HAND (2008) 3:316–319

DOI 10.1007/s11552-008-9129-8

ORIGINAL PAPER

Is Therapy Necessary After Distal Biceps Tendon Repair?

Edwin E. Spencer Jr. & Anita Tisdale & Kevin Kostka &
Robert E. Ivy

Received: 27 January 2008 / Accepted: 8 August 2008 / Published online: 11 September 2008
# American Association for Hand Surgery 2008

Abstract The EndoButton technique of distal biceps 22], while now there is a trend toward surgical repair or
tendon repair provides strong biomechanical fixation. This reconstruction of the distal biceps tendon [2, 3, 5, 7, 8, 18].
strength of fixation may allow earlier postoperative range of Several studies have cited superior results with repair of the
motion (ROM). A retrospective review of 15 male patients biceps tendon with the patients being able to return to their
undergoing single incision EndoButton repairs was used. preinjury level of activity after surgery [1–3, 8, 18, 21]. The
Six subjects participated in conventional supervised post- evolution of the distal biceps repair has led the authors to
operative rehabilitation while nine subjects were allowed adopt a single incision, EndoButton (Smith & Nephew,
unrestricted ROM after 2 weeks. Final ROM, time to full Andover, MA, USA) technique. The strength of this
ROM, and Disabilities of Arm Shoulder and Hand (DASH) fixation has been documented clinically and biomechani-
scores were compared. There was a significant difference cally [2, 23]. In light of the advent of stronger fixation, the
for time to full ROM (p<0.05). The mean time to full ROM purpose of this study was to determine if we could
was 8.67 weeks for the supervised therapy group and accelerate the postoperative rehabilitation. Our hypothesis
4.38 weeks for the unrestricted group. There were no was that patients with a surgically repaired distal biceps
reruptures in either group. There were no significant tendon via the EndoButton could undergo an accelerated
differences in final ROM or DASH scores. These data rehabilitation process with a low risk of rerupture.
suggest that unrestricted ROM results in a quicker return to
full ROM without an increased risk of rerupture.
Materials and Methods
Keywords Distal biceps tendon . EndoButton . Therapy .
Tendon repair A retrospective chart review was performed of all patients
undergoing a distal biceps tendon repair using the Endo-
Button fixation from 2003 to 2005 with at least a 1-year
Introduction minimum follow-up. The senior authors (EES and REI)
performed the surgery on all patients. A total of 17 patients
Rupture of the distal biceps brachii tendon accounts for were considered for the study, but two were unavailable for
only 3% of biceps tendon ruptures [18]; however, authors follow-up. Of the 15 patients that were available for follow-
have cited an average loss of 40% supination strength and a up, four required repairs of the nondominant arm and 11 of
30% average loss in flexion strength [3, 19]. Initially, a the dominant arm. All patients were male with ages ranging
conservative, nonsurgical approach was advised [3, 12, 19, from 31 to 64 years and a mean age of 46 years at the time
of surgery.
All surgeries were performed with Loupe magnification
E. E. Spencer Jr. (*) : A. Tisdale : K. Kostka : R. E. Ivy using the EndoButton fixation technique with number 2
Shoulder and Elbow Center, Knoxville Orthopaedic Clinic,
Fiberwire (Arthrex, Naples, FL, USA) through a single
260 Fort Sanders West Boulevard,
Knoxville, TN 37922, USA anterior incision described by Bain et al. [2]. Capture of the
e-mail: [email protected] EndoButton was confirmed with intraoperative fluoroscopy.
HAND (2008) 3:316–319 317

