Distal Bicep Tendonitis

Distal bicep tendonitis is part of a spectrum of diseases (tendinopathy) of the distal bicep. Muscles are attached to bones by fibrous connective tissues called tendons. The bicep muscle 

is attached to the elbow joint by the distal tendon. Tendons can become inflamed, swollen and painful due to overuse or repetitive activities. This condition is called tendinitis. It can be treated at home and resolves on its own in most cases unless it is complicated by a tear or rupture of the tendon, which requires immediate medical attention.

What is distal bicep tendonitis?

The bicep brachii muscle is an important muscle of the arm spanning from the shoulder to the elbow joint. It has two tendons, the proximal and distal tendons.

1. The proximal tendon is the point of muscle attachment to the bones of the shoulder joint
2. The distal tendon is the point of attachment of the muscle to the radial bone of the forearm at the elbow joint

The bicep muscle helps perform movement at the shoulder and elbow joints. It is mostly responsible for:

1. Flexion of the elbow – bending the elbow joint
2. Supination of the forearm – twisting the forearm so that the palm faces upward.

Tendonitis is the inflammation of tendons. Any tendon can be affected by inflammation but most commonly, tendons at the shoulder joint, proximal tendon of the bicep, tendons at the thumb, and the ankle tendon are affected.

Distal bicep tendonitis, inflammation of the distal tendon of the bicep muscle, is very uncommon and is not well-defined in scientific literature.

It is part of a spectrum of diseases termed distal bicep tendinopathy (abnormalities of the distal bicep tendon). 

Other conditions in this spectrum include:

1. Bicipitoradial bursitis – inflammation of the bursa between the bicep tendon and the radial bone of the forearm. A bursa is a soft fluid-filled lubricating cushion present between tendon and bone and it resists friction
2. Distal bicep chronic tendon degeneration – degeneration of the tendons with ageing and repetitive activity
3. Distal bicep partial tear – partial tearing of the distal bicep tendon is more uncommon than a complete tear
4. Distal bicep complete tear – complete tear of the distal bicep tendon accounts for 3% of all bicep muscle tears^1,2

In certain situations, terms like tendinitis (inflammation), tendinosis (degeneration/ weakness), and tendinopathy (abnormality of the tendon) are used interchangeably as they can co-exist.

Causes

Distal bicep tendonitis is an uncommon overuse syndrome. It occurs due to repetitive activities of the elbow joint, excessive or unaccustomed exercise, heavy lifting, strain, and injury. Some examples of these activities include:

• Pull-ups
• Weight lifting, with elbow bend at 90 degrees
• Throwing (that causes hyperextension of the elbow with pronation of the forearm)
• Repetitive stressful forearm rotation

Degeneration (weakness) of the tendon and loss of vascularity that occurs due to aging can also lead to tendonitis and partial tearing of the tendon.

A complete tear of the tendon occurs due to sudden forceful extension of the elbow or major trauma. A common example of this is while lifting a heavy object, if the object suddenly slips and the person tries to hold on to it, the weight of the object causes forceful extension at the elbow. A popping sound is heard with a rupture of the tendon. 

Weight lifters experience this type of injury while doing “negatives”. It is a type of exercise in which they do repetitive bending and extension at the elbow while holding weights.

Risk factors

The precise prevalence of distal bicep tendonitis is not known. Some factors that can increase the risk of developing tendonitis are:

• Smoking – smokers have a 7.5 times greater risk of rupturing their tendons¹
• Use of corticosteroids
• Certain systemic diseases like Rheumatoid arthritis, systemic sclerosis, gout, reactive arthritis, and diabetes

Signs and symptoms

1. Pain

pain can be around the elbow or at the elbow pit. This pain is variable and depends on the severity of the disease. Usually, the pain is elicited by the movement of the joint or when the natural motion is externally resisted.

2. Swelling

swelling is more pronounced in cases of a complete tear of the tendon. 

3. Bruising

some bruising can be appreciated at the elbow pit.

