Current Concepts Review   |    
Distal Biceps Tendon Injuries
Ryan G. Miyamoto, MD1; Florian Elser, MD2; Peter J. Millett, MD, MSc2
1 Fair Oaks Orthopaedic Associates, 3650 Joseph Siewick Drive, Suite 300, Fairfax, VA 22033
2 Clinical Research, Steadman Philippon Research Institute, 181 West Meadow Drive, Suite 1000, Vail, CO 81657. E-mail address for P.J. Millett: drmillett@steadmanclinic.net
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Arthrex).

Investigation performed at the Steadman Phillipon Research Institute, Vail, Colorado

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Sep 01;92(11):2128-2138. doi: 10.2106/JBJS.I.01213
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Distal biceps tendon ruptures present with an initial tearing sensation accompanied by acute pain; weakness may follow. The hook test is very reliable for diagnosing ruptures, and magnetic resonance imaging can provide information about the integrity and any intrasubstance degeneration of the tendon.

There are subtle differences between the outcomes of single and modified two-incision operative repairs. With regard to complications, there is a higher prevalence of nerve injuries in association with single-incision techniques and a higher prevalence of heterotopic ossification in association with two-incision techniques.

Fixation techniques include the use of bone tunnels, suture anchors, interference screws, and cortical fixation buttons. There is no clinical evidence supporting the use of one fixation method over another, although cortical button fixation has been shown to provide the highest load tolerance and stiffness.

Postoperative rehabilitation has become more aggressive as fixation methods have improved.

Figures in this Article
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    Peter J. Millett, MD, MSc, Ryan J. Warth, MD, Chris Espinoza-Ervin, MD
    Posted on April 29, 2013
    Response to Dr. Strauch's comment
    Steadman Philippon Research Institute, Vail, CO, USA, and Fair Oaks Orthopaedic Associates, Fairfax, VA, USA

    Several anatomic studies have shown that the short head of the distal biceps tendon travels medially and attaches distally to the radial tuberosity, in contrast to the long head, which travels laterally and attaches more proximally.2,3  While this description is correct, concluding that this orientation results in a ‘clockwise’ configuration in a left elbow may be confusing and, in fact, incorrect when viewing from proximal to distal.  Figure 1 illustrates the correct orientation of the distal biceps tendon as it approaches the radial tuberosity. Figure 2 demonstrates the spiraling of the distal fibers of the long head of the biceps tendon in both a right and left elbow.

    Although the work of Kulshreshtha et al.3 is commendable in describing fiber arrangement of the distal biceps tendon as it inserts upon the radial tuberosity, their description of a clockwise rotation in a left elbow may be confusing since the authors make no mention of whether the viewing angle is proximal to distal or distal to proximal. Therefore, without a point of reference, it is difficult to interpret the meaning of ‘clockwise’ in their description.  Because the illustration of fiber arrangement is correct in their presented figures, it may be concluded that “clockwise” refers to a viewing angle of distal to proximal, which would be consistent with the orientation that occurs while surgically repairing a torn distal biceps tendon.

    Thank you for pointing out this discrepancy and we hope that our figures clarify the correct anatomic orientation of the fibers of the insertion of the distal biceps.

    1. Miyamoto RG, Elser F, Millett PJ. Current Concepts Review: Distal Biceps Tendon Injuries. J Bone Joint Surg Am 2010;92:2128-2138.

    2. Eames MHA, Bain GI, Fogg QA, van Riet RP. Distal Biceps Tendon Anatomy: A Cadaveric Study. J Bone Joint Surg Am 2007;1044-1049

    3. Kulshreshtha R, Singh R, Sinha J, Hall S. Anatomy of the Distal Biceps Brachii Tendon and Its Clinical Relevance. Clin Orthop Relat Res 2006;456:117-120.

    Robert J. Strauch MD
    Posted on November 28, 2012
    Clockwise or Counterclockwise?
    Columbia University

    In performing a left distal biceps tendon repair with suture anchors yesterday, the resident confidently described the rotation of the fibers into the radial tuberosity as "clockwise", meaning, that if you are looking at the tuberosity from the viewpoint of the shoulder, that the lateral portion would rotate 90 degrees clockwise and insert on the distal portion of the tuberosity, while the medial portion would insert on the proximal portion.

    This is incorrect, as the lateral portion of the distal biceps tendon (long head origin) attaches proximally on the tuberosity and the medial portion (short head origin) attaches distally. The resident, however, pointed out that this JBJS Current Concepts Review (1) as well another review article (2) both noted a "clockwise" rotation in the left elbow and a "counter-clockwise" rotation in the right elbow.

    The origin for this erroneous information comes from the article by Kulshreshtha et al. (3) which correctly illustrates the anatomy, but incorrectly, or confusingly, describes the rotation as "clockwise" in a left elbow and "counter-clockwise" in a right elbow. This might be true if one is looking up at the elbow from the perspective of the hand, but is incorrect if, as is usually is the case, one is performing a distal biceps repair and wondering which direction the tendon rotates as it transits the antecubital fossa.

    2006 and 2007 were banner years for distal biceps tendon anatomy and there were three excellent anatomic studies of the distal biceps tendon, (3,4,5) all arriving at the same basic conclusion: the lateral portion of the biceps tendon inserts proximal to the medial tendon on the radial tuberosity. In a left elbow, if one were looking down on the elbow from the shoulder, this would be a "counter-clockwise" rotation, and in a right elbow, a "clockwise" rotation.

    The clinical utility of this information is debatable, however the anatomy is not.

    1. Distal biceps tendon injuries. Miyamoto RG, Elser F, Millett PJ. J Bone Joint Surg Am. 2010 Sep 1;92(11):2128-38.
    2. Surgical Treatment of Distal Biceps Rupture. Sutton KM, Dodds SD, Ahmad CS, Sethi PM. J Am Acad Orthop Surg March 2010 ; 18:139-148.
    3. Anatomy of the distal biceps brachii tendon and its clinical relevance. Kulshreshtha R, Singh R, Sinha J, Hall S. Clin Orthop Relat Res. 2007 Mar;456:117-20.
    4. The distal biceps tendon: footprint and relevant clinical anatomy. Athwal GS, Steinmann SP, Rispoli DM. J Hand Surg Am. 2007 Oct;32(8):1225-9.
    5. Distal biceps tendon anatomy: a cadaveric study. Eames MH, Bain GI, Fogg QA, van Riet RP. J Bone Joint Surg Am. 2007 May;89(5):1044-9.

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