Anatomy of the biceps muscle

The biceps muscle is located at the front of the upper arm.  It originates in and around the shoulder joint as two individual ‘heads’ (the long head and the short head). It provides stability to the shoulder by resisting abnormal movements that can cause subluxation and dislocation.  The long head of biceps is regularly injured and is often described as a prominent source of shoulder pain.

Both the long head and the short head of the biceps converge to form the biceps muscle. The biceps muscle forms the ‘distal tendon’ as it passes over the front of the elbow. The distal biceps tendon inserts into to the radius (long bone within the forearm) (see image below).

Distal biceps tendon - A graphic

The biceps perform flexion (bending) of the elbow with the forearm supinated (palm up). The prime action of the at the elbow is supination. Supination activities require the palm to be turned up. Repetitive supination also occurs during rotatory movements of the forearm e.g. weightlifting or using a screwdriver.

Distal biceps tendon - Graphic depiction of Biceps Brachii in Pronated and Supinated positions

How does the distal biceps tendon become injured?

Distal biceps tendon injuries are a common cause of anterior (the front) and occasional lateral (the outside) of elbow pain and are often associated with heavy lifting and repetitive use.

Distal biceps tendon injuries include and will be discussed below;

  • Tendinitis/tendinopathy
  • Tendon tears (partial and complete)

Risk factors associated with distal biceps injuries are (Wylie et al ,2017):

  • Gender – males are at the highest risk of injury with 90% of ruptures occurring between 40 and 50 years old.
  • Weight training  (especially heavy strength training)
  • Heavy repetitive manual work e.g. builders, floor layers and roofers
  • Smoking (this is a risk factor for many tendon injuries)
  • Anabolic steroid use (this is used to build muscle)

Distal biceps tendinitis/tendinopathy

When the distal biceps tendon is subjected to prolonged periods of repetitive activity or heavy loading it can cause the tendon to become swollen and painful. When the tendon becomes inflamed it is known as tendinitis. Reoccurring bouts of tendinitis results in poor tendon healing.  The tendon becomes thickened, compromising its structure and resulting in tendinopathy.

Symptoms of the distal biceps tendinitis/tendinopathy are:

  • Sharp pain experienced over the anterior (front) aspect of the elbow joint.
  • Pain during biceps contraction (bending of the elbow and turning wrist upwards).
  • A feeling of weakness in your arm
  • Pain with completing manual tasks such weightlifting, moving and lifting heavy objects or using a screwdriver.
  • Tendinitis pain is often short lived, commonly starting after a period of increased biceps activity. It is short lived lasting, on average, 2 weeks, and responds well to a period of rest.
  • Tendinopathic pain is often experienced as a dull ache in the anterior aspect of your elbow joint interspersed with episodes of sharp pain.

Distal biceps partial tears and complete ruptures

A reverse Popeye sign (right) is a clinical sign of a complete distal biceps rupture.

Distal biceps tendon - An image of a complete distal biceps rupture

Distal biceps partial tears and ruptures are relatively rare. Hutchinson et al. (2008) quotes a rupture rate of 1.2 in 100,000 people. A partial tear of the distal biceps tendon or a full/complete tendon rupture most commonly occur secondary to the weakness within the tendon associated with a tendinopathy.  However, tendinopathy can often be present but not cause pain so you won’t know if you have it.

Both partial tears and complete ruptures of the distal biceps tendon occur during the same action, only being separated by the level of damage sustained by the tendon.  The vast majority of tendon tears and ruptures occur when the bicep is contracting, under a heavy load, with the elbow at 90 degrees and the forearm fully supinated (quoted by Beazley et al, 2017).

Symptoms of distal biceps partial tear are very similar to tendinitis/tendinopathy however, Beazley et al (2017) state that distal biceps tendon rupture symptoms include:

Distal biceps tendon rupture symptoms include:

  • Sudden severe pain on the anterior aspect of the elbow
  • Sudden pain is often accompanied by an audible snap or pop sound
  • Change in shape of the biceps muscle. This is due to retraction of the muscle and is called ‘the reverse Popeye sign’ (as seen in above image)
  • Occasionally patients complain of a temporary feeling of numbness in and around the elbow

How do we diagnose a distal biceps injury?

During your assessment, you will be asked a series of questions to uncover how your symptoms started as well as what aggravates and eases your symptoms. An examination will also involve a series of clinical tests including range of movement, strength examinations and the hook test (O’Driscoll et al, 2007). The clinical examination will indicate if a distal biceps injury has been sustained however a diagnostic ultrasound is required to confirm the extent of the injury and to assess healing.

Research has revealed that diagnostic ultrasound and magnetic resonance imaging (MRI) are both gold standard imaging techniques for diagnosing distal biceps tendon partial tears and ruptures (O’Driscoll et al. 2007).