The surgical dissection for this procedure is similar to Results

others in that the distal biceps tendon is isolated and the
radial tuberosity is exposed while protecting the radial Follow-up averaged 23 months (12–36 months) and all
nerve and its branches. Number 2 Fiberwire or other patients were satisfied with their results. The DASH score
nonabsorbable suture is passed through the end of the for group 1 (supervised therapy) averaged 3.1 and group 2
tendon in a locking fashion with at least four throws to grab (no therapy) averaged 1. The six patients who participated
sufficient tendon. The Endobutton is tied to the end of the in therapy achieved an average of 139.1° flexion, 1.5°
biceps tendon with a small 2-mm gap between the end of extension, 76.6° supination, and 75.8° pronation in an
the tendon and the Endobutton. The radial tuberosity is average of 8.6 weeks. The nine patients who did not receive
prepared in full supination and the near cortex is decorti- formal therapy achieved an average of 138.5° flexion, 1.5°
cated down to cancellous bone. The far cortex is drilled extension, 76.5° supination, and 77.5° pronation in an
with a bit the same width as the Endobutton. Passing average of 4.1 weeks. There was a significant difference in
sutures are placed in the peripheral holes in the Endobuton the time to full ROM between the two groups (p<0.05)
and these passing sutures are passed through the radial hole with the unsupervised group achieving full ROM more
with a blunted Keith needle and retrieved percutaneously rapidly. Manual muscle testing revealed 5/5 strength for
on the dorsal side of the forearm. Traction is placed on one elbow flexion and supination. There were no cases of
of the passing sutures and the biceps tendon is pulled into heterotopic ossification or reruptures. There were two cases
the radial corticotomy. Once the Endobutton is through the of transient lateral antebrachial cutaneous nerve palsies that
far cortex, the other suture is pulled thereby flipping the resolved in 6 weeks.
Endobutton locking it on the other side of the radius and
securing the biceps tendon. This portion of the procedure
can be performed with fluoroscopic guidance. Discussion
The patients were evaluated with range of motion
(ROM) measurements and clinically at 1 year with Nonoperative treatment of distal bicep tendon ruptures has
Disabilities of Arm Shoulder and Hand (DASH) scores. been reported to result in loss of flexion and supination
The patients were divided into two groups: supervised strength along with decreased patient satisfaction [3, 12, 19,
therapy (group 1, n=6) and no therapy (group 2, n=9). Of 22]. This prompted many surgeons to recommend surgical
the 15 patients that were contacted, 13 agreed to complete repair. Most of the various surgical repairs and reconstructions
the DASH questionnaire (group 1, n=4; group 2, n=9). In have yielded good functional and clinical results [3–5, 7, 9].
both groups, a posterior splint at 90° was worn for the first There are, however, several complications such as hetero-
2 weeks. In the supervised therapy group, a hinged brace topic ossification and neuropraxias that have occurred with
was worn for the next 4 weeks. Passive ROM was initiated particular methods of repair [10, 11, 14]. There has been a
at 2 weeks but extension was limited to 40° and increased natural evolution of the repair techniques to avoid the
by 10°/week as tolerated with full extension allowed at complications and improve fixation strength.
6 weeks postoperative. The nonsupervised therapy group One of the proposed advantages of the single incision
had the postoperative splint removed at 2 weeks and were approach is a decrease in complications such as heterotopic
allowed to use the arm for simple daily activities such as ossification and radioulnar synostosis and injury to the
bathing, lifting a coffee cup, and simple lifting of no greater posterior interosseous nerve [2, 4, 18, 24]. Single incision
than 2 lbs. techniques usually involve the use of suture anchors, the
Descriptive statistics comparing end ROM and time to EndoButton, or an interference screw [2, 4, 13, 15, 16, 25].
full ROM in both groups of patients were computed. A one- A recent study compared the strength of fixation of
way analysis of variance was used to compare the time to suture anchors to the EndoButton [23]. Biomechanically,
full ROM of the two groups. DASH scores were calculated the EndoButton was found to have a higher load to failure
and compared between the two groups. The DASH and remained in contact with the bone longer before failure,
Outcome Measure is a 30-item self-report questionnaire but the difference did not reach statistical significance [23].
designed to measure physical function and symptoms in One of the best biomechanical studies was performed by
people with any of several musculoskeletal disorders of the Mazzocca et al. and compared the fixation strength of
upper limb. Each item of the DASH has five response suture anchors, the EndoButton, traditional bone tunnels,
options with a score summation range from 0 (no disability/ and interference screws. They found that the EndoButton
symptoms) to 100 (greater disability/symptoms). A high had a statistically higher load to failure than the other three
DASH score indicates more disability. The mean DASH methods [17].
score in population controls is 6.2. Manual muscle testing The first clinical results using the EndoButton were
was also performed by the examiner. reported by Bain et al. [2]. They reported on 12 patients
318 HAND (2008) 3:316–319

