Distal Biceps Tendon Repair in Competitive Strength Athletes: A Retrospective Series of 183 Athletes

Abstract

Background: Elbow injuries are common among strength athletes, particularly distal biceps tendon ruptures. These injuries can significantly affect athletes' performance and require effective treatment strategies to ensure optimal recovery and return to sport.

Purpose/hypothesis: The purpose of this retrospective cohort study was to evaluate the patient-reported outcomes, return-to-sport rate, and postoperative strength of competitive strength athletes who underwent distal biceps tendon repair. It was hypothesized that patients would show excellent patient-reported outcomes on validated questionnaires and exhibit high rates of return to sport as well as high subjective strength levels.

Study design: Case series; Level of evidence, 4.

Methods: A retrospective chart review was performed for cases of distal biceps tendon repair in athletes competing in strength sports, such as weightlifting and powerlifting, between August 2003 and July 2020. The preoperative and postoperative sporting activity, mechanism of injury, and complications were assessed. Clinical outcomes were evaluated using the Mayo Elbow Performance Score (MEPS) and the Single Assessment Numeric Evaluation (SANE). Additionally, the athletes were asked to rate their elbow strength as a percentage compared with their uninjured side.

Results: A total of 183 patients were included (88% follow-up rate), with a mean follow-up of 69.6 ± 61.0 months. Among them, 168 underwent primary repair, while 15 underwent revision procedures, of which 7 involved allograft augmentation. All athletes were able to return to sport, and 73% of patients achieved full subjective strength of their affected arm. The median MEPS score was 100 (interquartile range, 100-100), and the median SANE score was 100 (interquartile range, 95-100). Multivariate linear regression analysis showed that an increased time between injury and surgery was associated with a decrease in the MEPS score (standard error [SE] = 0.002; t = -2.113; P = .036) and self-assessed strength (SE = 0.053; t = -3.183; P = .002). Graft usage was associated with a nonsignificant decrease in the SANE score (SE = 1.538; t = -1.791; P = .075). There were 28 complications (15%) that occurred, including 5 tendon retears (3%) and 1 intraoperative brachial artery injury (1%).

Conclusion: Distal biceps tendon repair in competitive strength athletes resulted in a high return-to-sport rate and excellent recovery. However, delayed surgery negatively affected outcomes, and 27% of patients experienced persistent subjective strength deficits. Future research is needed to further optimize treatment strategies for athletes.

Keywords: athletes; biceps tendon rupture; postoperative outcome; strength training; tendon repair; weight training.

Figure 1.

For tendon repair, an incision was made at the joint level, extending distally. The radial tuberosity was then visualized, and anchors were inserted for tendon fixation. If the biceps tendon could not be grasped via the primary incision, an additional horizontal incision was made proximally to mobilize the tendon. Tendon repair with an allograft was performed on patients in whom anatomic repair was unfeasible. The allograft was doubled, and the free ends were sutured to the tendon stump. The distal end of the allograft was then used for tendon fixation.

Figure 2.

Distribution of sporting activities (n = 98) leading to a distal biceps tendon rupture. Although all injuries occurred in strength athletes, activities marked in gray represent those that happened during strength sport training or competitions, while activities marked in blue indicate injuries sustained during other types of sporting activities outside of strength sports.