Single-Incision or Two-Incision for a Torn Distal Biceps? Strength, Nerve Safety, and Recovery Side by Side

A torn distal biceps tendon tanks your palm-up strength (forearm supination) and makes everyday tasks—from opening jars to carrying a suitcase—frustratingly weak. Surgical repair is the gold standard for active patients, but there are two main approaches: a single-incision anterior approach and a two-incision approach that splits the work between the front of the elbow and a second incision near the back of the forearm. Each path has trade-offs for strength, nerve safety, and complications such as heterotopic bone formation. Understanding those differences helps you and your surgeon choose an operation that fits your anatomy, goals, and risk tolerance. ^[1]

Surgeons make one incision at the front of the elbow, find the torn tendon, and reattach it to the radius—often with cortical buttons and/or suture anchors seated inside the bone tunnel. This approach keeps everything in one field and is common when using modern intramedullary button constructs. ^[2]

Surgeons begin with a small incision in front to retrieve the tendon, then create a second incision on the dorsal forearm to expose the radial tuberosity more directly for transosseous fixation or button-based techniques. The goal is anatomical placement with less retraction on anterior neurovascular structures. ^[1]

Bottom line: Both techniques can put the tendon back where it belongs. The differences show up in which nerves are at risk, the likelihood of heterotopic bone, and the profile of other complications—not in whether the tendon can be reattached at all.

• Overall complications: Meta-analyses suggest single-incision repairs have higher total complication rates than two-incision techniques, driven largely by neurologic issues; two-incision techniques have more heterotopic ossification. ^[3]
• Strength and functional scores: Long-term patient-reported outcomes and strength are similar between approaches when fixation is sound and rehab is followed. Some pooled data show slightly greater elbow flexion and pronation range after single-incision, while neurologic complications are lower with two-incision. ^[4]
• Return to work/sport: Across studies, the average time to return to work is just over 14 weeks (~3–4 months), with sport return rates above 90 percent regardless of approach; job demands and sport intensity matter more than incision choice. ^[6]

When the tendon is securely fixed, both approaches restore forearm supination and elbow flexion strength to high levels in most patients. Network and systematic reviews comparing fixation constructs (buttons vs anchors vs transosseous) show construct strength differences in the lab, but clinical series generally find no consistent, large differences in postoperative strength ratios between approaches when modern fixation is used and rehab is adhered to. ^[2]

A 2020 Bone & Joint Journal meta-analysis found no significant difference in functional scores between single- and two-incision groups; small advantages in flexion and pronation range favored single-incision, but the clinical relevance was modest compared with the bigger signal—complication profile differences. ^[4]

Takeaway: If your top priority is raw strength, both approaches can deliver when the anatomy is restored in an anatomic position with secure fixation. Your surgeon’s familiarity with the chosen technique and fixation may matter more than the skin cuts themselves. ^[2]

• Single-incision (anterior): The lateral antebrachial cutaneous nerve (a sensory nerve to the forearm) is most commonly irritated or injured; the superficial radial nerve can also be affected. Rarely, the posterior interosseous nerve is at risk, particularly with aggressive retraction or drilling. ^[5]
• Two-incision: The strategy reduces stretch on anterior structures and is associated with lower overall neurologic complications, though posterior interosseous nerve palsy can still occur. ^[7]

A 2022 meta-analysis (2,429 patients) reported a significantly lower total complication rate with the two-incision approach (16.1% vs 23.1%) and a lower rate of neurologic injuries overall (9.1% vs 24.1%). Lateral antebrachial cutaneous nerve injuries were notably lower in two-incision (5.2% vs 19.5%), and superficial radial nerve injuries were also less common; posterior interosseous nerve injuries were not significantly different between groups. ^[7]

Earlier meta-analyses echo the theme: single-incision has more nerve-related issues, while two-incision has more heterotopic bone (see below). ^[3]

Technique nuance: Even within the single-incision family, limited anterior vs extensile anterior cuts differ. One large review found higher lateral antebrachial cutaneous nerve injury with limited anterior incisions, while extensile single-incision increased superficial radial nerve problems—illustrating how small technique choices modulate risk. ^[5]

Heterotopic ossification (HO) (unwanted bone in soft tissues) and radioulnar synostosis (bone bridging radius and ulna) can limit forearm rotation. Historically these were linked to older two-incision techniques; modern methods that protect the interosseous space have dramatically reduced risk, but two-incision repairs still carry a higher HO signal overall in pooled datasets. ^[3]

That said, heterotopic bone can occur after single-incision repairs too (case reports exist), so prophylaxis decisions (such as anti-inflammatory protocols in high-risk cases) are individualized. Recent reviews discuss evolving strategies for HO prevention after distal biceps surgery. ^[8]

Practical point: Ask how your surgeon protects the interosseous membrane (during drilling and dissection) and whether they use any HO prophylaxis in your risk profile. Technique details drive risk as much as the choice of one or two incisions. ^[9]

Classic meta-analyses found higher re-rupture and failed re-attachment rates reported with single-incision in older series, but as fixation evolved (intramedullary cortical buttons, suture anchors, hybrid constructs), differences have narrowed. Contemporary reviews suggest no single construct is universally superior in clinical outcomes, even though biomechanical testing often shows the double intramedullary cortical button constructs with higher failure loads versus anchors in the lab. Clinical success still hinges on precise tunnel placement, tendon length restoration, and protected rehab. ^[10]

• Which fixation do you prefer in my case, and why?
• How do you ensure anatomic footprint restoration on the radial tuberosity?
• What is your re-rupture rate and how do you protect the repair early on?

