Biceps Rupture Research Articles

‘A torn shoulder’: An emergency department case study

BackgroundRupture of the biceps is not a very common presentation to the emergency departments; as a result, it is poorly documented, especially in nursing literature. It is important that these patients are appropriately managed by registered advanced nurse practitioners. As the diagnosis of rupture is usually made on clinical grounds with imaging assisting in the diagnosis, left untreated these injuries can lead to considerable functional deficits. MethodsThe following paper is a case study based on a patient who presented to the emergency department with a proximal biceps rupture following trauma. The paper focuses on the clinical assessment and management of patients who present to the emergency department with these injuries. ResultsThis case study increases awareness of bicep ruptures and its management in the ED. Discussion points include the neurovascular assessment of these patients, the appropriateness of diagnostic imaging, and in-depth clinical examination techniques. ConclusionRupture of the biceps tendon is often a result of a sudden forceful extension of the elbow against a previously contracted biceps and flexed elbow. The patient often describes a popping noise and presents with a ‘popeye’ deformity over their biceps. It is important to be vigilant with these injuries as early recognition will optimise the patients' outcomes.

Endoscopic Distal Biceps Repair: Endoscopic Anatomy and Dual-Anchor Repair Using a Proximal Anterolateral “Parabiceps Portal”

Distal biceps rupture is associated with significant functional disability, and surgical treatment involves open or endoscopic-assisted repair of the ruptured tendon through an anterior incision. This report describes an endoscopic approach that is performed with 2 portals for visualization and instrumentation. Preoperative sonography is used to identify bony and soft-tissue landmarks. The viewing portal is a proximal anterolateral “parabiceps portal” developed by the author, and the landmarks and relevant anatomic relations have been derived from a preliminary anatomic study. The working portal is a distal anterior portal and permits access to the radial tuberosity through the internervous muscular plane. The parabiceps portal permits visualization of the anterior and medial region of the radial tuberosity. A detailed description of the endoscopic pathoanatomy of the distal biceps tendon region is presented. The distal anterior portal is used for retrieval of the ruptured tendon, and thereafter the tuberosity is debrided and anchors are placed under vision. The ruptured tendon is whipstitched and docked onto the tuberosity, and nonsliding knots are used to securely reattach the tendon to bone. Overall, the 2-portal technique provides a method for tendon repair under direct visualization and is safe and reproducible.

Distal Biceps Repair With Acellular Dermal Graft Augmentation

Rupture of the distal bicep brachii tendon has received significant attention as a result of increased awareness of injury, numerous surgical fixation techniques, and debate regarding single versus dual incision surgery. The majority of ruptures may be fixed primarily. On rare occasion, the tendon may be attritionaly thinned, or may not have the elasticity to be directly repaired back to the radial tuberosity. We describe a technique for using acellular dermal allograft to augment (not bridge) attritional distal biceps ruptures.

Dynamometer Elbow Strength and Endurance Testing After Distal Biceps Reconstruction w/Allograft

Objectives:The purpose of the current study is to investigate the functional strength outcomes of late distal biceps reconstruction using allograft tissue.Methods:Patients who underwent distal biceps reconstruction with allograft tissue between May 2007 and May 2013 were identified. Charts were retrospectively reviewed for post-operative complications, gross flexion and supination strength, and range of motion (ROM). Isokinetic strength and endurance in elbow flexion and forearm supination were measured in both arms. Tests were conducted using a dynamometer at 60o per second for isokinetic strength and 240o per second for endurance. Isometric strength testing was also measured for elbow flexion and forearm supination. Paired t tests were used for statistical analysis.Results:Ten patients with a mean age of 48 years (range 42 - 61 years) were included in the study. Distal biceps reconstruction was performed using an Achilles tendon allograft in 9 patients and a combination of tibialis anterior allograft and gracilis allograft in 1 patient. Of the reconstructions, 50% involved the dominant arm. Full ROM was observed in all patients at the time of their final follow up assessment. The mean follow-up for dynamometer strength testing was 34 months (range 13-81 months). No statistical differences were noted between data obtained from operative and contralateral extremities. The average peak torque of the operative limb (38.5± 5.9 Nm) was 91.7% of that of the contralateral limb (41.8±4.9 Nm) in flexion and 93.4% (operative, 5.7±1.3 Nm; contralateral, 6.1± 1.0 Nm) in supination. No significant differences were found in fatigue index between operative or contralateral limbs for flexion (operative, 34.1±17.1%; contralateral, 30.8±17.1%; p = 0.29) or supination (operative, 38.2±16.5%; contralateral, 42.1±11.9%; p = 0.65). . The only complication observed was a transient PIN palsy in one patient which resolved by 3 months post-operatively. All patients reported postoperative cosmetic deformity but found their gross appearance acceptable.Conclusion:Late reconstruction for chronic distal biceps rupture using allograft tissue is a safe and effective solution for symptomatic patients with functional demands in forearm supination and elbow flexion. Dynamometer testing shows near normal return of strength and endurance of both elbow flexion and supination following the procedure.

Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series

The purpose of this study was to report the outcome of a large cohort of patients undergoing distal biceps tendon repair. We compared the endobutton and transosseous suture repair techniques, both performed through a 2-incision approach. At an average of 2.1 years after a distal biceps repair, 46 male patients (19 endobutton and 27 transosseous suture) were reviewed. The mean age of our patients was 50 years. Forty-three patients (93%) were satisfied with the results of their distal biceps tendon repair. The average pain score was 1.3 of 10 at a mean 2.1 years after repair. More than 80% of patients had regained their premorbid function in both recreational and occupational activities. The mean Mayo Elbow Performance Score was 93 of 100. Biodex strength testing demonstrated restoration of 92% of low-velocity supination power, 102% of high-velocity supination power, and 104% endurance compared with the contralateral limb. There was no statistically significant difference in postoperative strength between the transosseous suture and endobutton groups. There were 3 complications in this series, 1 case of heterotopic ossification and 2 cases of injury to the lateral cutaneous nerve of the forearm. In this large cohort of 2-incision distal biceps repairs, we found a high degree of patient satisfaction and a low complication rate. We did not find any difference in clinical outcome with regard to subjective patient rating, pain, range of motion, or supination strength when comparing the 2-incision endobutton and transosseous suture fixation techniques.

Reconstruction of delayed diagnoses simultaneous bilateral distal biceps tendon ruptures using semtendinosus and quadriceps tendon autografts.

IntroductionSimultaneous bilateral distal biceps rupture is rarely reported, but several issues has to be taken into account and the here presented case brings up some of these aspects.Case descriptionThis case presents a simultaneous bilateral distal biceps ruptures, and due to delayed diagnosis, bilateral muscle retraction had occurred. Surgical reconstruction was challenged both by social circumstances and by previous harvesting of the Semitendinous tendon on one side. The surgery was performed as a staged approach, using a Semitendinosus graft at one side and later using a Quadriceps tendon graft on the opposite site. At follow-up 14 month postoperatively the Oxford Elbow Score was 92 percent for both elbows and the MRI’s bilaterally demostrates that the grafts are tight.Discussion and evaluationThe Quadriceps tendon is a previously non reported type of graft material for this type of surgery. Based on the experience from this case it is concluded that six weeks after trauma the degree of retraction of the distal biceps tendon can impair direct repair.ConclusionWhen reconstruction of the ruptured distal biceps tendon is needed, subjective normal forces can be obtained using both the semitendosus graft as well as the quadriceps graft, however with a minor increased donor site morbidity with respect to the quadriceps graft.

Distal biceps reconstruction 13 years post-injury.

Distal biceps tendon ruptures are relatively rare injuries most commonly caused by an eccentric contraction of the biceps brachii. The majority of complete ruptures receive early surgical intervention, however, some patients do present in a delayed fashion. There are many surgical options at this time for acute and chronic injuries, and this case report describes an Achilles allograft reconstruction in a male who sustained a complete tear 13 years prior to presentation. At 12-month follow up, he had regained full function of his dominant extremity as evidence by returning to work with no limitations and by a Disabilities of the Arm, Shoulder, and Hand (DASH) score of zero. We are unaware of a successfully surgically reconstructed distal biceps tendon of this chronicity. As the literature on this subject is sparse, this case report gives credence to the idea that certain patients with a chronic distal biceps rupture should be considered for operative reconstruction and not relegated to continued failed conservative treatment. Discussed are the surgical treatment options and controversies for chronic distal biceps ruptures, and we review various outcome studies using different surgical techniques.

