Biceps Tendon Rupture

This matters most, because the two are handled in opposite ways.

At the shoulder (proximal rupture). The injury happened at the front of the shoulder, and the biceps muscle has bunched into a bulge in the upper arm. This is the common one. It can usually be managed without surgery ⁶, and non-surgical care is the standard first step ⁴.

At the elbow (distal rupture). The injury happened at the crease of the elbow instead. This is the less common injury, and it usually needs surgical repair ⁶. If that sounds like you, get it assessed promptly at an appointment with us or by your GP. Don't wait to see whether it settles.

And the shoulder around it. If lifting your arm out to the side is weak or painful, or you can't sleep on that side, the problem may be partly in the rotator cuff. Our Rotator Cuff Tear page covers that pattern. We check for it at every assessment for this injury.

A complete tear at the shoulder is usually obvious once someone looks at your arm. The muscle bunches into a bulge, and when you tighten it, it sits closer to the elbow than the biceps on your other side ⁷. Partial tears are harder to pick. You'll be asked to bend your elbow and tense the biceps, and pain when you do that can point to one ⁷.

We also check the front of the elbow, because a tear at that end leaves a gap there ⁷. An X-ray can't show the tendon itself, but it can pick up other causes of shoulder pain. Ultrasound shows the soft tissue, though how useful it is depends a lot on who's doing the scan, and an MRI can show both partial and complete tears ⁷.

The first job is confirming which end of the tendon has gone and whether anything else in the shoulder is involved. That's done by examining you. Scans can help but aren't always needed ², and shoulder problems in general tend to be over-investigated ⁵. From there:

Anti-inflammatory medication and corticosteroid injections. Both are part of the recognised non-surgical approach for this injury ⁴. They're prescribed or given by a doctor, not by physiotherapists, so that's a conversation with your GP, not with us.

Surgery. Surgery for a shoulder-end rupture is generally for people whose symptoms don't settle with non-surgical care ⁴. What triggers it is persistent symptoms, not the size of the tear. There are two main options: a tenotomy, where the tendon is released and left to settle, and a tenodesis, where it's reattached lower down the upper arm bone.

The evidence comparing them cuts both ways. A tenotomy carried about two and a half times the risk of a visible Popeye bulge, and scored slightly lower on a shoulder function score at two years ³. Cramping in the muscle and pain at the front of the shoulder have also been reported more often after tenotomy ⁴. But the same researchers described that two-year difference as clinically irrelevant and recommended either technique ³. Pain, elbow bending strength and forearm strength showed no significant difference ³, and neither did overall function or patient satisfaction ⁴. One caveat: those trials looked at long head biceps problems generally, not only ruptures ³.

In plain terms, the choice is largely about appearance and preference, not about getting your strength back. If you do have surgery, post-operative rehab is where we come back in.

A ruptured long head of biceps is managed along The Well Motion Recovery Path™. The tendon stays torn, so you step up a phase when the arm copes with more, not when a date comes round.

• Reset: the first days. We confirm which end of the tendon went and check the rotator cuff, then relative rest gives way to gentle movement ². Expect the bulge to stay. We move you on once everyday movement no longer stirs the pain up.
• Rebuild: the longest phase. Exercise prescription and conditioning loads the arm and shoulder in steps ², with manual therapy when stiffness gets in the way. Cramping in the biceps is a recognised problem with this injury ⁴, so expect some. We move you on when the arm does what your daily tasks ask of it.
• Return: back to lifting, overhead work, the gym or sport. We test the tasks you need at the loads you need, and you leave with a loading program. If symptoms do not settle, a surgeon decides the next step ⁴ and sets the pace of rehab after any operation.

How long it usually takes. We found no study timing recovery from this rupture without surgery. For shoulder pain in general, about half of people treated conservatively recover within six months ⁵. After tenodesis, one series of 18 men with no comparison group used a sling for 6 weeks, added resistance from week 12 and allowed usual activity from week 16 ⁸.

Prevention hasn't been put through a trial for this injury, so what follows comes from its recognised risk factors:

• Heavy overhead lifting. Too much weight in the gym, and jobs with a lot of heavy overhead lifting, both add wear to these tendons ⁷. Lifting without a proper warm-up is another recognised cause of tendon trouble ¹. Build your loads up slowly and rest between similar sessions ².
• Repetitive overhead sport. Swimming and tennis are the two examples orthopaedic surgeons give for wearing a shoulder tendon down over time ⁷.
• A sore shoulder you've been putting up with. Tendinitis, impingement and rotator cuff injuries each put extra stress on the biceps tendon, which makes it more likely to weaken or tear ⁷. Slow fraying is a more common cause than a single injury ⁷, so an ache that has lasted months is worth having checked.
• Smoking. Nicotine can weaken tendons ⁷.