The distal biceps tendon attaches the biceps muscle to the radius bone just below the elbow. It powers elbow bending and, even more importantly, turning the palm up (supination), the motion used to turn a screwdriver or doorknob. A rupture usually happens when a heavy load forces a bent elbow straight, such as catching a falling object or lifting furniture. Dr. Andrew Dold, a board-certified, fellowship-trained sports medicine surgeon in Frisco, Texas, repairs distal biceps ruptures with a single-incision technique.
- Most common in men in their 40s, usually in the dominant arm
- Without repair, turning-the-palm-up strength is often permanently reduced
- Dr. Dold repairs the tendon through a single small incision using a cortical button
- Repair is ideally done within the first 2 to 3 weeks, before the tendon scars and retracts
- About 9 in 10 patients return to sport, on average around 6 months after surgery
Distal Biceps Avulsion — Orthobullets
Dr. Dold is a listed author of the Distal Biceps Avulsion topic on Orthobullets, an online educational resource for orthopedic surgeons, residents and students. The topic covers how these injuries are diagnosed and the surgical techniques used to repair them.
Who gets a distal biceps rupture?
In a population study, distal biceps ruptures occurred in about 1.2 per 100,000 people per year, mostly in men with an average age of 47, and the dominant arm was involved in 86%. Smokers had a 7.5 times higher risk.1
Symptoms
- A sudden pop or tearing sensation at the front of the elbow
- Pain, swelling and bruising at the elbow and forearm
- A change in the shape of the upper arm as the muscle pulls up (“reverse Popeye” sign)
- Weakness turning the palm up and bending the elbow
Diagnosis
Dr. Dold examines the front of the elbow to feel for the tendon (the “hook test”) and checks strength. An MRI confirms whether the tear is complete or partial and shows how far the tendon has pulled back. Some tears involve only one of the tendon’s two heads and can be easy to miss on examination.2
Treatment without surgery
Non-surgical treatment is an option for lower-demand patients who accept some loss of strength, and for some partial tears. In a study of unrepaired ruptures, patients were generally satisfied, but supination strength was about 63% of the other arm compared with about 92% in surgically repaired patients; elbow-bending strength was less affected.3
Surgery
For active patients, Dr. Dold recommends surgical repair, ideally within the first 2 to 3 weeks after the injury, while the tendon is still long enough to reach the bone easily. He uses a single-incision technique through a small incision in the front of the forearm: the tendon is prepared with strong sutures and pulled into a bone tunnel in the radius, where it is held by a cortical button on the far side of the bone.
Watch Dr. Dold explain distal biceps repair
In a randomized trial comparing single-incision and two-incision repair, final outcomes were the same at two years, apart from slightly greater bending strength with the two-incision technique; temporary numbness of the forearm skin nerve was more common with a single incision.4
Late (chronic) ruptures
When a rupture is diagnosed late, the tendon may scar and retract. A systematic review of direct repair performed on average about 4 months after injury found good satisfaction and function when enough tendon remained, although the evidence is limited.5 If the tendon cannot reach the bone, it can be reconstructed with a tendon graft.
Risks
A review of more than 3,000 repairs found an overall complication rate of 25%, mostly minor; the most common was numbness over the forearm from irritation of the skin nerve (about 9%), which usually recovers. Major complications occurred in 4.6%, including injury to the posterior interosseous nerve (1.6%) and re-rupture (1.4%); most nerve injuries resolved on their own.6
Recovery and return to sport
After surgery, most patients wear a splint or brace briefly and start gentle motion early, followed by gradual strengthening. Heavy lifting is restricted for several months. A 2025 systematic review of 1,093 patients found that 91.5% returned to sport, with 85% returning to their previous level or higher, at an average of about 6 months.7 In athletes, earlier return was associated with acute (rather than delayed) repair.8
See also biceps tendinitis and tears at the shoulder.
What the research shows
Here is what larger studies add about distal biceps repair.
