Purpose <p>The purpose of this study was to compare subjective and objective outcomes of conservative and operative treatment of complete distal biceps tendon ruptures in young and physically active patients.</p> Methods <p>Eleven patients were treated conservatively. Subjective and objective results were compared with those of a matched group of 11 surgically treated patients. At final follow-up, duration of work incapacity, complications, patient satisfaction, range of motion, flexion strength, supination torque, MEPS and DASH score were assessed.</p> Results <p>All conservatively treated patients were satisfied and able to fully return to work and sports activities. Two patients in the surgical group experienced complications requiring revision surgery. The mean duration of work incapacity was four&#xa0;days in the conservative group compared with 120&#xa0;days in the surgical group. No differences were observed between groups with respect to range of motion, DASH score or MEPS. Compared with the contralateral side, mean loss of flexion strength was 12% in the conservative group and 10% in the surgical group. The mean side-to-side loss of supination torque was 13% in conservatively treated patients and 4% in surgically treated patients.</p> Conclusion <p>Conservative treatment of acute distal biceps tendon ruptures allows a rapid return to occupational and recreational activities and results in good clinical outcomes and high patient satisfaction, even among young and physically active patients. Losses in flexion and supination strength are modest and not functionally relevant in daily life. Conservative treatment is also cost effective and should therefore be explained and made available to all patients who have sustained a complete rupture of the distal biceps tendon.</p>