Distal Biceps Tendon Repair in Nashville, TN: Dr. Damon H. Petty

If you felt a sudden pop in the front of your elbow while lifting, fell on an outstretched arm and now cannot turn a doorknob, or have a visible bulge in your upper arm where the muscle has bunched up, the most likely diagnosis is a distal biceps tendon rupture. The window to repair it cleanly is short. After roughly four to six weeks the tendon retracts and scars, and a straightforward single-incision repair becomes a much harder reconstruction with a tendon graft. The fix matters. So does the timing.

Dr. Damon H. Petty has performed hundreds of distal biceps tendon repairs over 25 years in Nashville. His recurrent tear rate is under 1 percent. To date he has had zero instances of nerve injury and zero cases of radioulnar synostosis, the two complications most patients are warned about before this surgery. He is board-certified in Orthopedic Surgery and Sports Medicine, fellowship-trained under Drs. James Andrews and William Clancy in Birmingham, Alabama, and served as Head Orthopedic Team Physician for the Tennessee Titans from 2018 to 2026. His distal biceps repair patients have included NFL players and a World Record Holder in the Highland Games.

What follows is what a distal biceps tendon rupture actually is, how Dr. Petty repairs it, what recovery looks like week by week, and why an early evaluation matters more than most patients realize.

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What Is a Distal Biceps Tendon Rupture?

The biceps muscle is the large muscle in the front of your upper arm. It runs from two attachments at the shoulder down to a single tendon at the elbow. That single tendon, called the distal biceps tendon, attaches to a small bump on the radius bone in your forearm called the radial tuberosity. Its job is to bend the elbow and to rotate the forearm into a palm-up position, the motion called supination.

A distal biceps tendon rupture is a tear of that tendon away from the radius bone. Most ruptures are complete, meaning the tendon pulls fully off the bone. Partial tears occur but are less common. The injury typically happens to men between 35 and 60, almost always from a single sudden eccentric load. The classic mechanism is catching a heavy object you were not expecting to catch, or lifting a weight that jerks the arm into extension while the biceps is contracted hard. Falls onto an outstretched arm and weightlifting injuries account for many of the rest. Smoking, anabolic steroid use, and chronic tendon degeneration all raise the risk.

Distal biceps ruptures are far less common than proximal biceps ruptures at the shoulder, but they are functionally more significant. A proximal biceps rupture can often be left alone with minimal long-term consequence because the second proximal head and other shoulder structures compensate. A distal biceps rupture has no biological backup. Without surgical repair, supination strength drops by roughly 40 to 50 percent and elbow flexion strength by roughly 30 percent, and that loss is permanent.

Symptoms of a Distal Biceps Tendon Tear

Most people know something serious has happened the moment it happens. The symptoms of a distal biceps tear are unmistakable, and the classic presentation of symptoms is hard to mistake for anything else.

The most common symptoms include:

Sudden Elbow Pain

Floating in the joint that cause catching or locking.

Loss of Strength

Weakness when bending the elbow against resistance and when twisting the forearm palm-up.

Pop or Tearing Sensation

An audible or palpable “pop” or tearing sensation.

Reverse Popeye Deformity

A visible deformity in the upper arm where the biceps muscle has bunched up away from the elbow, sometimes called a reverse Popeye sign.

Bruising

Bruising that develops over the next 24 to 72 hours along the inside of the elbow and down the forearm.

Persistent Arm Cramping

Cramping or aching that persists in the upper arm for days after the initial injury

If you have any combination of these symptoms (a pop, sudden bruising in the front of the elbow, and weakness in supination), get evaluated quickly. The clinical exam is reliable in experienced hands, and an MRI confirms the diagnosis and shows whether the rupture is partial or complete and how far the tendon has retracted. Ultrasound is sometimes used in lieu of MRI for confirming the diagnosis when MRI is not available or not tolerated.

Why Prompt Repair Matters

After a distal biceps tendon rupture, the most important decision you will make in the first week is to get evaluated. Not whether you want surgery yet. Just the evaluation.

A torn distal biceps tendon is no longer attached to anything that holds it down. The biceps muscle, which is naturally under tension, retracts up the arm. After about two to three weeks the tendon end starts to scar and shorten. By four to six weeks the retraction is far enough that pulling the original tendon back down to its insertion site without excess tension becomes difficult or impossible. After six weeks, most surgeons need to perform a reconstruction with a tendon graft (usually a hamstring autograft or an Achilles allograft). That is a bigger operation, with a longer recovery and somewhat lower final strength.