with no significant complications and good results. We, return to full strength but some of these data are reflected in
therefore, started performing our repairs using the Endo- the DASH score.
Button technique. Based on the good results of some of our In conclusion, the EndoButton fixation has been shown
noncompliant patients that removed their splints, we to have superior fixation strength at time 0 and yields
modified our postoperative therapy protocol. Instead of equivalent clinical outcomes with decreased operative time
supervised physical therapy with hinged braces, we simply and complications. It also seems to be strong enough to
removed the splint 2 weeks postoperatively and asked the allow early active ROM with quicker return of normal
patient to not lift anymore than 2 lbs. They were allowed to ROM with minimal risk for rerupture.
use the arm for routine activities of daily living including
active elbow flexion. These patients with an accelerated
unsupervised rehabilitation protocol were compared to a References
cohort of patients who had a more conventional supervised
rehabilitation protocol. 1. Agins HJ, Chess JL, Hoekstra DV, Teitge RA. Rupture of the
All patients were surgically treated in a similar fashion distal insertion of the biceps brachii tendon. Clin Orthop Relat Res
1988. (234):34–8.
with fixation of the distal biceps to the radial tuberosity
2. Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of
using the EndoButton, but the postoperative protocols distal biceps tendon rupture: a new technique using the Endo-
differed markedly after the first 2 weeks. Interestingly, we button. J Shoulder Elbow Surg 2000;9(2):120–6. doi:10.1016/
found that the unsupervised group regained their motion S1058-2746(00)90040-5.
3. Baker BE, Bierwagen D. Rupture of the distal tendon of the
quicker, had no reruptures, and had similar DASH scores. biceps brachii. Operative versus non-operative treatment. J Bone
This would seem to indicate that the strength of fixation Jt Surg Am 1985;67(3):414–7.
provided by the Endobutton is sufficient to allow early 4. Balabaud L, Ruiz C, Nonnenmacher J, Seynaeve P, Kehr P, Rapp
active unsupervised ROM. A study by Cheung et al. E. Repair of distal biceps tendon ruptures using a suture anchor
and an anterior approach. J Hand Surg Br 2004;29(2):178–82.
utilized a more aggressive rehabilitation protocol and they
doi:10.1016/j.jhsb.2003.07.002.
also found that they had a more rapid return of ROM, 5. Bell RH, Wiley WB, Noble JS, Kuczynski DJ. Repair of distal
although they still had the patients in a postoperative biceps brachii tendon ruptures. J Shoulder Elbow Surg 2000;9
hinged brace [6]. In addition, Ozyureko et al. compared the (3):223–6. doi:10.1016/S1058-2746(00)90059-4.
6. Cheung EV, Lazarus M, Taranta M. Immediate range of motion
clinical results of the two incision bone tunnel fixation to
after distal biceps tendon repair. J Shoulder Elbow Surg 2005;14
single incision suture anchor or EndoButton fixation and (5):516–8. doi:10.1016/j.jse.2004.12.003.
found that the results were similar in all three groups but 7. D’Alessandro DF, Shields CL Jr, Tibone JE, Chandler RW. Repair
the operative time was decreased with both of the single of distal biceps tendon ruptures in athletes. Am J Sports Med
1993;21(1):114–9. doi:10.1177/036354659302100119.
incision techniques and the return to work and sport were
8. D’Arco P, Sitler M, Kelly J, Moyer R, Marchetto P, Kimura I, et
quicker as well [20]. al. Clinical, functional, and radiographic assessments of the
These data provoke the idea to reassess the need of conventional and modified Boyd–Anderson surgical procedures
therapy and the possibility of overutilization of therapeutic for repair of distal biceps tendon ruptures. Am J Sports Med
1998;26(2):254–61.
services for ROM regarding this surgical procedure.
9. Davison BL, Engber WD, Tigert LJ. Long term evaluation of
Therapy still may be warranted on an individual basis if repaired distal biceps brachii tendon ruptures. Clin Orthop Relat
ROM goals are not met or a patient has pain complaints Res 1996. (333):186–91.
where modalities for pain could assist in achieving full 10. El-Hawary R, Macdermid JC, Faber KJ, Patterson SD, King
GJ. Distal biceps tendon repair: comparison of surgical tech-
ROM. Therapeutic strengthening or a work-hardening
niques. J Hand Surg Am 2003;28(3):496–502. doi:10.1053/
program may be appropriately prescribed after full ROM jhsu.2003.50081.
is achieved, as the patient may need assistance in 11. Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD. Proximal
strengthening the appropriate muscle groups for return to radioulnar synostosis after repair of distal biceps brachii rupture
by the two-incision technique. Report of four cases. Clin Orthop
sport or work.
Relat Res 1990. (253):133–6.
This study is limited by the fact that it is a retrospective 12. Hovelius L, Josefsson G. Rupture of the distal biceps tendon.
study with a small sample size and an uneven number of Report of five cases. Acta Orthop Scand 1977;48(3):280–2.
patients in each group. However, even with a small sample 13. Idler CS, Montgomery WH 3rd, Lindsey DP, Badua PA, Wynne
GF, Yerby SA. Distal biceps tendon repair: a biomechanical
size, statistical significance was reached with regard to
comparison of intact tendon and 2 repair techniques. Am J Sports
ROM as the differences between the two groups was so Med 2006;34(6):968–74. doi:10.1177/0363546505284185.
large. Further study with a larger subject population is 14. Kelly EW, Morrey BF, O’Driscoll SW. Complications of repair of
necessary to support these findings. Additional research the distal biceps tendon with the modified two-incision technique.
J Bone Jt Surg Am 2000;82-A(11):1575–81.
might also be warranted for this surgical technique focusing
15. Khan W, Agarwal M, Funk L. Repair of distal biceps tendon
on more detailed strength measurement, as this report did rupture with the Biotenodesis screw. Arch Orthop Trauma Surg
not look at dynamometer-measured strength and time to 2004;124(3):206–8. doi:10.1007/s00402-004-0639-8.
HAND (2008) 3:316–319 319