Complete clinicians are fully qualified physiotherapists and musculoskeletal sonographers who are experienced in diagnosing and treating distal biceps tendon pathology. During your initial assessment, your complete clinician will be able to accurately assess your biceps using both clinical tests and musculoskeletal diagnostic ultrasound imaging.

If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email

How do we treat distal biceps tendinitis/tendinopathy?

The majority of patients suffering from distal biceps tendinitis/tendinopathy do well with conservative management in the form of physiotherapy. After a comprehensive assessment, your physiotherapist will be able to prescribe a rehabilitation program to strengthen the distal biceps tendon and to promote good quality healing. This usually involves a progressive strengthening program for the biceps.

Distal biceps tendon - A graphic of a man showing two different free-weight movement positions.

What happens if conservative management of distal biceps tendinitis/tendinopathy is unsuccessful?

If conservative management has failed and your symptoms remain persistent for over three months an injection therapy may be suitable for you.

Injection therapy is used to reduce pain and inflammation associated with tendinitis/tendinopathy.  The reduction in pain experienced from an injection allows you to be able to rehabilitate your injury effectively.

Injection therapy is particularly effective when your pain is:

  • Affecting your ability to sleep or wakes you at night
  • Affecting your ability to work or perform activities of daily living
  • Affecting your ability to partake in physiotherapy rehabilitation

Research has highlighted increased accuracy rates and higher efficacy with musculoskeletal injections when they are performed under ultrasound guidance. All injections at Complete are carried out using ultrasound guidance. An ultrasound scan is used to obtain real-time imagery allowing accurate placement of the needle within the target tissue.

Complete has a team of highly specialised physiotherapists and musculoskeletal sonographers who are experienced in performing ultrasound-guided injections for distal biceps tendinitis/tendinopathy.

For more information or would like to book an appointment please contact us on 0207 4823875 or email

There are two evidence-based injection options available when treating distal biceps tendinitis/tendinopathy. Both techniques are completed under ultrasound guidance and accompanied with a local anaesthetic (short-acting numbing agent).

Ultrasound-guided corticosteroid

Research has shown ultrasound-guided corticosteroid injections as an effective way of reducing pain in distal biceps tendinitis/tendinopathy (Sellon et al., 2014).  During this technique, a small amount of corticosteroid medication is deposited around the distal biceps tendon. Corticosteroid is a potent anti-inflammatory medication which is routinely used in musculoskeletal medicine for reducing pain and inflammation. This injection does not enter your tendon due to the very small risk of tendon rupture. It bathes the surrounding inflamed tissue allowing pain-free rehabilitation to occur. Ultrasound guidance allows for accurate needle placement targeting the intended inflammation whilst preserving tendon structure.

Ultrasound-guided platelet-rich plasma injection (PRP) therapy

Evidence by Barker et al (2015) reveals that PRP injections are a safe and effective injection technique for distal biceps tendinitis/tendinopathy. No medication/drug is used for this technique. Plasma within the blood has an anti-inflammatory effect and is regularly used with great effect to treat tendon pain within musculoskeletal medicine. A small amount of blood is removed via a vein in your arm and spun at high speeds using a centrifuge machine. This separates the plasma molecules from the blood before it is re-injected in and around the biceps tendon using ultrasound guidance.

How do we treat partial tears and complete ruptures?

Research reveals the success rates of conservative management of high-grade partial tears are relatively low. If MRI or diagnostic ultrasound imaging reveals a tear involving over 50% of the tendon then the chances of conservative management being successful is significantly reduced (Bauer et al., 2018). Bauer et al (2018) observed a 55.7% failure rate of all partial-thickness distal biceps tendon tears with conservative management. This study reveals the importance of an accurate diagnosis. Diagnostic imaging (using either MRI or ultrasound imaging) is an essential diagnostic tool capable of selecting the most appropriate treatment options and predicting treatment success.

Beazley et al. (2017) suggest surgical management for Partial Thickness Distal Biceps Tendon Tears may be required if:

  • Conservative management has been unsuccessful
  • There is a high functional demand required of the biceps. Either during sporting or occupational activities.
  • Your symptoms remain persistent for over 6 months

Treatment options for partial tears or complete distal biceps tendon ruptures.

Treatment options for complete ruptures are dependent on what demands you will be placing on the biceps and elbow joint. If you have a low functional demand (you do not require your biceps to work hard during your work or leisure activities) then a non-operative approach is often successful. If, however, your requirements are higher either to complete your work or for sporting purposes, then surgical repair is necessary (Beazley at el., 2017). This can be discussed with your clinician and a surgical referral made if required.

Complete has a team of highly specialised physiotherapists and musculoskeletal sonographers who are experienced in treating all types of distal biceps problems and performing ultrasound-guided injections when required.

For more information or if you would like to book an appointment please contact us on 0207 4823875 or email If you are unsure if we are able to help, our expert clinicians are happy to speak to you over the phone to discuss any queries you may have.

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