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Repair and Rehabilitation of Distal Biceps Ruptures

Etiology: Distal biceps tendon ruptures, which account for approximately 10% of all biceps ruptures, typically occur after a sudden, unexpected extension force to the flexed arm. Most injuries are complete ruptures, with the tendon avulsing from the radial tuberosity. Tearing of the bicipital aponeurosis may or may not occur. Patients are usually men between the ages of 30 and 60 years; complete rupture has been reported in a woman in only one instance. Although most patients are asymptomatic before rupture, it is thought that preexisting chronic degeneration plays a role in most, if not all, injuries. Mechanical impingement (decreased radioulnar distance resulting in less space available for the tendon) is also cited as a potential cause. More than 4 in 5 injuries occur in the dominant arm, and ruptures are 7.5 times more likely in smoker. Treatment and Repair Techniques: Surgical reinsertion of the biceps tendon to the radial tuberosity is considered the treatment of choice for most complete ruptures (and for partial tears that have failed nonoperative management). Nonoperative management is typically considered only for elderly, low-demand patients, or for those too ill to consider surgical intervention. Patients who choose nonoperative treatment typically lose 20% to 30% of arm flexion and 30% to 50% of supination strength and may suffer chronic activity-related arm and forearm pain. Recently, however, some authors have questioned the severity of disability associated with nonoperative management. Outcomes: In general, most studies describe excellent clinical outcomes irrespective of fixation method. Two-incision techniques may result in slightly greater flexion strength and may better restore supination strength, by virtue of positioning the repair more posteriorly, in a more anatomic position, on the tuberosity than the one-incision methods. Rehabilitation: With improvement in surgical techniques, and greater knowledge of pull out and failure complications, current rehabilitation progressions have advanced. As mentioned, the native distal bicep tendon has a strength of 200 to 225 N. The present literature suggests that surgical fixation with the Endobutton technique has a failure load of 259±28 N, obviously higher than the natural attachment. However, there should always be caution with any aggressive protocol, and communication with the physician is imperative. Particularly with a distal biceps repair, it will be very important to know the level of tendon retraction, tissue quality, and security of fixation that the surgeon was able to achieve. With this knowledge, the rehabilitation may move slower, or more quickly, but the most important factor in progression of this patient population postoperatively is the achievement of clinical milestones. Protocols are a good guideline for rehabilitation but should rarely be used as an exact recipe. The rehabilitation after repair of the distal biceps tendon has undergone evolution, but basic principles still hold true. Progression can be guided by a protocol but should be largely based on communication between physician and rehabilitation specialist. As with any surgery, parameters and outcomes may vary based on the severity of the injury and the ability of the surgeon to achieve ideal fixation. No 2 surgeries are exactly alike, but safe rehabilitation guidelines can be established for any patient with the right attention to detail.