Expert insight from Dr. Richard Cunningham, Orthopaedic Surgeon at Vail-Summit Orthopaedics & Neurosurgery

There are different types of biceps tears. The location of a biceps tear makes a major difference in how the injury presents and how the injury is treated. In most cases, the most important consideration is whether the bicep tendon tore from its distal attachment (at the elbow) or whether it tore from its proximal attachment (at the shoulder).

Below, Dr. Richard Cunningham of Vail-Summit Orthopaedics & Neurosurgery explains why these two injuries behave differently, how they affect strength and function, and when biceps repair surgery may be recommended.

Quick Takeaways

• A distal biceps tendon tear involves the tendon pulling off of the radius bone, which is one of the two forearm bones that joint the bottom of the humerus to create the elbow joint. These injuries lead to weakness when lifting or supinating the forearm (rotating the forearm externally or turning the palm upward).
• A proximal biceps tendon tear involves the biceps tendon pulling off of the top of the glenoid or shoulder socket. Isolated tears at this location cause less functional loss.
• With a ruptured biceps, one usually experiences a sudden pop with associated pain, swelling and bruising. The location of this pain and swelling differ depending on where the tear occurs. Some biceps injuries, particularly isolated proximal tears, can be treated non surgically, while distal tears usually require surgery.

Understanding the Anatomy of the Biceps Tendon

The biceps is composed of two different tendons that attach at the shoulder. The long head of the biceps attaches to the top of the shoulder socket (glenoid). The short head of the biceps attaches to the coracoid, which is a protrusion of the scapula bone. As you move down the arm, the tendon fibers become muscle fibers. As you move farther down the arm, the muscle fibers become a single tendon. This tendon attaches to the radius bone at the elbow.

A proximal biceps tendon rupture occurs when the long head of the biceps tendon detaches from the glenoid attachment. This injury is often associated with age related degeneration, shoulder arthritis, or rotator cuff problems. It is very rare for the short head of the biceps tendon to ever tear from the coracoid (part of the scapula).

By contrast, a distal biceps tendon rupture occurs when the tendon pulls away from the radius bone at the elbow. This injury is less common than proximal tears of the long head of the biceps, but it is a more serious injury causing significant weakness.

Dr. Cunningham explains, “because there are two separate biceps tendon attachments at the shoulder, if one has an isolated tear of one of the long head of the biceps, there is the backup short head attachment. When one tears the distal attachment from the elbow, there is no backup tendon attachment. As a result, distal tears cause one to lose significant strength, particularly in forearm supination or turning one’s palm upward against resistance.”

Why Distal Tears Feel More Severe

Patients who experience a bicep distal tendon rupture often describe a sudden pop in the elbow followed by bruising and weakness. Everyday activities like turning a screwdriver, opening jars, or lifting objects suddenly becomes much more difficult.

Without treatment, patients may permanently lose a significant percentage of their forearm rotation strength. Because of this, most active patients and athletes choose bicep tendon repair surgery to restore strength and function.

Why Proximal Tears Often Feel Different

A bicep proximal tendon rupture typically produces a different set of symptoms.

Many patients notice a bulge in the upper arm, sometimes called a “Popeye” deformity, along with mild discomfort in the shoulder. However, overall arm strength may remain relatively preserved.

That is because the short head biceps attachment is still intact. Therefore, older patients with isolated long head of biceps tendon tears do not typically require surgery. However, there is a significant chance that if you tore your long head of biceps tendon that you also have an associated rotator cuff tear. For this reason, you should be seen and evaluated by an orthopedic shoulder specialist to rule out a rotator cuff tear.

Dr. Cunningham notes, “Proximal ruptures often affect appearance more than function. Distal ruptures tend to affect strength much more significantly.”

When Bicep Rupture Surgery Is Recommended

Treatment decisions depend on several factors including age, activity level, and the location of the tear.

In general, biceps surgery is more commonly recommended for distal tendon tears because of the strength loss.

Surgical repair involves reconnecting the tendon to the bone thus allowing one to regain all of their strength. When bicep rupture surgery is performed, rehabilitation focuses on gradually restoring motion and rebuilding strength over several months.

For isolated proximal biceps tendon tears, surgery may be considered if patients experience persistent cramping, weakness, cosmetic concerns, or shoulder dysfunction. However, many individuals can do well without surgery.

When to Seek Orthopaedic Evaluation

Symptoms that should prompt evaluation include:

• A sudden pop when lifting which classically occurs when resisting a weight as the elbow is straightening.
• Bruising around the elbow or upper arm
• Visible change in arm shape with the biceps muscle bunching up
• Loss of strength when bending the elbow or rotating the forearm
• Persistent shoulder pain following an injury

Early diagnosis helps determine whether a bicep distal tendon rupture or another injury is present and whether surgical treatment may improve long term function.

About Dr. Richard Cunningham

Dr. Richard Cunningham is a board certified orthopedic surgeon and sports medicine specialist at Vail-Summit Orthopaedics & Neurosurgery. He specializes in complex shoulder injuries, including biceps and rotator cuff injuries. His goal is getting patients back to the sports and activities they love.

If you are experiencing symptoms of a bicep proximal tendon rupture or another arm injury, early evaluation can help determine the most effective treatment plan. Contact his team today!