The biceps brachii is a powerful muscle in the upper arm that connects to the bones via tendons, allowing for elbow bending and forearm rotation. A torn biceps refers to a rupture of one of these tendons, which can be partial or complete. The decision of whether a torn biceps requires surgery is not straightforward, as the necessary treatment depends entirely on the location of the tear.
Differentiating Proximal and Distal Bicep Tears
The biceps muscle has two main attachment points in the shoulder, known as the proximal tendons, and a single attachment point at the elbow, called the distal tendon. Proximal biceps tears occur near the shoulder joint and are the most common type of rupture, accounting for approximately 96% of all biceps tendon injuries. This injury usually involves the long head of the biceps tendon, which attaches to the shoulder socket.
A distal biceps tear occurs at the elbow, where the single tendon attaches to the radius bone in the forearm. These tears are much less frequent, making up about 3% of biceps ruptures. They often happen when a forceful eccentric load is placed on the elbow as it straightens.
Conservative Management for Proximal Tears
The majority of proximal biceps tendon tears, which occur at the shoulder, can be managed effectively without surgical intervention. This is because the short head of the biceps often remains attached to the shoulder blade, preserving most of the arm’s strength and function. Treatment focuses on reducing pain and inflammation while restoring mobility and strength in the surrounding musculature.
Initial non-operative treatment involves rest, ice application, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) to manage swelling and discomfort. Following this acute phase, a structured physical therapy program begins, aiming to maintain the full range of motion in the shoulder and elbow joints. Rehabilitation progresses to strengthening exercises that target the remaining biceps tendon and other shoulder muscles to compensate for the injury.
While a cosmetic deformity, sometimes called a “Popeye” sign, may result from the muscle retracting down the arm, patients generally regain functional strength suitable for daily activities. Outcomes for non-operative management regarding pain and range of motion are often similar to those who undergo surgery. For individuals who are older or who do not have high physical demands, conservative management is the recommended course of action. Most patients see sufficient recovery within six to eight weeks.
Surgical Necessity for Distal Tears
Distal biceps tendon ruptures at the elbow are functionally different from proximal tears and typically necessitate surgical repair, especially for active individuals. The distal tendon is the sole attachment point at the elbow, and its primary function is to supinate the forearm, in addition to flexing the elbow. When this single tendon completely ruptures, the ability to perform forceful supination is severely compromised.
Non-operative treatment for a complete distal tear results in a significant loss of strength, including up to a 40% deficit in supination strength and a 30% loss in elbow flexion strength. Because of this substantial functional impairment, surgical reattachment is recommended to restore maximum strength and endurance. The surgery involves reconnecting the torn tendon directly back to its insertion point on the radial tuberosity of the forearm bone.
The timing of the surgical intervention is important; ideally, the repair is performed within two to three weeks of the injury. Delaying the surgery can cause the tendon and muscle to retract and scar, making the procedure more complex and leading to less predictable outcomes. For highly active patients or those whose occupations require significant arm strength, surgery is necessary to achieve the best functional result.
Recovery and Functional Outcomes
Recovery following a biceps tendon tear depends on the treatment path taken, with timelines varying significantly between non-surgical and surgical cases. For most proximal tears treated non-operatively, the focus is on a progressive physical therapy regimen, with the goal of returning to full activity generally achieved within a few months. Initial recovery focuses on pain control and regaining basic range of motion, followed by a gradual increase in resistance exercises to rebuild strength.
Surgical repair for a distal tear involves a more structured and lengthy rehabilitation process to protect the reattached tendon. The post-operative period begins with a few weeks of immobilization in a splint or brace to allow the tendon-to-bone connection to heal. This phase is followed by carefully controlled, progressive range-of-motion exercises; strengthening is usually delayed for two to three months to avoid stressing the repair.
Patients who undergo distal biceps repair can expect a return to light activities around three months, but full recovery often takes four to six months. The long-term prognosis for both treatment types is favorable, with most individuals regaining a high degree of arm function, provided they adhere to the prescribed physical therapy protocol.