Posterior Interosseous Nerve Incarceration With Endobutton Repair of Distal Biceps

Distal biceps ruptures are uncommon injuries that comprise approximately 3% of all biceps pathology. This injury is most commonly seen in 40- to 60-year-old men, and the mechanism of injury involves a forceful extension movement to a flexed elbow. Without surgical intervention, patients are left with measurable weakness in elbow flexion and supination as well as a cosmetic deformity that often leaves them dissatisfied. Consequently, early surgical repair is advocated for physically active individuals. A variety of surgical approaches and fixation devices are currently used for distal biceps repair. The single-incision cortical button repair for distal biceps avulsions has become popular since Bain introduced the technique in 2000. The advantage of the cortical button biceps repair technique is the significantly higher failure strength than either the 2-incision technique or the suture anchor repair. The initial repair strength of the cortical button technique allows immediate active elbow range of motion and accelerated rehabilitation. Additionally, the single-incision anterior approach is less invasive than the 2-incision biceps repair and results in a lower incidence of heterotopic ossification. One disadvantage of this approach, however, is the risk of injury to the posterior interosseous nerve. The authors report a case in which the posterior interosseous nerve was incarcerated between the cortical button and the radius during acute distal biceps repair, resulting in complete posterior interosseus nerve palsy. This case report details the surgery leading to the nerve palsy and the subsequent nerve exploration that identified the cause of the nerve palsy. Recommendations are made on how to avoid this complication during distal biceps tendon repairs.

Isolated subscapularis repair for massive rotator cuff tear.

The best surgical treatment for an irreparable rotator cuff tear is controversial. In such cases, partial rotator cuff repair, primarily involving the posterior cuff in most reports, has been shown to be beneficial. The authors retrospectively investigated 41 patients who underwent arthroscopic subscapularis-only repair and greater tuberoplasty between April 2003 and August 2009 for massive 3-tendon cuff tears with irreparable supraspinatus and infraspinatus tendons after 3 months of conservative management was unsuccessful. Twenty-five patients (61%) underwent biceps tenotomy, and the remaining 39% had preexisting biceps tenotomy or rupture. The patients were assessed with American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Of the 41 patients, 34 (83%) were available for a follow-up telephone questionnaire after a minimum of 12 months (mean, 35 months; range, 12-84 months). Mean ASES and SANE scores were 76% and 63%, respectively. Mean postoperative passive range of motion was 156° of forward flexion and 39° of external rotation. Of the patients queried, 74% (25 of 34) were able to actively raise their arms above shoulder level. For those with a positive belly-press test result preoperatively, 22 of 27 patients had a negative test result postoperatively. A total of 3 complications (7.3%) occurred. Workers' compensation claim was a strong predictor of lower shoulder scores. Arthroscopic subscapularis-only repair and greater tuberoplasty may offer a promising and safe method for treating massive rotator cuff tears when the supra-spinatus and infraspinatus tendons are irreparable. Workers' compensation claim may predict lower outcome scores.

The biceps tendon: from proximal to distal: AAOS exhibit selection.

Ding, David Y. MD1; Garofolo, Garret BS1; Lowe, Dylan MD1; Strauss, Eric J. MD1; Jazrawi, Laith M. MD1 Author Information

Complications following subpectoral biceps tenodesis with interference screw fixation

BackgroundSubpectoral biceps tenodesis is considered an effective and increasingly popular method to manage long head of the biceps tendon pathology and combined lesions of the biceps labral complex. The purpose of this study was to report the complications following this procedure in a large prospective group of patients using a consistent technique.HypothesisSubpectoral biceps tenodesis is a safe and effective method for treating long head of the biceps pathology with a low complication rate.Study designCase series. Level of evidence IV.MethodsThis study had prior Institutional Review Board approval. Over a period of 5 years, 636 patients underwent subpectoral biceps tenodesis by the same surgeon. Patients who underwent subpectoral tenodesis with interference screws using a standardized technique were included in the analysis. Those who underwent biceps tenodesis for a chronic long head biceps rupture, those who underwent concomitant shoulder arthroplasty and those who underwent revision biceps tenodesis were excluded. All patients included in the study also underwent a postoperative physical examination.ResultsFrom November of 2005 to June of 2011, 491 patients met the inclusion criteria, 344 patients were male, 147 female and 39 were worker compensation cases. Out of the 491 patients with subpectoral biceps tenodesis, complications occurred in 12 patients of which 11 were considered minor and 1 was considered a major complication. The major complication was a proximal humerus fracture that occurred through the drill hole 2 weeks postoperatively. This was clearly due to a technical error where the drill hole was placed eccentrically in the humeral shaft. There were 11 minor complications; 5 cases had a rupture at the fixation site, 2 other cases had ruptures at the muscle-tendon junction site (distal to the tenodesis) and 1 patient had a rupture in continuity. Two cases had minor sprains that presented only with mild pain and resolved completely and one other case needed to be revised due to a prominent screw. All of the complications occurred within the first 2 months after surgery and 2 were in worker compensation cases.ConclusionAn overall complication rate of 2.4 % validates the hypothesis of a low complication rate after subpectoral biceps tenodesis. These results support the conclusions from previous biomechanical studies that have shown good bone-tendon-screw interface fixation strength.

Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw

The use of cortical suspensory fixation in conjunction with an interference screw to treat distal biceps ruptures has yielded favorable results. However, literature examining the incidence of fixation failure in a large consecutive series of patients treated with this technique is lacking. A retrospective review of electronic medical records identified 170 distal biceps ruptures in 168 consecutive patients (164 men and 4 women) treated using a cortical button in conjunction with an interference screw. The study group was an average age of 48 years (range, 20-71 years). Records were reviewed from the time of the initial clinic visit to the most recent follow-up. Early failures were defined as those that occurred within 12 weeks of the index procedure. Failed repair was defined as tendon defect, deformity, or significant weakness in supination. The early incidence of failure was 1.2%, with 2 of the fixations meeting the criteria for failure. One patient had significant brachial artery thrombosis. Other complications included posterior interosseous nerve palsy, lateral antebrachial cutaneous nerve-related complication, and numbness about the radial nerve. The use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure.

Distal biceps and triceps injuries in athletes.

Biceps and triceps ruptures are rare, but can cause significant disability. They typically result from a forceful eccentric contraction, resulting in weakness and pain. Biceps and triceps tendon injuries represent the most and least common tendinous injuries about the elbow, respectively. Nonoperative management of these injuries is generally reserved for partial ruptures or patients unfit for surgery. Surgical repair has become the preferred method of treatment for acute, complete ruptures. Anatomy, epidemiology, clinical evaluation, and treatment of these injuries are described in this review.

Treatment of Supination Deformity for Obstetric Brachial Plexus Injury: A Systematic Review and Meta-Analysis

To conduct a systematic review and meta-analysis of the literature evaluating treatment outcome for supination deformity in obstetric brachial plexus injury. We included studies on brachial plexus and supination deformity with follow-up of at least one year and quantitative measurements of forearm mean passive pronation and position at rest. Meta-analysis was used to explore modifying factors. An elaborate search strategy resulted in 366 studies, of which 13 were included totaling 238 patients (157 osteotomies and 71 biceps rerouting). There was a 75° gain in position at rest and a 65° gain in passive pronation for the osteotomy group, compared to a 79° gain in position at rest for the biceps rerouting group. More severe deformities had greater gains. No influence of age was found. Important adverse effects were hardware failure and a biceps rupture. Recurrence in the osteotomy group was 20% to 40%, versus none in the soft-tissue group. This review showed an overall benefit for forearm osteotomies and for biceps rerouting for supination deformity with the gain proportionate to the severity of the deformity. Therapeutic III.

Complications from a Distal Bicep Repair: A Meta-Analysis of a Single Incision Versus Double Incision Surgical Technique

Objectives:Anatomical reinsertion of the distal biceps is critical for restoring elbow flexion and forearm supination strength. Surgical techniques utilizing one and two incisions have been reported in the literature, describing complications and outcomes. However, which technique is associated with a lower complication rate remains unclear.Methods:A systematic review was conducted using the PubMed, Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTSDiscus, and the Cochrane Central Register of Controlled Trials database to identify articles reporting distal biceps ruptures through August 2013. We included English language publications based on adult patients with a minimum of three cases. Both single and dual incision technique studies were incorporated. The demographic and outcome data of all studies was retrieved and pooled. A Meta-analysis on the pooled data was then conducted to determine the role of surgical technique on different complications. This was adjusted for age, gender and other independent variables.Results:Fifty-five articles met the inclusion criteria. The complication rate in the single incision group was 28.3% (222/785) versus 20.9% (104/498) in the double incision group. Neuropraxia was the most common complication in the single incision group at 9.8% (77/785), while heterotopic ossification was the most common in double incision cases at 7% (35/498). Re-rupture and failed reattachment occurred in 2.5% of single incision cases, versus 0.6% of double-incision cases (p < 0.034). Posterior interosseous nerve (PIN) palsy occurred in 2.7 % (13/785) of single incision procedures versus 0.2% (1/498) in the double incision group (p< 0.001). When combining heterotopic ossification and synostosis rates, the double incision group demonstrated complications in 9.8% of cases versus 3.2% for single incision cases.Conclusion:Surgical intervention for distal biceps ruptures may help restore function to an active individual; however, this procedure is not without risk of complications. The single incision technique has a higher rate of failed re-attachment and re-rupture compared to the double incision technique. The single incision technique also has a higher rate of overall nerve palsy (PIN, LABC, and Radial Nerve) compared to the double incision technique. The double incision technique does have higher rates of HO compared to the single incision. These complications are important for surgeons to consider and disclose to patients deciding on operative repair.

