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Distal Biceps Rupture in a Snowboarder

James S. Williams, Jr, MD; David W. Hang, MD; Bernard R. Bach, Jr, MD


In Brief: As in this case study of a snowboarder, the typical history for distal biceps brachii rupture involves a single traumatic event, an audible popping sound, and intense pain. The physical exam will reveal ecchymosis in the antecubital area and weakness with both supination and elbow flexion; the distal biceps brachii tendon will not be palpable. Though distal biceps rupture is far less common than its proximal counterpart, primary care physicians should be aware of the diagnostic criteria. Referral for surgical treatment is necessary to preserve elbow flexion and supination strength.

In the fast-growing sport of snowboarding, lower-extremity injuries are as common as or more common than upper-extremity injuries (1-3). But snowboarders, when losing their balance, will often try to right or catch themselves with their arms. This can cause a sudden eccentric load to the biceps brachii muscle, putting it at risk for injury. We have seen three such sprains of the distal biceps tendon in snowboarders; this case study describes the first rupture we have seen. Proper diagnosis and treatment of such ruptures is critical, especially for athletes, because the physical demands of sports participation require good elbow flexion and supination strength.

Case Report

A 25-year-old experienced snowboarder fell sideways while making a turn. When he tried to break his fall with his dominant right arm, he heard a sudden pop about the right elbow and noted a sharp sudden pain that quickly resolved. He continued to snowboard that day. Not until later that evening did he notice that his upper arm appeared "abnormal."

When he presented to our office 5 days later, physical examination revealed ecchymosis within the antecubital fossa, soft-tissue swelling, and a soft retracted palpable mass in his distal upper arm consistent with a distal biceps rupture. The distal biceps tendon was not palpable at its insertion. Active motion and resistance to elbow flexion was limited because of the patient's discomfort and apprehension. There was no elbow instability or generalized ligamentous laxity. The patient was neurovascularly intact. He said he did not use anabolic steroids (a potential predisposing factor for tendon rupture).

Six days after his injury, he underwent biceps tendon reattachment using the two-incision technique described by Boyd and Anderson (4). He was found to have a complete avulsion of the distal biceps tendon from the radial tuberosity.

Postoperatively, he was treated in a posterior splint at 90° of elbow flexion and full supination. After 10 days, he was allowed out of the splint for daily gentle range-of-motion exercise from 30° to 100° of flexion. At 3 weeks, his splint was discontinued and he began active assisted flexion and active extension range-of-motion exercises. Full elbow flexion and extension were regained over the ensuing 4 weeks. Once he had regained normal motion at 6 weeks, he started gentle resistance exercises, which were increased over time.

At 6 months, the patient had full range of motion with normal manual muscle strength and was allowed to return to full participation in athletic activities. The patient was pleased with his outcome: He was pain free and could perform all activities including heavy lifting without difficulty. The contour of his biceps was minimally asymmetric to the contralateral arm.

Diagnosing the Rupture

Distal biceps brachii tendon rupture from the radial tuberosity (bicipital tuberosity) occurs far less frequently than its proximal counterpart, though the true prevalence is unknown. In 1925, Gilcreest5 reported that of biceps tendon ruptures, 96% were proximal long-head ruptures, 1% were short head, and 3% were distal.

The injury typically occurs in men between the fourth and sixth decades of life, although an age range of 21 to 70 has been reported (4,6-11). The senior author (BRB) reported a mean age of 46 (range 31 to 66 years) in his clinical experience (12). The typical history includes a single traumatic event involving eccentric contraction of the biceps. Examples include lifting a heavy load (over 40 kg) with the elbow flexed 90° and violent biceps contraction against unexpected resistance (11). In 1956, Davis and Yassine (13) suggested that preexisting degenerative changes in the biceps tendon or at the insertion site may be a predisposing factor for tendon rupture.

Symptoms at the time of injury involve an audible popping sound, intense pain, and a noticeable deformity in the biceps. The intense pain usually subsides over a few hours; the patient may be left with only a dull ache. Common findings include swelling and tenderness in the antecubital fossa and weakness to supination and flexion. Radiographs are typically normal, although occasionally a small fragment of bone may avulse from the bicipital tuberosity of the radius.

[FIGURE 1]In this patient's case, a sudden eccentric contraction probably resulted in avulsion of the tendon (figure 1). The patient demonstrated the classic signs of distal biceps brachii tendon rupture: ecchymosis in the antecubital area, nonpalpable distal biceps brachii tendon, weakness with both supination and elbow flexion, and a palpable distal defect.

Conservative vs Surgical Treatment

Treatment options for distal biceps brachii tendon ruptures include a nonoperative approach and surgical repair (6-8,10,14-21). Early reports advocated conservative treatment (8,15,16), but this approach often results in significant loss of elbow flexion and supination strength (11,18). Morrey et al (18) found a mean loss of 40% of supination strength and variable loss of flexion strength, averaging 30%. Although this level of functioning may be adequate for daily activities, fatigue is a common complaint. In addition, with conservative management, the distal biceps will scar to the brachialis muscle so that the normal contour does not return (19).

Serious athletes, body builders, people who require strong supination for their work, and those who deem deformity unacceptable are candidates for operative repair. A number of authors (4,6,7,9-11,18,22,23) report satisfactory results by reattaching the avulsed distal biceps tendon to the radial tuberosity via drill holes using Boyd and Anderson's two-incision technique. Patients typically regain nearly full flexion-extension and pronation-supination, more than 100% of their strength in dominant arms, and about 90% of their strength in nondominant arms (7). Objectively and subjectively, patients treated surgically with this technique have better results than conservatively treated patients.

Some authors (10,17,19) have recommended attaching the biceps tendon to the brachialis muscle to avoid the risk of radial nerve injury. However, with this type of repair, supination strength is unlikely to return to normal because of the failure to restore normal anatomy (18).

Referral Alert

Primary care physicians should know how to diagnose distal biceps brachii rupture. Because conservative treatment has less-than-optimal results, referral to an orthopedic surgeon is recommended. Surgical repair through reattachment of the avulsed distal biceps tendon to the radial tuberosity provides the greatest likelihood of a maximal functional result and return to sports.


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Dr Williams is an orthopedic sports medicine physician at The Cleveland Clinic Foundation in Westlake, Ohio. Dr Hang is chief resident and Dr Bach is associate professor and director of orthopedic sports medicine at Rush-Presbyterian-St. Luke's Medical Center in Chicago. Dr Bach is an editorial board member of The Physician and Sportsmedicine. Address correspondence to James S. Williams, Jr, MD, Dept of Orthopaedic Surgery, Section of Sports Medicine, The Cleveland Clinic Foundation, Westlake Family Health Center, 30033 Clemens Rd, 3rd Floor, Westlake, OH 44145; e-mail to [email protected].