From the Guidelines
In the emergency room setting, ultrasound is the preferred initial imaging modality for suspected bicep tears due to its availability, cost-effectiveness, and ability to provide real-time dynamic assessment. The ER physician should order an ultrasound of the affected arm, which can identify complete tears with approximately 80-90% accuracy, as reported by de la Fuente et al 1. If ultrasound results are inconclusive or if a partial tear is suspected, MRI would be the next appropriate step, though this is typically arranged as an outpatient follow-up rather than in the ER. MRI provides superior soft tissue contrast and can better characterize partial tears, tendinosis, and associated injuries, as shown by Nicolay et al 1. X-rays are not useful for direct visualization of bicep tears but may be ordered to rule out associated fractures or bony abnormalities. CT scans are rarely indicated for isolated bicep tears. The choice of imaging is influenced by the clinical presentation, with acute complete tears often presenting with the characteristic "Popeye" deformity, pain, and weakness in elbow flexion and supination. Prompt diagnosis is important as surgical repair outcomes are generally better when performed within 2-4 weeks of injury, particularly for complete tears of the distal biceps tendon.
Some key points to consider when using ultrasound for bicep tear imaging include:
- The use of US to evaluate the distal biceps tendon is well described in the literature 1
- US can identify complete tears with approximately 80-90% accuracy, but may be less accurate for partial tears 1
- MRI is more accurate than US for detecting partial tears and tendinosis, but US is more readily available and cost-effective 1
- The choice of imaging modality depends on the clinical presentation and the suspected type of injury 1
It's also important to note that recent studies have shown that US can be used to detect subtle low blood flow using superb microvascular imaging, and that sonoelastography has shown promising outcomes for detection of medial epicondylalgia 1. However, these techniques may not be widely available and may require further training and expertise. Overall, the choice of imaging modality should be based on the individual patient's needs and the availability of resources.
From the Research
Bicep Tear Imaging in the Emergency Room
- Bicep tears can be diagnosed using various imaging techniques, including ultrasound and MRI 2, 3.
- Ultrasound examination can be beneficial in diagnosing distal biceps tendon tears, but its sensitivity depends on the expertise of the examiner, with a sensitivity of 91% when performed by a radiologist-specialist and 40% when performed by a non-specialist 2.
- MRI is also useful in evaluating patients with suspected distal biceps tendon injury, with axial MR images being more valuable than sagittal images in accurately grading the injury 3.
- Ultrasound assessment of the distal biceps tendon is challenging due to its complex anatomy, and a combination of approaches and examination techniques are utilized to ensure complete evaluation 4.
Imaging Techniques
- Ultrasound:
- Can be used to diagnose distal biceps tendon tears
- Sensitivity depends on the expertise of the examiner
- Can be beneficial in diagnosing acute injuries
- MRI:
- Can be used to diagnose distal biceps tendon tears
- Axial MR images are more valuable than sagittal images in accurately grading the injury
- Can be beneficial in diagnosing chronic injuries or in cases where ultrasound is inconclusive
Diagnosis and Treatment
- Distal biceps tendon tears can be diagnosed using a combination of clinical examination, medical history, and imaging techniques 5.
- Treatment options depend on the extent and timing of the injury, and include nonoperative management, repair, and reconstruction with or without repair of the bicipital aponeurosis 5.
- Operative treatment has been shown to result in superior outcomes compared to nonoperative management, including improved strength, endurance, and patient-reported outcomes 6.