Lateral antebrachial cutaneous nerve compression after traumatic rupture of the long head of the biceps: a case series

Lateral antebrachial cutaneous (LABC) nerve compression is a rare but debilitating injury. There are limited data on the association of LABC nerve compression and proximal biceps rupture. We theorized that because of distal migration, the biceps muscle and tendon cause compression on the nerve. We present 2 cases in which patients had proximal biceps ruptures with tendon retraction and developed neurologic symptoms associated with the LABC nerve. To demonstrate our theory, we performed a cadaveric experiment. After making an incision to expose the entire biceps muscle and the musculocutaneous nerve and its branch into the LABC nerve, we marked each structure in 2-cm increments with a marking pen. The long head of the biceps was then cut to simulate a proximal biceps rupture. The relationship between the 3 structures was then studied, showing no change in position of the musculocutaneous nerve or LABC nerve. The biceps muscle and tendon had migrated distally toward the LABC nerve, demonstrating compression of the nerve. Proximal biceps tears commonly occur from trauma as well as iatrogenically after a biceps tenotomy for treatment of biceps tendinopathy. However, it is unusual for neuropathy of the LABC nerve to occur. Patients who develop neuropathy associated with the LABC nerve after a proximal biceps rupture can be effectively treated with LABC nerve decompression and biceps plasty. We found that this was an effective surgical treatment of LABC neuropathy without the need for proximal biceps tenodesis.

Repair and Rehabilitation of Distal Biceps Ruptures

Etiology: Distal biceps tendon ruptures, which account for approximately 10% of all biceps ruptures, typically occur after a sudden, unexpected extension force to the flexed arm. Most injuries are complete ruptures, with the tendon avulsing from the radial tuberosity. Tearing of the bicipital aponeurosis may or may not occur. Patients are usually men between the ages of 30 and 60 years; complete rupture has been reported in a woman in only one instance. Although most patients are asymptomatic before rupture, it is thought that preexisting chronic degeneration plays a role in most, if not all, injuries. Mechanical impingement (decreased radioulnar distance resulting in less space available for the tendon) is also cited as a potential cause. More than 4 in 5 injuries occur in the dominant arm, and ruptures are 7.5 times more likely in smoker. Treatment and Repair Techniques: Surgical reinsertion of the biceps tendon to the radial tuberosity is considered the treatment of choice for most complete ruptures (and for partial tears that have failed nonoperative management). Nonoperative management is typically considered only for elderly, low-demand patients, or for those too ill to consider surgical intervention. Patients who choose nonoperative treatment typically lose 20% to 30% of arm flexion and 30% to 50% of supination strength and may suffer chronic activity-related arm and forearm pain. Recently, however, some authors have questioned the severity of disability associated with nonoperative management. Outcomes: In general, most studies describe excellent clinical outcomes irrespective of fixation method. Two-incision techniques may result in slightly greater flexion strength and may better restore supination strength, by virtue of positioning the repair more posteriorly, in a more anatomic position, on the tuberosity than the one-incision methods. Rehabilitation: With improvement in surgical techniques, and greater knowledge of pull out and failure complications, current rehabilitation progressions have advanced. As mentioned, the native distal bicep tendon has a strength of 200 to 225 N. The present literature suggests that surgical fixation with the Endobutton technique has a failure load of 259±28 N, obviously higher than the natural attachment. However, there should always be caution with any aggressive protocol, and communication with the physician is imperative. Particularly with a distal biceps repair, it will be very important to know the level of tendon retraction, tissue quality, and security of fixation that the surgeon was able to achieve. With this knowledge, the rehabilitation may move slower, or more quickly, but the most important factor in progression of this patient population postoperatively is the achievement of clinical milestones. Protocols are a good guideline for rehabilitation but should rarely be used as an exact recipe. The rehabilitation after repair of the distal biceps tendon has undergone evolution, but basic principles still hold true. Progression can be guided by a protocol but should be largely based on communication between physician and rehabilitation specialist. As with any surgery, parameters and outcomes may vary based on the severity of the injury and the ability of the surgeon to achieve ideal fixation. No 2 surgeries are exactly alike, but safe rehabilitation guidelines can be established for any patient with the right attention to detail.