• Single-incision: One scar in the antecubital region; less dorsal forearm tenderness, but a higher chance of patchy forearm numbness if the lateral antebrachial cutaneous nerve is irritated. ^[5]
• Two-incision: Two smaller scars (front and dorsal forearm). Slightly more risk of heterotopic bone and rare synostosis, but often less anterior nerve irritation. ^[3]

Cosmetic differences are usually modest; patient satisfaction is more tightly tied to strength recovery and absence of complications than to scar count.

A systematic review of return-to-work outcomes reported an average of just over 14 weeks after distal biceps repair, with a realistic range of 3–4 months depending on job demands (desk vs heavy manual). The review did not find a consistent difference in time to work by approach; job type and postoperative protocols dominate. Return to sport rates are high (≈95 percent), with level of play and sport type shaping timelines. ^[6]

• 0–2 weeks: Splint or brace; controlled passive range; protect the repair.
• 2–6 weeks: Gradual increase in elbow motion; avoid resisted supination early.
• 6–12 weeks: Begin light strengthening; regain full range.
• 3–6 months: Progress to heavier lifts and sport-specific tasks; manual laborers return as strength and endurance normalize.

Key variable: adherence. Patients who respect early restrictions and follow a graded strengthening plan tend to recover more predictably, regardless of incision choice. ^[6]

• Two-incision may be favored when your surgeon prioritizes lower neurologic complication risk (especially lateral antebrachial cutaneous nerve issues) and wants direct visualization of the radial tuberosity for anatomic reattachment. ^[7]
• Single-incision may be chosen for simplicity, familiarity with specific button/anchor systems, or to avoid a second posterior forearm incision—particularly in patients with thin soft tissues over the ulna. Some analyses show less heterotopic bone and lower reoperation with single-incision, albeit with higher sensory nerve irritation. ^[4]

Reality check: The surgeon’s experience with a chosen technique is often the strongest predictor of smooth surgery. Choose the surgeon, not just the incision.

Will I end up weaker if I pick the “wrong” approach?

Unlikely. When the tendon is anatomically reattached with solid fixation and you complete rehab, strength and function are comparable between approaches in pooled studies. Complication profiles—not strength—are where the differences tend to live. ^[4]

Which approach has fewer nerve problems?

Across large datasets, two-incision repairs show lower overall neurologic complications, especially fewer lateral antebrachial cutaneous nerve injuries. Posterior interosseous nerve palsy is uncommon and not clearly different between techniques. ^[7]

Which approach has more heterotopic bone?

Historically and on meta-analysis, two-incision carries a higher heterotopic ossification signal, though modern technique has reduced rates. Single-incision cases can still develop HO; prevention is individualized. ^[3]

Do fixation devices change outcomes more than incision choice?

In the lab, double intramedullary cortical buttons are very strong, but clinical outcomes are excellent with multiple constructs when the footprint is restored and rehab is sound. No device universally outperforms in clinical series. ^[11]

When can I return to work or lifting?

Average return to work is ≈14 weeks, varying by job demand; many athletes return to play with high success rates. Your plan is tailored to pain-free range, symmetric grip, and recovering supination strength. ^[6]

• Risk profile: Are you more concerned about sensory nerve symptoms (favoring two-incision) or heterotopic bone (slightly higher with two-incision)? ^[7]
• Fixation preference: Which button/anchor/transosseous method does your surgeon use most, and why for your anatomy? ^[2]
• Rehab plan: What are the first 6 weeks of protection and motion? How do we progress supination loading? ^[6]
• Outcomes and volumes: What are the team’s complication, re-rupture, and reoperation rates with each approach? (Surgeon experience matters.) ^[4]

• Both approaches restore strength well when the tendon is reattached anatomically with secure fixation and rehab is followed. ^[4]
• Two-incision repairs show lower overall neurologic complication rates (notably fewer lateral antebrachial cutaneous nerve injuries). ^[7]
• Single-incision repairs show lower rates of heterotopic ossification and reoperation in some analyses but carry higher sensory nerve irritation risk. ^[4]
• Return to work averages ~14 weeks; incision choice matters less than job demands, fixation quality, and disciplined rehabilitation. ^[6]

Also Read:

• Why Your Tennis Elbow Treatment is Failing: Signs of a Distal Biceps Injury
• What Causes Tennis Elbow to Flare Up
• Performing Wrist Stretch, Ball Squeezing, and Electrotherapy: Does it Help Tennis Elbow?