Repair within the first two to three weeks gives you the best chance of returning to full strength. Repair within four weeks is usually still a primary repair. After that, the surgery and the recovery both change.

So even if you are not sure you want surgery, get the evaluation early. Waiting takes options off the table.

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How the Distal Biceps Repair Surgery Is Performed: Single-Incision Technique

Dr. Petty uses a single-incision anterior approach for nearly all primary distal biceps repairs. A well-done single-incision repair gives clean exposure of the radial tuberosity, allows for anatomic reattachment with strong fixation, and avoids the second posterior incision (and the extra soft-tissue dissection) that the two-incision technique requires.

The procedure typically takes 60 to 90 minutes and is performed as outpatient surgery at a Tennessee Orthopaedic Alliance surgical center.

Anesthesia and positioning

A regional nerve block is placed in your shoulder for postoperative pain control. General anesthesia or deep sedation is used during the surgery itself. You are positioned on your back with the affected arm out on a hand table.

The incision

A short transverse or longitudinal incision (usually about 4 to 5 centimeters) is made in the front crease of the elbow. The torn tendon end is identified, often retracted up into the arm by several centimeters, and pulled back down to its anatomic position.

Tendon preparation

The end of the tendon is debrided of frayed tissue and whip-stitched with high-strength braided sutures (Dr. Petty uses #5 Fiberwire sutures, the same braided sutures used in major rotator cuff and ACL repairs). Some surgeons use a suture anchor (or several suture anchors) for fixation instead of a bone tunnel. Dr. Petty’s preferred technique uses a bone tunnel with a cortical button rather than a suture anchor because the construct biomechanics are stronger and the failure mode is more predictable than with an anchor-based repair.

Bone tunnel preparation

A small bone tunnel is drilled in the radial tuberosity, the precise anatomic insertion site of the original tendon. Anatomic placement matters. Off-axis placement weakens supination strength.

Fixation with cortical button

The whip-stitched tendon is pulled into the bone tunnel by the trailing sutures and secured on the far cortex with a titanium Endobutton. This cortical button fixation gives biomechanical pull-out strength that exceeds the strength of the tendon itself, which is why immediate gentle range of motion is safe with this construct.

Closure

The deep fascia and skin are closed in layers with absorbable sutures and a sterile dressing is applied. The arm is placed in a posterior splint with the elbow at about 90 degrees of flexion and the forearm in neutral rotation.

The patient goes home the same day with a sling, prescription pain medication, and detailed recovery instructions.

Diagnosis and Non-Surgical Treatment

Diagnosis is usually straightforward. Dr. Petty examines the elbow for tenderness over the antecubital fossa, palpates the proximal arm for the bunched-up muscle belly, and tests supination strength against resistance. The “hook test,” where the examiner tries to hook a finger under the lateral edge of the distal biceps tendon, is positive in nearly every complete rupture. MRI and sometimes ultrasound confirm the diagnosis and grade partial tears.

Surgery is not always the right treatment. Dr. Petty will tell you so directly when it is not.

When Non-Surgical Treatment May Be Appropriate

Non-surgical treatment is reasonable for older, less active patients (typically over 70) who are willing to accept a 30 to 50 percent permanent strength loss in elbow flexion and forearm supination. It can also be the right call for patients with significant medical comorbidities that push surgical risk above the functional gain. For partial tears, a non-operative treatment plan of physical therapy, activity modification, and sometimes a corticosteroid or PRP injection can be appropriate before committing to surgery.

When Surgery Is Typically Recommended

For everyone else, particularly active adults, weekend lifters, tradespeople, and athletes, surgical treatment is the standard recommendation. The strength loss without treatment is significant and permanent. The surgery itself is well-tolerated, and most patients get back to where they were.

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Recovery Timeline After Distal Biceps Repair Surgery

Recovery from distal biceps repair is structured around protecting the repair while it heals into bone, then progressively rebuilding strength. The cortical button construct is biomechanically strong from day one, which is why Dr. Petty’s protocol allows for relatively early gentle motion rather than the prolonged immobilization some older protocols required.

Week 1

Posterior splint with the elbow at 90 degrees. Sling at all times except for hygiene and dressing changes. Ice and elevation. Pain typically peaks at 24 to 48 hours and improves quickly thereafter. Most patients are off opioid medication within a few days.

Weeks 2 to 6

Transition to a hinged elbow brace. Physical therapy starts at the first post-op visit and focuses on passive and active-assisted range of motion, gradually progressing the motion arc as comfort allows. The brace protects against accidental forced extension while the tendon-to-bone interface is healing. No active resisted elbow flexion or supination.