Repair compared with no repair
Pooled studies find better outcomes after surgical repair than without it, particularly for turning the palm up. Non-surgical care remains reasonable for some lower-demand patients.
Single or double incision
Function scores are similar after single- and double-incision repairs. The single-incision approach has been associated with better motion and less heterotopic (extra) bone formation, while the double-incision approach has had fewer sensory nerve symptoms. Cortical button fixation is among the strongest constructs in laboratory testing and has had low complication rates clinically.
Recovery
Recent reviews find that early motion after repair is as safe as a period of immobilization, and most athletes return to sport about 6 months after surgery.
Partial and late tears
Partial tears that do not improve with non-surgical care have done well with surgical repair. Even many chronic tears can be repaired directly, and a graft can be used when the tendon will not reach.
Why see Dr. Dold
- Board certified by the American Board of Orthopaedic Surgery, with subspecialty certification in Sports Medicine
- Sports medicine and arthroscopy fellowship at NYU Langone / Hospital for Joint Diseases; orthopedic residency at the University of Toronto
- Fellow of the American College of Surgeons (FACS), the American Academy of Orthopaedic Surgeons (FAAOS), the American Orthopaedic Association (FAOA) and the Royal College of Surgeons of Canada (FRCSC)
- Author of a SLAP repair book chapter (Springer, 2017) and research on shoulder suture anchors (KSSTA, 2013)
- Team physician and surgical consultant to Rugby Canada; has cared for professional athletes from the NFL, NBA, NHL, MLS, PGA Tour and Major League Rugby
- D Magazine Best Doctors (Collin County), 2019–2026 · Rated 4.9 on Google
Frequently asked questions
Do I need surgery for a torn distal biceps tendon?
Not always. Without repair, many people function well but lose a significant amount of strength turning the palm up.3 For active patients, Dr. Dold usually recommends repair.
How soon should it be repaired?
Ideally within the first 2 to 3 weeks. Over time the tendon retracts and scars, which makes repair more difficult and may require a graft.
What kind of surgery does Dr. Dold perform?
A single-incision repair in which the tendon is pulled into a bone tunnel in the radius and held with a cortical button.
How long until I can return to sport or lifting?
On average about 6 months; in a large review, more than 90% of patients returned to sport.7
What are the risks?
Most complications are minor, such as temporary numbness of the forearm skin. Serious complications such as nerve injury or re-rupture are uncommon.6
Research cited on this page
- Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002;(404):275-283. PubMed
- Iqbal K, Leung B, Phadnis J. Distal biceps short head tears: repair, reconstruction, and systematic review. J Shoulder Elbow Surg. 2020;29(11):2353-2363. PubMed
- Freeman CR, McCormick KR, Mahoney D, Baratz M. Nonoperative treatment of distal biceps tendon ruptures compared with a historical control group. J Bone Joint Surg Am. 2009;91(10):2329-2334. PubMed
- Grewal R, Athwal GS, MacDermid JC, Faber KJ. Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial. J Bone Joint Surg Am. 2012;94(13):1166-1174. PubMed
- Tzeuton S, Johns W, Campbell B, et al. Outcomes and Patient Satisfaction of Delayed Distal Biceps Repairs without Graft Augmentation: A Systematic Review. JBJS Rev. 2023;11(5). PubMed
- Amarasooriya M, Bain GI, Roper T, et al. Complications After Distal Biceps Tendon Repair: A Systematic Review. Am J Sports Med. 2020;48(12):3103-3111. PubMed
- Boufadel P, Daher M, Lopez R, et al. Return to Sport After Distal Biceps Tendon Repair: A Systematic Review. Am J Sports Med. 2025;53(7):1769-1778. PubMed
- Pitsilos C, Gigis I, Chitas K, et al. Systematic review of distal biceps tendon rupture in athletes: treatment and rehabilitation. J Shoulder Elbow Surg. 2022;31(8):1763-1772. PubMed
