• Rupture of the biceps tendon, most frequently at the proximal end of the long head of the bicep
  • Rupture of the triceps tendon, most frequently at the insertion of the medial or lateral head to the olecranon


  • Biceps Tendon

    • The biceps muscle is divided into two tendons proximally:
      • The short head of the bicep inserts at the coracoid process. It is rarely a source of pain and helps with arm flexion.
      • The long head of the bicep runs over the top of the humerus and inserts at the glenoid. It is primarily responsible for arm abduction and is a common source of anterior shoulder pain.
    • The distal tendon inserts at the radial tuberosity

      Triceps Tendon Anatomy (

  • Triceps Tendon
    • The triceps muscle has three heads:
      • The long head arises from the infraglenoid tubercle, with the tendon attaching to the glenoid cavity.
      • The lateral head attaches to the upper margin of the radial grove of the humerus.
      • The medial head originates below the lateral margin of the radial groove and inserts at the posterior surface of the humerus
    • Distally, the triceps tendon inserts at the olecranon process


  • Biceps Tendon Rupture
    • Location (Clayton 2008)
      • Proximal end of the long head of the bicep at the glenoid – 96%
      • Distal along the radial tuberosity – 3%
      • Short head of the bicep – 1%
    • Usually seen in older patients – median age 46
    • Risk factors include recurrent tendinitis, a history of a rotator cuff injury, a contralateral biceps tendon rupture, age, poor conditioning and rheumatoid arthritis (Harwood 2005)
  • Triceps Tendon Rupture
    • The least common of all tendon injuries. Accounts for less than 1% of all tendon ruptures within the upper extremity
    • Most commonly occurs at the insertion of the medial or lateral head to the olecranon (Khiami 2012)
    • Typically occurs in males, with ages 30-50 being the most common
    • Risk factors include anabolic steroid use, local steroid injections for bursitis, oral steroid use, renal disease, diabetes and familial tendinopathy (Dunn 2017)

Popeye Deformity – Proximal Biceps Rupture (


  • Biceps Tendon Rupture
    • Mechanism
      • Fall on an outstretched hand or after lifting something heavy
      • Can occur after routine athletic activities (i.e. throwing a football, taking a slap shot while playing hockey)
    • Patients may complain of anterior shoulder pain and/or pain radiating down the region of the biceps
    • Patients will often hear an audible pop or snap
    • Physical Exam
      • Tenderness with palpation over the biceps groove

        Reverse Popeye Deformity – Distal Biceps Tendon Rupture (

        (worse with internal rotation of arm)

      • Difficulty supinating arm, may or may not have difficulty flexing arm
      • “Popeye” muscle deformity
        • Rupture of the proximal tendon of the biceps results in the muscle collecting distally.
      • Reverse Popeye deformity (seen in distal tears)
  • Triceps Tendon Rupture
    • Mechanism
      • Typically occurs from forced bending of the elbow during a pushing activity
      • Unlike biceps tendon ruptures, triceps tendon ruptures are almost always traumatic, as they require a large amount of force
      • May occur after weightlifting or playing a contact sport such as football
    • Patients often hear a pop with sudden acute pain along the course of the rupture

      Olecranon Defect – Triceps Tendon Rupture (

    • Patients will have difficulty extending their elbow
    • Physical Exam
      • There will typically be a noticeable defect just above the olecranon
      • Modified Thompson’s Test
        • Elbow is flexed to 90 degrees and arm is abducted
        • Examiner squeezes triceps muscle below and observes for elbow extension
        • If none is present, a complete tear is likely
      • Easy to misdiagnose complete tear as swollen elbow can limit patient’s ability to extend

“Flake” Sign (


  • Obtain AP and lateral X-rays of the elbow with suspected triceps tendon ruptures, as they are typically associated with avulsion injuries
    • “Flake sign”: 
      • Lateral radiographs of the elbow showing an avulsion fracture where the triceps insert at the olecranon
  • MRI is the gold standard to determine severity and location of the tear for both biceps and triceps tendon ruptures but can be deferred to outpatient follow up

ED Management

  • Provide analgesia
  • Close follow up with orthopedics (within 1 week)
  • Cases of isolated biceps or triceps tendon ruptures can be discharged from the ED with supportive care measures (rest, ice, analgesia, sling).  In a community hospital without an in-house orthopedic surgeon, these patients do not warrant an emergent ortho consult in the ED
  • A triceps tendon rupture with an associated avulsion injury warrants either ED ortho consult or very close (24-48 hours) follow up, as these patients require surgical repair within 2 weeks of injury

Prognosis (Leslie 2002)

  • Biceps Tendon Rupture
    • The main indication for operative repair is restoration of supination strength. However, patients may also elect to have operative treatment for cosmetic reasons.
    • If supination strength and/or cosmetics are not important to the patient, non-operative treatment can be considered.
    • Flexion and supination strength generally return to near baseline levels. Patients can expect to return to normal functioning between 4-9 months after surgery.
    • The most common complication is a neuropraxia of the lateral antebrachial cutaneous nerve.
  • Triceps Tendon Rupture
    • Complete tears are debilitating and should be repaired surgically.
    • Partial tears >50% with significant weakness should also be repaired surgically.
    • Partial tears in which patients retain their ability to extend their elbow against gravity can be treated non-operatively with physical therapy and NSAIDs.
    • Patients can expect to regain almost full range of motion of the elbow, with possible loss of a few degrees of elbow extension.
    • Patients can expect to return to full activities 12 weeks after surgery.
    • Complications include elbow stiffness and ulnar nerve injury, the latter of which is very rare.
  • Generally, patients treated nonoperatively for biceps and triceps tendon ruptures have weaker supination/flexion and elbow extension, respectively, compared to patients treated surgically. 

Take Home Points

  • Biceps tendon rupture can be a result of trauma or overuse, but can also present after relatively routine activities. Triceps tendon ruptures are almost always traumatic and typically require a large amount of force
  • Patients typically hear a popping sound and will present with difficulty supinating and/or flexing their arm (biceps) or extending their elbow (triceps)
  • For suspected triceps tendon rupture, elbow X-rays should be obtained to evaluate for an avulsion injury. However, non-emergent MRI is the gold standard for both bicep and triceps tendon ruptures
  • Patients can be discharged from the ED but warrant close follow-up with an orthopedic surgeon

Read More

OrthoInfo: Biceps Tendon Tear at the Shoulder

Orthobullets: Biceps Tendonitis

Orthobullets: Distal Biceps Avulsion

Orthobullets: Triceps Rupture


Clayton RA, Court-Brown CM. The epidemiology of musculoskeletal tendinous and ligamentous injuries. Injury. 2008. 39(12): 1338. PMID: 19036362

Dunn JC et al. Triceps Tendon Ruptures: A systematic Review. Hand. 2017; 12(5): 431-438. PMID: 28832209

Harwood MI, Smith CT. Superior labrum, anterior-posterior lesions and biceps injuries: diagnostic and treatment considerations. Prim Care. 2005; 31(4): 831. PMID: 15544823

Kelly MP et al. Distal Biceps Tendon Ruptures: An Epidemiological Analysis Using a Large Population Database. Am J Sports Med. 2015; 43(8): 2012-7. PMID: 26063401

Khiami F et al. Distal partial ruptures of triceps brachii tendon in an athlete. Orthopaedics & Traumatology: Surgery & Research. 2012; 98(2): 242-246. PMID: 22381568

Leslie BM, Ranger H. (2002) Biceps Tendon and Triceps Tendon Ruptures. In: Baker C.L., Plancher K.D. (eds) Operative Treatment of Elbow Injuries. Springer, New York, NY.