A complete biceps tendon rupture often results in a visible deformity known informally as a “Popeye bicep.” This distinctive appearance occurs when the detached tendon, typically at the shoulder (long head) or the elbow, allows the muscle belly to recoil. The sudden, forceful retraction of the muscle creates a noticeable lump or ball in the upper arm, signaling the underlying injury. Repairing this injury requires symptom recognition, medical confirmation, treatment selection, and structured rehabilitation.
Identifying the Bicep Tendon Rupture
The mechanism for a biceps tendon rupture is usually a sudden, heavy load or a forceful extension of the arm against resistance. This often occurs in middle-aged men during weightlifting or similar strenuous activities. When the force exceeds the tendon’s strength, it tears away from its bony attachment point. The injury is frequently accompanied by a distinct, sudden sharp pain and an audible “pop” or tearing sensation.
The classic “Popeye” appearance results from the biceps muscle belly retracting, creating a prominent bulge. If the rupture is distal (at the elbow), the muscle retracts proximally toward the shoulder, leaving a gap near the elbow crease. If the rupture is proximal (at the shoulder), the muscle retracts distally, creating the bulge lower in the arm. Immediate symptoms also include bruising and acute weakness, especially when attempting to twist the forearm (supination) or bend the elbow.
Medical Confirmation and Treatment Decision
A physician will begin the diagnosis by listening to the patient’s account of the injury and performing a focused physical examination. Specific tests are then used to confirm the location and completeness of the tear. The Hook test, for example, is performed with the elbow flexed and the forearm supinated; the examiner attempts to hook a finger under the distal biceps tendon. The inability to do so strongly suggests a complete distal rupture.
Another examination, the Biceps Squeeze test, involves squeezing the muscle belly and observing for passive supination of the forearm, which will be absent if the tendon is fully ruptured. Imaging tests, such as ultrasound or Magnetic Resonance Imaging (MRI), confirm the clinical diagnosis and assess tendon retraction. MRI is useful for distinguishing between a partial tear and a complete rupture, and for determining the distance the tendon has pulled away from the bone.
The decision between surgical and non-surgical treatment depends on the rupture location, the patient’s age, and their functional demands. Non-surgical management is typically reserved for proximal ruptures of the long head of the biceps in less active individuals. In these cases, the short head of the biceps and other muscles can compensate for function. However, for a complete distal biceps tendon rupture at the elbow, surgery is necessary for active people to prevent a significant loss of strength in both elbow flexion and forearm supination. Surgical intervention is also considered for proximal tears when the patient desires a complete return to strength and correction of the cosmetic deformity.
Surgical Repair Techniques
Surgical repair aims to re-anchor the retracted tendon securely back to its original bony attachment point. For a distal biceps rupture at the elbow, the goal is to reattach the tendon to the radial tuberosity. This must be performed acutely, ideally within a few weeks of the injury, before the tendon scars and shortens significantly. If the repair is delayed, a tendon graft may be necessary to bridge the gap.
Two main surgical approaches are used for distal repair: the single-incision technique and the double-incision technique. The single-incision approach is made over the front of the elbow crease. The surgeon retrieves the tendon and reattaches it to the radius using fixation devices like suture anchors or a suture button system. This method is favored for its smaller scar but carries a slight risk of injury to a sensory nerve.
The double-incision approach involves a small incision in the front of the elbow and a second, smaller incision on the side. This helps mitigate the risk of nerve injury and heterotopic ossification, which is the formation of bone in soft tissue. Regardless of the incision technique, the tendon is secured to the bone using strong, non-absorbable sutures threaded through the fixation device. For a proximal long-head rupture, the procedure is called a biceps tenodesis, where the detached tendon is reattached to the humerus bone instead of the shoulder socket.
The Rehabilitation Process
Recovery following a biceps tendon repair is a multi-phased and structured process. It is designed to protect the repair while gradually restoring strength and mobility. Initially, the arm is immobilized in a splint or sling, usually with the elbow bent to reduce tension on the repaired tendon for the first one to two weeks. During this period, light hand and wrist exercises are encouraged to maintain circulation and prevent joint stiffness.
The next phase introduces passive range of motion (PROM) exercises, where the arm is moved by a therapist or device to prevent scar tissue formation without actively engaging the biceps muscle. This is followed by active range of motion (AROM) exercises, which begin around six to eight weeks post-surgery. These focus on regaining the ability to bend the elbow and twist the forearm independently.
Progressive strengthening begins once sufficient healing and range of motion are achieved. This starts with light isometric contractions and advances to resistance exercises. Full, unrestricted activity and a return to sports or heavy labor are achieved around four to six months after the surgery. Adherence to the rehabilitation protocol is necessary to prevent re-rupture and ensure the tendon fully integrates with the bone.