Overview
The biceps muscle has two tendons around the shoulder and one tendon at the elbow, giving it a Y-shaped configuration. Although they involve the same muscle, proximal (shoulder) and distal (elbow) biceps injuries are very different conditions and are treated differently.
Proximal Biceps Rupture
A proximal rupture almost always involves the long head of the biceps. When I see a proximal biceps rupture, I no longer worry about treating the rupture itself. Instead, it alerts me that there may be a problem with the rotator cuff above. These injuries are treated conservatively. Patients gradually return to activities over approximately 4–6 weeks, and most regain near-normal function because the brachialis muscle continues to provide excellent elbow flexion strength.
Arthroscopic Biceps Tenodesis
During arthroscopic treatment of impingement or rotator cuff disease, I routinely evaluate the biceps tendon. If it is inflamed, frayed, or torn, I commonly perform an arthroscopic biceps tenodesis. The tendon is released from its attachment inside the shoulder and secured lower on the humerus with a suture anchor. The procedure adds only a few minutes to the overall arthroscopic operation.
After surgery, patients may actively use the arm but are limited to 1–2 pounds of curling for the first six weeks. From six to twelve weeks, resistance is gradually increased, with unrestricted strengthening beginning at approximately twelve weeks. If the tenodesis does not heal, it most commonly results in a Popeye deformity with very mildweakness and, occasionally, mild cramping or spasms.
Distal Biceps Rupture
Distal biceps ruptures occur at the elbow and are a completely different injury from proximal biceps problems around the shoulder. They usually occur during an eccentric contraction, often when lifting something heavier than expected. Patients experience sudden pain, weakness—particularly with forearm supination—and may develop a classic Popeye deformity.
If a complete rupture is suspected, prompt evaluation is important because repair is ideally performed within 4–6 weeks. This injury has some urgency. An MRI is commonly obtained to confirm the diagnosis, followed by open reattachment of the tendon back to the bone. Following surgery, elbow function and the amount of resistance allowed are gradually increased over approximately six months. Temporary numbness from small sensory nerves around the incision is common and almost always resolves with time.