Biceps Hook Test and Squeeze Test: Distal Biceps Tendon Rupture Guide
In short
A sudden pop in the antecubital fossa during heavy eccentric lifting signals a distal biceps tendon rupture. Learn how the Biceps Hook test and Biceps Squeeze test deliver 100 percent diagnostic sensitivity.
In this guide (8 sections)
Pathomechanics of Distal Biceps Rupture
The distal biceps tendon inserts onto the radial tuberosity, serving as the most powerful supinator of the forearm and a secondary elbow flexor.
Distal ruptures occur almost exclusively during unexpected eccentric load on a flexed elbow (such as catching a falling heavy piece of furniture or heavy gym deadlifts). Immediate clinical recognition is urgent because surgical re-anchoring yields optimal results when performed within 2 to 3 weeks before tendon retraction.
The O'Driscoll Biceps Hook Test Technique
The Biceps Hook test evaluates the anatomical presence of the tendon in the cubital fossa:
- Arm Setup: The patient actively flexes the elbow to 90 degrees and fully supinates the forearm (palm facing upward).
- The Hook Maneuver: The clinician approaches from the lateral side and attempts to hook their index finger under the lateral edge of the cord-like distal biceps tendon in the antecubital fossa.
- Intact Finding: In an intact or partially torn tendon, the clinician finger easily hooks under a taut, cord-like structure that can be pulled anteriorly.
- Positive (Ruptured) Finding: In a complete rupture, there is no cord to hook; the examiner finger slides straight into an empty soft-tissue space across the antecubital fossa.
The Biceps Squeeze Test (Simmonds Analog)
Similar to the Thompson calf test for Achilles rupture, the clinician firmly squeezes the biceps muscle belly with both hands while the patient forearm rests on their lap. In an intact tendon, squeezing the muscle belly mechanically produces visible passive forearm supination. Lack of supination confirms tendon discontinuity.
Diagnostic Performance Matrix
| Clinical Examination Maneuver | Sensitivity | Specificity | Diagnostic Reliability | |
|---|---|---|---|---|
| Biceps Hook Test | 100 percent | 100 percent | Near-perfect clinical gold standard for complete avulsion | |
| Biceps Squeeze Test | 96 percent | 100 percent | Highly reliable alternative when swelling is severe | |
| Reverse Popeye Deformity | 85 percent | 92 percent | Muscle belly retracts proximally toward upper arm |
Frequently Asked Questions
Can the lacertus fibrosus create a false negative in the Hook test?
Yes. An intact lacertus fibrosus (bicipital aponeurosis) can sometimes feel taut under palpation. The clinician must ensure they hook from the lateral side deeply toward the radial tuberosity.
What functional deficit occurs if a distal biceps rupture is not repaired?
Non-operative management results in a permanent 30 to 40 percent loss of forearm supination power and a 20 to 30 percent loss of elbow flexion strength.
Distal Biceps Tendon Avulsion Mechanics
The distal biceps tendon inserts onto the radial tuberosity. Complete rupture typically occurs when a heavy eccentric load is suddenly applied to an elbow flexed at 90 degrees (such as catching a falling heavy object). Patients describe a sudden audible pop followed by retraction of the muscle belly proximal into the arm (reverse Popeye sign).
Surgical Repair vs Conservative Management Decision
Active individuals typically undergo anatomic surgical re-attachment to the radial tuberosity within 2 to 3 weeks using cortical buttons or suture anchors to preserve supination power. Sedentary patients managed conservatively must accept a permanent 30 to 40 percent reduction in forearm supination torque.
Post-Operative Rehabilitation Pathway
Following repair, the elbow is protected in a hinged brace locked at 90 degrees, gradually opening extension by 10 to 15 degrees weekly. Passive supination begins early, while resisted bicep loading is delayed until week 8 to protect tendon-to-bone healing.
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