Distal Biceps Tendon at the Elbow in Vienna
A snap in the crook of the elbow, then bruising and suddenly too little strength to open a bottle: that is how a tear of the distal biceps tendon usually begins. This tendon connects the biceps to the radius and therefore belongs to the elbow. It is almost always reattached surgically — and the timing matters.
In short
The distal biceps tendon anchors the biceps (the two-headed muscle of the upper arm) to the radius in the crook of the elbow. If it tears, the muscle belly slips upwards towards the shoulder, a hollow and a bruise appear in the crook of the elbow, and strength is missing when bending the arm and above all when turning the forearm outwards (supination). I make the diagnosis from the conversation, the clinical examination and ultrasound in the practice, supplemented by an MRI where needed. Treatment is almost always surgical: I anchor the tendon stump back at its original site on the radius (refixation). Only rarely do I stay conservative — and the earlier the tear is recognised, the more straightforward the reattachment.
What the distal biceps tendon does at the elbow
The biceps has two heads at the top but only a single tendon at the bottom. It runs through the crook of the elbow and attaches to a roughened area on the radius (the tuberositas radii) — the radius being the forearm bone on the thumb side. The entire force of the muscle reaches the forearm through this one strand.
Two tasks hang on it: bending the elbow, where the brachialis muscle helps substantially, and turning the forearm outwards, supination — the movement you use to open a bottle or guide a screwdriver. For supination the distal biceps tendon is the main source of power, especially with the elbow bent.
This is exactly where it differs from the long head of the biceps tendon at the shoulder: there, other parts of the muscle take over some of the work; at the elbow there is no such substitute. How the two tendons differ in their symptoms is set out in the overview of biceps tendon tears.
How the tear happens
The typical mechanism is sudden extension against resistance: the arm is bent and holding a load that gives way abruptly or turns out heavier than expected — a tipping crate, a dumbbell, a fall with the arm tensed. In that moment the tendon usually tears completely, often with an audible snap.
Frequently it was already damaged beforehand: at its attachment it passes through a narrow space between the radius and the ulna and is deflected with every rotating movement, and wear and a poorer blood supply at that point make a tear more likely. Those affected are predominantly men in middle age, often from strength sports or from physical work — a pattern I also know from a pectoralis tendon rupture. Partial tears occur as well; they cause pain at the attachment and loss of strength when rotating without changing the muscle contour conspicuously, and are easily missed.
Why strength for outward rotation is lost
The tendon does not attach to the front of the radius but wraps around towards the inner side of the bone. When the biceps pulls, it unwinds the radius like a rope from a spool — and that produces the outward rotation. If that pull is gone, supination is left essentially to the supinator muscle. It works on a much shorter lever and tires more quickly, particularly with the elbow bent, where the biceps would otherwise be at its strongest.
In daily life this shows up in movements nobody plans: opening a bottle, setting a screwdriver, tipping a full pan. Bending strength is deceptive here, because the neighbouring muscles largely take it over — many patients consider the arm to be fine at first and come late.
Typical symptoms
- Snap in the crook of the elbow — clearly heard or felt at the moment of injury.
- Bruising — in the crook of the elbow, often delayed and tracking down the forearm.
- Hollow at the attachment — the tendon can no longer be felt as a taut cord.
- Muscle belly moves upwards — the front of the upper arm looks shorter and higher.
- Loss of strength when turning outwards — clearer than when bending, and with rapid fatigue.
- Pulling on the inner side of the upper arm — under load, in the first days after the tear.
How I make the diagnosis
At the beginning there is the conversation: how did it happen, was there a snap, since when has strength been missing when rotating? I then palpate the crook of the elbow and compare both sides — if the tendon has torn, it can no longer be hooked with a finger like a taut cord (hook test). I test bending strength and rotational strength separately, because only rotational strength shows the loss reliably. Ultrasound in the practice displays the tendon while it moves, separates a partial tear from a complete one and shows how far the stump has retracted. Where the findings remain unclear I arrange an MRI, and where a bony avulsion is suspected an X-ray; both take place outside the building.
Why the timing matters
A torn tendon does not stay where it was. It retracts towards the muscle, the tissue around it scars, and the muscle itself shortens. Soon after the tear, the stump can be led back to its original site without much traction; the longer the tear has been there, the more resistance has to be overcome. If too much time passes, anchoring at the old attachment may no longer be possible — what remains then is a tendon graft or fixation at a different site, more demanding and with a less predictable result.
If strength when rotating is missing after a snap in the crook of the elbow, have the arm examined quickly. You will usually get an appointment at the practice in Vienna-Döbling within a week; for acute cases I keep slots outside regular consulting hours.
Refixation of the distal biceps tendon
The procedure has one clear aim: to anchor the tendon stump back where it belongs. Through a small approach in the crook of the elbow I find the retracted stump, freshen it and lead it back to its attachment on the radius. There I fix it to the bone; suture anchors and button-shaped implants are available for that. Which technique fits depends on the findings and on how far the tendon has retracted.
