it with surgery, or have I waited too long? I am very active in multiple sports and really need the full use of my arm.

Please advise me, and thank you.

Storm

Statistically distal biceps injuries are more common among people in their fifties, but I typically see them in active individuals in their thirties. That might be a result of the patient population I see, though.

Mechanism of injury and diagnosis of a biceps tendon rupture

For readers unfamiliar with Storm’s description of the injury, let me explain what he sees and feels. A Popeye deformity occurs when the biceps tendon tears off the bone (the radius) in the forearm and allows the muscle to retract up the arm. The retraction allows the biceps muscle in the arm to look larger than normal. The hook test is a test where a physician tried to hook his or her finger around the biceps tendon in the front of the elbow. If the tendon has torn and retracted, there is no tendon to hook.

Popeye deformity from a distal biceps tendon rupture
Note the bruising around the elbow as well as the prominence of the biceps muscle (“Popeye” deformity).

Is surgery needed for a biceps tendon rupture

I think surgery is necessary in active individuals, whether they are in their thirties or fifties or sixties. It is certainly possible to have a good outcome without surgery, but most patients complain of residual weakness. The weakness is more related to decreased supination than elbow flexion. Common complaints of patients who treated their distal biceps tendon rupture nonoperatively include weakness with turning a screwdriver or a doorknob. Young active patients are significantly limited, so most sports medicine surgeons recommend surgery.

Timing of surgery for a biceps tendon rupture

Surgical repair is best in the first week or two before the tendon retracts. The more a tendon retracts, the more flexed the elbow has to be to reattach it to the bone, and consequently the slower the rehab process to regain motion. If the tendon is too retracted up into the arm, it is possible that it cannot be reattached. In these cases, other options, including using a donor tendon to reconstruct the biceps, have to be considered.

In my experience, active individuals who have surgery to reattach a distal biceps tendon rupture early usually regain full range of motion by 4-6 weeks and can start strengthening quickly. Sports might be held off for 3-4 months, but they usually have full function without limitation then.

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