Biceps Tendon Rupture: Contemporary Evidence, Evolving Techniques, and a Mechanics-to-Management Clinical Framework

Biceps tendon rupture represents a spectrum of injuries ranging from the degenerative attrition of the long head proximally to acute mechanical failure of the distal insertion. This review synthesises contemporary evidence on anatomy, biomechanics, diagnostic strategies, operative and non-operative management, and long-term outcomes. Proximal ruptures typically occur in hypovascular, degenerative tissue and often coexist with rotator-cuff pathology, whereas distal ruptures result from sudden eccentric overload and produce significant supination and flexion deficits. Diagnosis relies on clinical examination supported by ultrasound or magnetic resonance imaging (MRI) when chronicity or partial tearing is suspected. Management strategies vary by location: proximal ruptures often respond well to tenotomy or tenodesis depending on patient preference, while distal ruptures generally require anatomic repair or graft reconstruction when delayed. Surgical outcomes are excellent when anatomic footprint restoration and proper tensioning are achieved; complications are uncommon and usually transient. Future directions include biologically active fixation, improved imaging biomarkers, and value-based surgical decision-making. Understanding the mechanical and biological differences between proximal and distal biceps pathology remains central to guiding personalised treatment.