Nerves and vessels lie close to the attachment in the crook of the elbow, so the approach is planned carefully and prepared gently. The procedure is open, because the tendon has to be guided onto the bone under direct view. The aim is to restore strength when bending and when turning the forearm outwards. Whether and when surgery takes place depends on the findings and on the demands you place on the arm; we take the decision together — accompanied by the elbow specialist in Vienna from planning to aftercare.
For patients who play sport and are physically active, I plan the refixation promptly once the findings are confirmed: anyone who relies on rotational strength in strength sports or physical work will feel the loss if the tendon stump retracts further and scars in the meantime.
When conservative treatment comes into consideration
Rarely — but those cases exist. I discuss doing without the operation above all where the demands on rotational strength are low, where concomitant conditions argue against a procedure, or where a partial tear is present that barely affects strength. A deliberate decision against surgery after full explanation belongs here too.
Conservative then means: protect the arm at first, move it under guidance and build up the bending muscles in a targeted way; physiotherapy and exercise therapy are available in the same building at the Orthozentrum Döbling. Where the attachment is irritated, an ultrasound-guided injection can help, and for partial tears PRP therapy comes into consideration. Two things I say openly: the hollow in the crook of the elbow remains, and strength for turning the forearm outwards does not come back fully without refixation.
Aftercare in principle
I deliberately give no fixed timings here — the plan follows the findings, the anchoring chosen and the course of recovery. In principle the aftercare runs in three stages:
- Protect — a splint limits extension at first, so that no traction reaches the freshly anchored tendon.
- Move — guided movement starts early, because after procedures at the elbow stiffness is the more common problem.
- Load — only once the tendon has healed in does strength work follow: bending before rotating, guided exercises before free weights.
When each stage is due I set out with you and with physiotherapy. The same principle applies to returning to strength and contact sports: last, and only once the findings allow — more on that under sports orthopaedics in Vienna.
Locations, procedure and billing
I carry out necessary procedures at the ATOMOS Klinik Währing, the Privatklinik Döbling or the Rudolfinerhaus, and I accompany you from planning through the procedure to aftercare.
My practice is a private practice, in Austria a Wahlarztordination. I do not settle directly with any public health insurer; you receive an invoice and submit it to your insurer — on request I take care of the submission for you. How that works in detail is set out under private practice and reimbursement. Bring everything you already have to your first appointment: e-card, previous findings, doctors' letters and images. No referral is needed.
Frequently asked
Common questions about the distal biceps tendon
Usually there is a snap in the crook of the elbow, followed by pain, swelling and bruising that tracks down the forearm. The tendon can no longer be felt there as a taut cord, and the muscle belly moves upwards towards the shoulder. What stands out most is the loss of strength when turning the forearm outwards. Certainty comes only from the examination with ultrasound.
Because the tendon wraps around the radius and unwinds the bone as the muscle contracts — that is what produces the outward rotation. If that pull is gone, supination is left only to the supinator muscle, which works on a much shorter lever. Bending is largely taken over by the neighbouring muscles, rotation is not. That is why the loss shows up when opening a bottle or guiding a screwdriver.
As a rule, yes. At the elbow there is no second strand of tendon to take over the task; without reattachment, rotational strength in particular stays permanently reduced. I therefore discuss refixation as the rule and stay conservative only rarely — for instance where the demands on rotational strength are low, or where concomitant conditions argue against the procedure.
As soon as possible. Soon after the tear, the tendon stump can be brought back to its original site without much traction; over time it retracts further, scars and shortens. You will usually get an appointment within a week, and for acute cases I keep slots outside regular consulting hours.
The arm remains usable, but strength when turning the forearm outwards does not come back fully, and endurance during rotating movements drops off. The changed muscle contour on the upper arm and the hollow in the crook of the elbow remain. Anyone who later does decide on surgery meets the more difficult conditions of a delayed repair.
Through a small approach in the crook of the elbow I find the retracted tendon stump, freshen it and bring it back to its attachment on the radius. There I anchor it to the bone; suture anchors and button-shaped implants are available for that. The procedure is open, because the tendon has to be guided onto the bone under direct view.
First the arm is held in a splint that limits extension and keeps traction off the anchored tendon. Guided movement starts early, so that the elbow does not stiffen. Building strength comes later, bending before rotating. When each step is due I set out with you and with physiotherapy, and adapt it as recovery goes on.
My practice is a private practice, in Austria a Wahlarztordination. I do not settle directly with any public health insurer; you receive an invoice and submit it to your insurer — on request I take care of the submission for you. For an operation, direct settlement with a supplementary private insurance is possible.
Dr. med. Martin Eigenschink
Specialist in Orthopaedics and Traumatology · Specialist in elbow, shoulder and hand surgery
Surgical and conservative treatment of the elbow, shoulder and hand, preferably minimally invasive. Practice at the Orthozentrum Döbling, 1190 Vienna. More about my background
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