Weeks 6 to 12

The brace comes off. Active range of motion is full or nearly full. Gentle resisted exercise begins, starting with light bands and progressing to light dumbbells. Driving is generally permitted once you are out of the brace and have confidence in your reflexes.

Months 3 to 6

Progressive strengthening with no weight restrictions on isolated exercises by month four. Most patients return to office work within 2 to 4 weeks, to driving and most non-lifting activities within 6 weeks, and to more physically demanding work between weeks 8 and 12 depending on job demands. Heavy lifting and contact sports are generally restricted until the 4 to 6 month mark.

Months 6 to 12

Return to full activity, including heavy lifting, contact sports, and combat sports. By the 9 to 12 month mark the tendon-to-bone interface has fully matured and the repair behaves like native tissue. Most patients regain 95 to 100 percent of pre-injury strength on objective testing.

The single biggest predictor of a poor outcome after a well-performed distal biceps repair is poor compliance with the postoperative protocol. Patients who push through the brace phase, lift too heavy too early, or skip physical therapy can stretch out the repair and compromise final strength. Patients who follow the protocol almost always do well.

Hundreds of Distal Biceps Repairs in Nashville

Distal biceps tendon repair is not high-volume for most orthopedic surgeons. Many Nashville general orthopedic practices do a handful a year. Dr. Petty has performed hundreds across his 25 years in practice, with outcomes that line up with what the published series from the highest-volume distal biceps surgeons in the country report.

The numbers that matter:

Hundreds of distal biceps repairs over 25 years
Recurrent tear rate under 1 percent across his series
Zero cases of permanent nerve injury to date
Zero cases of radioulnar synostosis to date (radioulnar synostosis is abnormal bone bridging between the radius and ulna and is the complication most discussed for this procedure)
Patients have included NFL players and a World Record Holder in the Highland Games, athletes whose careers depend on full supination and flexion strength

The same single-incision anterior technique with bone tunnel and cortical button fixation, the same #5 Fiberwire suture and titanium Endobutton hardware, and the same surgeon-performed approach apply whether the patient is a recreational lifter from East Nashville or a professional athlete. There is no separate “elite athlete” protocol. The protocol that produces the best outcomes for elite athletes is the protocol that produces the best outcomes for everyone.

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Distal Biceps Repair Complications and How They Are Managed

Every surgery carries risk. Distal biceps repair has a well-defined complication profile that an experienced elbow surgeon can largely avoid.

Nerve injury

The lateral antebrachial cutaneous nerve runs in the surgical field and can be stretched or irritated during exposure, causing temporary numbness on the outside of the forearm in some patients. Permanent nerve injury, particularly to the posterior interosseous nerve or the radial nerve, is rare and is mostly seen with the two-incision technique and aggressive lateral retraction. Dr. Petty has had no cases of permanent nerve injury, a record he attributes to careful single-incision exposure and respect for the soft tissue planes.

Radioulnar synostosis

This is abnormal bone formation between the radius and ulna that locks the forearm in a fixed position. It is the complication most discussed for this procedure, historically tied to the two-incision approach when bone debris from the radial tuberosity contaminates the interosseous membrane. Dr. Petty has had zero cases. Single-incision technique, careful bone debris management, and routine indomethacin prophylaxis all help.

Re-rupture (recurrent tear)

The cortical button construct is biomechanically strong, and a recurrent tear is uncommon when the postoperative protocol is followed. Dr. Petty’s recurrent tear rate is under 1 percent. Most reported re-ruptures happen in patients who returned to heavy lifting before the tendon had fully integrated into bone.

Heterotopic ossification

Abnormal soft-tissue bone formation around the repair, treated prophylactically with a short course of indomethacin (an anti-inflammatory medication) when there is no contraindication.

Wound and infection

Standard surgical risks. Antibiotic prophylaxis at the time of surgery, sterile technique, and careful wound care keep this well under 1 percent for elective elbow surgery.

The overall complication profile is favorable. Most patients who have had a distal biceps repair will tell you it was one of the more predictable surgical recoveries they have been through.

Why Patients Choose Dr. Petty for Distal Biceps Repair

Distal biceps tendon repair is a procedure where surgical experience and technical detail are everything. For nearly every active patient the question is not whether to have the surgery. The question is who performs it.

Experience. Dr. Petty has performed hundreds of distal biceps repairs across 25 years in practice. Nashville has orthopedic surgeons who do this procedure occasionally and surgeons who do it routinely. Routine is what you want.