16. Krushinski EM, Brown JA, Murthi AM. Distal biceps tendon rupture: 21. Rantanen J, Orava S. Rupture of the distal biceps tendon. A report
biomechanical analysis of repair strength of the Bio-Tenodesis screw of 19 patients treated with anatomic reinsertion, and a meta-
versus suture anchors. J Shoulder Elbow Surg 2006;16(2):218–23. analysis of 147 cases found in the literature. Am J Sports Med
17. Mazzocca AD, Burton KJ, Romeo AA, Santangelo S, Adams DA, 1999;27(2):128–32.
Arciero RA. Biomechanical evaluation of 4 techniques of distal 22. Sotereanos DG, Pierce TD, Varitimidis SE. A simplified method
biceps brachii tendon repair. Am J Sports Med 2007;35(2):252–8. for repair of distal biceps tendon ruptures. J Shoulder Elbow Surg
doi:10.1177/0363546506294854. 2000;9(3):227–33. doi:10.1016/S1058-2746(00)90060-0.
18. McKee MD, Hirji R, Schemitsch EH, Wild LM, Waddell JP. 23. Spang JT, Weinhold PS, Karas SG. A biomechanical comparison
Patient-oriented functional outcome after repair of distal biceps of EndoButton versus suture anchor repair of distal biceps tendon
tendon ruptures using a single-incision technique. J Shoulder injuries. J Shoulder Elbow Surg 2006;15(4):509–14. doi:10.1016/
Elbow Surg 2005;14(3):302–6. doi:10.1016/j.jse.2004.09.007. j.jse.2005.09.020.
19. Morrey BF, Askew LJ, An KN, Dobyns JH. Rupture of the distal 24. Stearns KL, Sarris I, Sotereanos DG. Permanent posterior
tendon of the biceps brachii. A biomechanical study. J Bone Jt interosseous nerve palsy following a two-incision distal biceps
Surg Am 1985;67(3):418–21. tendon repair. Orthopedics 2004;27(8):867–8.
20. Ozyurekoglu T, Tsai TM. Ruptures of the distal biceps brachii 25. Verhaven E, Huylebroek J, Van Nieuwenhuysen W, Van Overschelde
tendon: results of three surgical techniques. Hand Surg 2003;8 J. Surgical treatment of acute biceps tendon ruptures with a suture
(1):65–73. doi:10.1142/S0218810403001431. anchor. Acta Orthop Belg 1993;59(4):426–9.