Distal Biceps Pain
The biceps brachii is a big muscle in the front of the upper arm. It is composed off two heads, the long head originates from the supraglenoid tubercle and the short head from the coracoid process. The short head sits medially and the long head laterally. The muscle bellies extends over the front of the humerus they come together just proximal of the elbow joint to form a conjoint tendon. Here the two portions of the tendon spin 180 degrees over one another so that the long head had a more proximal attachment and the short a more distal attachment at the radial tuberosity. Anatomy, Shoulder and Upper Limb, Biceps Muscle – StatPearls – NCBI Bookshelf
The distal biceps tendon can be affected by tendinopathy and acute injuries ranging from partial tears to full thickness tears. The bicipitoradial bursa lies between the distal tendon of the biceps brachii surrounding the radial tuberosity and is less commonly a cause of ‘distal biceps pain’.
What are the signs and symptoms?
With acute injuries ranging from partial tears of the distal tendon all the way to full-thickness tears, there is often a story of suddenly catching or saving something heavy from falling. There are immediate symptoms and weakness, often more appreciable with forearm supination, localised ecchymosis (bruising) and, with full ruptures, often a ‘popeye’ sign where the muscle has retracted proximally up the arm. A simple test named the ‘hook test’ can be helpful to see if the distal biceps tendon can be palpated; in full-thickness tears this will be absent. Reliability and Validity of the Hook Test for Diagnosis of Distal Biceps Tendon Ruptures – PubMed
With tendinopathy of the distal tendon, there is not that traumatic history, and it is usually associated with manual workers and regular gym goers. They describe localised symptoms in the front of the elbow exacerbated with resisted elbow flexion and wrist supination. Involvement of the bicipitoradial bursa is uncommon but can be seen alongside tendinopathy and tears of the distal tendon. This is typically picked up when imaging is requested.
How is it diagnosed?
The diagnosis of your ‘distal biceps pain’ will usually be made from a combination of your clinical history (as discussed above), examination findings (as discussed above) and imaging. This will involve either an ultrasound or an MRI.
Imaging can confirm partial or full thickness tears, tendinopathic changes and the presence of bicipitoradial bursitis. They can also confirm the extent of tendon retraction in full-thickness tears, which is important information for the surgical management.
How is it treated?
For young, high-demand patients with full-thickness distal biceps ruptures, surgical management is often offered. This is usually done quickly to minimise any tendon retraction and muscle atrophy, allowing the best possible chance of a good outcome from your surgical repair. For elderly and less demanding patients, they can often live with a ruptured biceps tendon. The pain will subside, and it will have very little effect on their functional capabilities. Surprisingly, the biceps tendon only provides roughly 30% of elbow flexion strength. It has a more drastic effect on forearm supination strength (roughly 50-60% loss), but this rarely causes any concerns in an ageing patient. Distal biceps tendon rupture: a comprehensive overview – PMC
Partial tears can be managed either conservatively or surgically depending on the size of the tear and the patient requirements. Tears that involve less that 50% of the tendon can be successfully managed conservatively. While tears that involve more than 50% of the tendon are more likely to fail conservative options. Partial tear of the distal biceps tendon: Current concepts – PMC In the right patient, Conservative options typically involve a period of unloading and then a slow progressive return to activities over a 3–6-month period. Platelet Rich plasma (PRP) injection can sometimes be considered to facilitate any tendon healing but their effectiveness is still poorly understood Partial tear of the distal biceps tendon: Current concepts – PMC
For non-traumatic causes of ‘distal biceps pain’, such as tendinosis or bicipitoradial bursitis (less common), these are managed on the whole conservatively. Activity modification, with progressive rehab to improve the tolerance and capacity of the tendon, is first-line management. For refractory cases a local anaesthetic and steroid injection under ultrasound guidance can sometimes be considered either around the distal tendon or into the bursa. There are some small associated risks with this which will be discussed prior to the procedure if this is being considered. Other injection options include an ultrasound-guided PRP injection into the distal tendon. Evidence is controversial but there is support of its benefits as a better longer-term treatment option for patients with distal biceps tendinosis. Ultrasound-guided platelet-rich plasma injection for distal biceps tendinopathy – PMC
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