Biceps Tendon Rupture: Overview and Evidence Summary

Condition Overview

A biceps tendon rupture refers to a complete tear of either the long head or the distal tendon of the biceps brachii. These two injury types present differently, affect different populations, and have distinct implications for function.

Long head ruptures are far more common and typically occur in older adults or individuals with underlying degenerative tendon changes. The long head tendon, which runs through the bicipital groove and into the shoulder joint, gradually weakens over time. A sudden load—such as lifting a heavy object, catching oneself during a fall, or performing an unexpected pulling action—may cause the tendon to finally give way. Patients often report a sharp pain followed by the appearance of a characteristic “Popeye” bulge in the upper arm as the muscle retracts.

Distal biceps ruptures, although less frequent, are more functionally significant. They usually occur in middle-aged men during forceful elbow flexion or when resisting a heavy load. Distal tears lead to greater loss of supination strength, making tasks such as turning keys, tightening screws, or lifting rotational loads more difficult.

Both types of rupture are painful at onset, though long head tears often become surprisingly manageable within days or weeks. Distal ruptures, in contrast, significantly impact forearm rotation strength and are more commonly managed surgically.

Summary of Current Evidence for Biceps Tendon Rupture

Evidence-Based Management Discussion

Understanding the Injury

The biceps brachii performs elbow flexion and forearm supination, but each tendon plays a slightly different role. The long head assists with shoulder stabilization, while the distal tendon is the primary contributor to supination torque. This difference explains why distal ruptures produce more noticeable functional deficits.

Long head ruptures are often the culmination of chronic tendon degeneration. In many individuals, the rupture itself brings relief from persistent anterior shoulder discomfort by removing a sensitized structure. Functionally, most people adapt well because the short head of the biceps remains intact.

Distal ruptures, by contrast, are nearly always traumatic and significantly affect strength. Without repair, individuals may lose up to 40–50% of supination power, making daily tasks more challenging.

Conservative Management

For long head ruptures, conservative management is often effective. Treatment focuses on restoring shoulder motion, strengthening the remaining rotator cuff and scapular muscles, and gradually reintroducing functional loading. The cosmetic “Popeye” deformity remains but does not affect performance for most people.

Conservative management of distal ruptures is appropriate only for elderly individuals, those with low functional demand, or those medically unable to undergo surgery. Even with rehabilitation, supination strength typically remains reduced.

Exercise Therapy

Rehabilitation principles include:

• Restoring full shoulder and elbow range of motion

• Strengthening the short head of the biceps, brachialis, and brachioradialis

• Improving scapular control to reduce compensatory overuse

• Progressive loading to return to functional tasks

Post-surgical protocols for distal repairs involve staged progression from protected ROM to strengthening and, ultimately, return to full load-bearing tasks.

Manual Therapy

Manual therapy can help reduce stiffness after the acute phase, especially around the shoulder in long head ruptures or around the forearm after distal repair. Joint mobilization and soft tissue work support comfortable movement but do not change tendon healing directly.

Medications and Injections

NSAIDs may help initially with pain. Corticosteroid injections are avoided after rupture due to risk of further tissue compromise.

Surgical Considerations

Long Head Rupture

Surgery (tenodesis or tenotomy) may be considered for:

• Younger patients bothered by cosmetic deformity

• Athletes requiring high loads through the shoulder

• Individuals with persistent pain or associated cuff pathology

Distal Biceps Rupture

Surgical repair is the standard of care for active individuals, restoring supination strength and improving elbow flexion power. Early repair yields the best outcomes.

References

American Academy of Orthopaedic Surgeons. Management of Rotator Cuff Injuries: Clinical Practice Guideline. 2025.

Chillemi, C., et al. “Long Head of Biceps Tendon Rupture: Clinical Presentation and Treatment Options.” Journal of Orthopaedics and Traumatology, 2011.

Kettler, M., et al. “Distal Biceps Tendon Rupture: Biomechanics and Management.” Journal of Shoulder and Elbow Surgery, 2007.

Bain, G., et al. “Biceps Tendon Pathology and Treatment Options: Clinical Insights and Surgical Considerations.” Sports Medicine and Arthroscopy Review, 2010.

Safran, M., et al. “Distal Biceps Tendon Injuries: Diagnosis, Management, and Rehabilitation.” Sports Health, 2014.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.