Repair of distal biceps tendon acute ruptures with two suture anchors and anterior mini-open single incision technique: clinical follow-up and isokinetic evaluation

All the techniques described in literature for treatment of acute distal biceps tendon ruptures provide good functional outcomes. The purpose of this study is to report the results of a single limited-incision technique for repair of acute distal biceps ruptures using two suture anchors. Fourteen patients, all man, were treated consecutively from one author between January 2009 and December 2011 and evaluated at a mean follow-up of 26months. All patients were evaluated clinically, through DASH and MEPS score questionnaires, and with isokinetic biomechanical tests. All patients achieved complete elbow flexion and extension. Deficit for supination of the forearm was found in only two patients (7° and 13°). Mean DASH score was 4.7 points, and mean MEPS was excellent (96.8 points). There was no nervous complication involving posterior interosseous nerve (PIN) and no case of failure of the sutures. The isokinetic evaluation detected an average flexion strength increase by 10.2% compared to the opposite arm not operated. Our study shows that mini-open access and fixation with two suture anchors achieved in medium-term excellent functional and cosmetic results needed short rehabilitation times and is minimally invasive.

Distal biceps tendon rupture reconstruction using muscle-splitting double-incision approach.

To evaluate the clinical and functional results after repair of distal biceps tendon tears, following the Morrey's modified double-incision approach. We retrospectively reviewed 47 patients with distal rupture of biceps brachii treated between 2003 and 2012 in our Orthopedic Department with muscle-splitting double-incision technique. Outcome measures included the Mayo elbow performance, the DASH questionnaire, patient's satisfaction, elbow and forearm motion, grip strength and complications occurrence. At an average 18 mo follow-up (range, 7 mo-10 years) the average Mayo elbow performance and DASH score were respectively 97.2 and 4.8. The elbow flexion range was 94%, extension was -2°, supination was 93% and pronation 96% compared with the uninjured limb. The mean grip strength, expressed as percentage of respective contralateral limb, was 83%. The average patient satisfaction rating on a Likert scale (from 0 to 10) was 9.4. The following complications were observed: 3 cases of heterotopic ossification (6.4%), one (2.1%) re-rupture of the tendon at the site of reattachment and 2 cases (4.3%) of posterior interosseous nerve palsy. No complication required further surgical treatment. This technique allows an anatomic reattachment of distal biceps tendon at the radial tuberosity providing full functional recovery with low complication rate.

Factors affecting supination strength after a distal biceps rupture

This study quantified pain (visual analog pain scale [VAPS]), disability (Disabilities of the Arm, Shoulder and Hand [DASH]) and isometric supination torque at 3 forearm positions in a prospective cohort of biceps-deficient arms to assess the potential for functional return with nonoperative treatment. Twenty-three men (50 ± 11 years) with complete unilateral distal biceps avulsion underwent isometric supination strength testing of both limbs at 60° of supination, 0° (neutral), and 60° of pronation. After exclusion of 1 outlier patient, the mean time from injury to evaluation was 44 days (range, 4-455 days). Pain level (VAPS) and functional outcome (DASH) were assessed; supination strength was normalized to the uninjured arm. The uninjured arm was stronger (P < .001), and peak torque varied with forearm position (P < .043). Peak torque was greater in pronation compared with supination, regardless of injury (P < .002). No differences were detected in supination strength as a result of forearm position or arm dominance. Supination strength did not correlate with time from injury to evaluation. One patient regained supination strength (115%) at 60° of pronation and 72% in neutral with a lengthy time from injury. VAPS (5 of 10) and DASH (39 of 100) scores decreased with time and did not relate to supination strength. Biceps tendon rupture led to a 60% decrease in supination strength in the neutrally oriented forearm. Peak torque observations can be explained using forearm moment arms. VAPS and DASH scores decreased with time but did not affect strength. We speculate that supination strength from pronation to neutral can improve as one strengthens the brachioradialis but strength deficits from neutral to supination are more difficult to overcome.