- Looney AM, Day J, Bodendorfer BM, et al. Operative vs. nonoperative treatment of distal biceps ruptures: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2022;31(4):e169-e189. PubMed
A meta-analysis of about 2,500 cases found surgical repair gave better outcomes than non-surgical treatment. - Castioni D, Mercurio M, Fanelli D, et al. Single- versus double-incision technique for the treatment of distal biceps tendon rupture. Bone Joint J. 2020;102-B(12):1608-1617. PubMed
A meta-analysis of 2,622 patients found similar function scores after single- and double-incision repair; single-incision repair had better bending and turning motion and less heterotopic bone. - Hurley ET, Luthringer TA, Manjunath AK, et al. Complications of Single-Incision Versus Dual-Incision Distal Biceps Repair A Systematic Review and Meta-Analysis of Comparative Studies. Bull Hosp Jt Dis (2013). 2022;80(3):270-276. PubMed
Double-incision repair had fewer overall complications and sensory nerve injuries but more heterotopic bone than single-incision repair. - Watson JN, Moretti VM, Schwindel L, et al. Repair techniques for acute distal biceps tendon ruptures: a systematic review. J Bone Joint Surg Am. 2014;96(24):2086-90. PubMed
Complication rates were similar between one- and two-incision repairs, and bone tunnel and cortical button fixation had fewer complications than suture anchors or screws. - Taylor AL, Bansal A, Shi BY, et al. Optimizing Fixation for Distal Biceps Tendon Repairs: A Systematic Review and Meta-regression of Cadaveric Biomechanical Testing. Am J Sports Med. 2021;49(11):3125-3131. PubMed
A review of laboratory studies found cortical button fixation the strongest construct, and suture anchors alone weaker. - Forlenza EM, Lavoie-Gagne O, Parvaresh KC, et al. Two Intramedullary and 1 Extramedullary Cortical Button, With or Without Interference Screw, Show Biomechanical Properties Superior to Native Tendon in Repair of the Distal Biceps Tendon: A Systematic Review and Network Meta-analysis of Biomechanical Performance. Arthroscopy. 2023;39(2):390-401. PubMed
Cortical button constructs matched or exceeded the strength and stiffness of the native tendon in laboratory studies. - Chiossi S, Spoliti M, Sessa P, et al. Distal biceps tendon repair and posterior interosseous nerve injury: clinical results and a systematic review of the literature. Med Glas (Zenica). 2021;18(1):196-201. PubMed
A review of cortical button repairs found posterior interosseous nerve injury was uncommon and usually recovered. - Schönweger F, Cuzzolin M, Sangiorgio A, et al. Distal biceps tendon repair: immobilization versus early mobilization. A systematic review and meta-analysis. EFORT Open Rev. 2026;11(7):849-858. PubMed
A 2026 review found early mobilization and immobilization after repair gave similar outcomes. - Simpson ER, Jawanda H, Patel I, et al. No Clinically Significant Differences in Patient-Reported Outcomes and Range of Motion Between Early and Delayed Mobilization After Primary Distal Biceps Tendon Repair: A Systematic Review and Meta-analysis. Am J Sports Med. 2025;53(13):3261-3274. PubMed
A 2025 review found no clinically significant difference in failure or complications between early and delayed motion after repair. - Behun MA, Geeslin AG, O’Hagan EC, et al. Partial Tears of the Distal Biceps Brachii Tendon: A Systematic Review of Surgical Outcomes. J Hand Surg Am. 2016;41(7):e175-89. PubMed
Partial tears that did not improve without surgery did well after completing the tear and repairing it to the bone. - Murthi AM, Ramirez MA, Parks BG, et al. Lacertus Fibrosus Versus Achilles Allograft Reconstruction for Distal Biceps Tears: A Biomechanical Study. Am J Sports Med. 2017;45(14):3340-3344. PubMed
In a laboratory study, a reconstruction using the patient’s own lacertus fibrosus was as strong as an Achilles allograft for chronic tears.
Medically reviewed by Andrew P. Dold, MD, FAOA, FAAOS, FACS, FRCSC. Last reviewed October 2026. This page is general information, not medical advice. Individual results vary.
