Bicep Rupture

  • Of all injuries to the biceps, the vast majority are proximal, and nearly all involve the proximal long head. Injuries are usually the result of repetitive microtrauma and overuse.
  • Steroids, whether injected locally or used systemically, can accelerate the breakdown of tendons.
  • Biceps tendon rupture usually occurs when there is sudden or prolonged contraction against resistance in middle-aged and older individuals with a history of chronic bicipital tenosynovitis.
  • A snap or pop is usually described, and pain is present in the anterior shoulder. Examination of the anterior shoulder will reveal swelling, tenderness, and often crepitus over the bicipital groove.
  • Flexion of the elbow, best accomplished with the arm abducted and externally rotated, will elicit pain and may produce a midarm "ball," which represents the distally retracted biceps muscle.
  • Comparing arms for symmetry helps.
  • Loss of strength is minimal due to the function of the brachialis and supinators.
  • Avulsion fractures occasionally occur, so radiographs of the shoulder should be obtained.
  • ED treatment includes sling, ice, analgesics, and referral to an orthopedic surgeon for definitive care.
  • Surgical repair is usually recommended for young, active patients.
  • A conservative approach with immobilization may be adequate for elderly patients whose activities of daily living are not significantly compromised by the injury.


Distal Biceps Injuries
  • Are less common than proximal injuries.
  • Complete ruptures of the tendon are most common in middle-aged men, and usually involve the dominant extremity.
  • Partial tears are seen in men and women. Mechanism of injury is similar to that of proximal injuries.
  • In ruptures of the distal biceps, pain is felt in the antecubital fossa, with swelling, ecchymosis, and tenderness to palpation noted on examination.
  • A distal rupture is indicated by an inability to palpate the distal biceps tendon in the antecubital fossa and a mid-arm "ball."
  • Strength loss, especially supination, is usually greater than with proximal ruptures.
  • A "biceps squeeze test," similar to the Thompson test for assessing Achilles tendon rupture, has been described.
  • With the patient seated and the forearm resting on the patient's lap, the examiner squeezes the muscle belly of the biceps brachii, which should result in supination of the forearm. Lack of supination is considered a positive test, indicating rupture of the distal biceps brachii.
  • Radiographs should be obtained to search for an associated avulsion fracture.
  • Although most complete distal ruptures are diagnosed clinically, MRI and US can aid in confirming the diagnosis of partial tears.


  • ED treatment includes sling, ice, analgesics, and referral to an orthopedic surgeon for definitive care.
  • Without surgical repair of complete ruptures, supination strength is decreased by approximately 50% and flexion strength by almost 30%.
  • Therefore, in young active individuals, surgical repair is recommended