Outcomes. Recurrent tear rate under 1 percent. Zero permanent nerve injuries to date. Zero cases of radioulnar synostosis to date. These are top-of-the-literature numbers, and they hold up across his series.

Sports medicine credentials. Board-certified in Orthopedic Surgery and Sports Medicine, fellowship-trained under Drs. James Andrews and William Clancy at the American Sports Medicine Institute in Birmingham, one of the most selective sports medicine fellowships in the country. Andrews is widely considered the most prominent sports medicine surgeon in the world.

Athlete-level care available to every patient. Dr. Petty was Head Orthopedic Team Physician for the Tennessee Titans from 2018 to 2026, has been team physician for Tennessee State University for the last 15 years, and was head orthopedic surgeon for the Nashville Sounds during their Pittsburgh Pirates affiliation. He has treated players from the New York Yankees, Pittsburgh Pirates, Tampa Bay Rays, and Kansas City Royals organizations. The surgical protocol he uses for those athletes is the surgical protocol he uses for every patient.

Surgeon-performed throughout. The exam, the surgical decision, the operation itself, and the postoperative follow-up visits are all performed by Dr. Petty personally. The biceps repair is not delegated to a fellow or PA, and neither is the long-term follow-up.

Established Middle Tennessee elbow program. Distal biceps repair sits inside a broader elbow and throwing-athlete practice that also covers Tommy John surgery (UCL reconstruction), tennis elbow surgery, elbow arthroscopy, and PRP and stem cell therapy for chronic tendinopathy. Patients with a complex elbow problem do not need to look elsewhere for any piece of it.

What Patients Say About Dr. Petty

“Dr Petty did a partial shoulder replacement for me several Yrs back. He was the first and only Orthopedic I thought of when I began having an elbow issue. I would give 10 stars instead of 5 if it were allowable.”

— Mike Beckman

“Exceptional experience. Dr Petty lived up to his reputation. Clearly knowledgable but he listens, too.”

— Jeff Freas

“Dr Damon Petty is the best! He’s genuine. He’s honest and he’s skilled.”

— Gary VanAtta

"Dr Petty is a wonderful doctor. He is brilliant in diagnosing your issue and knowing what to do. If there are options, he explains those. He is very calm, kind and listens. He repaired my meniscus, repaired my college baseball player son’s shoulder, then he patiently dealt with my 89 yr old mother when she broke her shoulder/arm. I highly recommend for his skills and overall how he cares for his patients!"

— Janice Goodwin

Frequently Asked Questions About Distal Biceps Repair

A complete distal biceps tear cannot heal back to its bony attachment without surgery. The retracted tendon scars in place but never reattaches to the radial tuberosity. Without surgery, supination strength drops by roughly 40 to 50 percent and elbow flexion strength by roughly 30 percent, and that loss is permanent. Non-surgical management is reasonable in older or less active patients and in some partial tears, but for most active adults surgical repair is the standard recommendation.

The complications most discussed in the surgical literature are temporary numbness in the forearm from stretching of a small sensory nerve (usually resolves), permanent nerve injury (rare with single-incision technique), heterotopic ossification or radioulnar synostosis (treated prophylactically with indomethacin), re-rupture (uncommon with cortical button fixation when protocol is followed), and standard surgical risks like infection. Dr. Petty has had zero cases of permanent nerve injury and zero cases of radioulnar synostosis to date.

Both techniques can produce excellent outcomes in experienced hands. Dr. Petty uses the single-incision anterior approach for nearly all primary repairs. Single incision avoids the second posterior incision and the additional dissection it requires, and the modern cortical button fixation provides anatomic placement and strong fixation through that single anterior exposure. The two-incision technique remains useful in specific situations, particularly in delayed cases requiring tendon graft reconstruction.

Physical therapy is a standard part of the recovery protocol and significantly improves outcomes. Patients who skip therapy or try to do their own rehabilitation often end up with stiffness, incomplete range of motion recovery, or strength deficits that take much longer to resolve. Dr. Petty’s protocol starts physical therapy at the first post-op visit and continues for approximately 8 to 12 weeks.

Schedule Your Distal Biceps Repair Consultation

If you felt a pop in the front of your elbow with bruising and weakness in your arm, do not sit on it. The window for a primary repair closes within four to six weeks, and getting evaluated early keeps every option on the table.

We serve patients from Nashville, Brentwood, Franklin, Murfreesboro, Hendersonville, Gallatin, Lebanon, and the greater Middle Tennessee area. Dr. Petty also sees patients who travel for world-class care, some from over 500 miles away, including recent patients from Kansas City, drawn by his specific expertise and reputation.

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