4. Weakness of the muscle and fatigue

this occurs more in the cases of tendon tears. The person is still able to perform all the activities due to the contribution of other muscles of the arm but there is weakness and easily fatigued after repetitive activities for example, turning a screwdriver.

5. Popeye deformity

on the complete tearing of the bicep tendon, the muscle pulls back into the arm as a painful ball-like swelling. This resembles the arms of the famous cartoon character Popeye.

Your doctor can check for tendon tears on physical examination by checking the strength of the muscle and performing tests called the squeeze test and hook test.

Ultrasound scans and an MRI also help diagnose any tears and can show the condition of the tendon.

Treatments

Mild symptoms of distal bicep tendonitis do not require any special treatment and usually go away after some time. Your doctor will advise resting the joint and avoiding repetitive activities to give the tendon time to heal.

Treatment of distal bicep tendonitis includes

Home remedies:

1. Resting the elbow, restricting movement – avoid moving it for 2-4 days
2. Icing – applying ice packs or frozen peas wrapped in a kitchen towel for up to 20 minutes, every 2-3 hours
3. Supporting the joint – wrapping an elastic bandage or wearing a soft brace around the elbow. This should not be tight and should be removed before going to bed

Medication:

1. Painkillers – Oral painkillers like paracetamol or Non-steroidal anti-inflammatory drugs and NSAIDs like ibuprofen help to relieve the pain
2. NSAID cream and gels 
3. Ultrasound-guided steroid injections – steroid injections around the tendon are done in cases of severe pain
4. extracorporeal shock wave therapy – can be advised by your GP and can help with healing

Physiotherapy:

After an initial 2-3 days of immobilization, when you can move your arm without pain stopping you, it is important to keep it moving so the joint does not become stiff.

Your GP might refer you for physiotherapy, if the pain is severe, last for a long time or movement is limited. It is done for stretching and strengthening the muscles.

Physiotherapy is also advised after 6 weeks of surgery²

Surgery

Surgery is sometimes required in cases of partial tear of the tendon, depending on the degree of tear and in all cases of complete rupture of the bicep tendon. The ruptured tendon is reattached to the bone or the adjacent muscle. The outcome of the procedure is good, with a complete return to activity in 6 months.

After surgery, in rehab, the elbow is immobilized using an elbow hinge brace. Strengthening exercises and physiotherapy are commenced after 6 weeks. 

Chronic rupture, that is, tendon rupture presenting after 4-6 weeks, has a poorer outcome after surgery as repair becomes difficult. Complete strength of the muscle is returned when the tear is repaired as early as possible²

When should I contact my doctor?

You should contact your doctor if

1. You have pain that is not resolving with rest and painkillers
2. You have marked swelling at the elbow or a ball-like swelling in your arm
3. You hear a popping sound at the time of the injury
4. You experience weakness in the movements of your arm

Can distal bicep tendonitis heal on its own?

Tendonitis in the absence of tear or rupture can heal on its own within 2-3 weeks. It is important to rest the tendon and avoid moving it for 2-3 days. It is also crucial to avoid excessive repetitive movements and offending activities that cause inflammation. 

Summary

Distal bicep tendonitis is the inflammation of the distal tendon of the bicep brachii muscle, which results in pain, stiffness, and swelling around the elbow. The bicep brachii muscle is an important muscle of the arm and it extends from the shoulder to the elbow. It is attached to the radial bone in the forearm by the distal tendon.

Distal bicep tendonitis is uncommon and occurs as a result of overuse and repetitive activities at the elbow and lifting heavy weights. It usually resolves on its own with rest and painkillers. In certain cases, heavy lifting or trauma can result in a complete tear of the tendon. A rupture of the tendon causes pain, weakness, and deformity of the muscle. This requires immediate medical attention as treatment is done by surgical repair. 

It is critical, in order to reach a complete restoration of movement within the muscle, to undergo surgical repair as early as possible. Delays in surgical repair can be difficult, and result in weakness in the tendon.