What are the imaging and treatment options for a biceps tendon tear?

Imaging and Treatment for Biceps Tendon Tear

Imaging Algorithm

Start with plain radiographs to rule out fractures or bony abnormalities, then proceed directly to MRI without contrast, which is the most accurate imaging modality with 86.4% accuracy for complete tears compared to ultrasound's 45.5%. 1, 2, 3

Initial Imaging

• Plain radiographs are mandatory first to exclude associated fractures, bony abnormalities, or hypertrophic bone formation at the radial tuberosity 1, 2, 4, 5

Definitive Imaging

• MRI without contrast is the gold standard with superior diagnostic accuracy (80.6% overall), sensitivity (76%), and specificity (50%) compared to ultrasound 1, 2, 3
• Use the FABS view (flexion-abduction-supination) for optimal visualization of the distal biceps tendon—patient positioned prone with elbow flexed 90°, shoulder abducted, and forearm supinated 1, 2, 4
• Axial MR images are more valuable than sagittal images for accurately grading distal biceps tendon injury preoperatively, with 100% agreement with surgical findings 6
• MRI demonstrates soft tissue abnormalities in the biceps tendon with high accuracy and can distinguish partial from complete tears 7

Alternative Imaging

• Ultrasound can be considered only when MRI is contraindicated, but recognize its significant limitations: accuracy of only 51.6% overall and 45.5% for complete tears 1, 2, 4, 3
• Ultrasound is particularly limited for detecting partial tears and tendinopathy, and proximal biceps lesions are hidden under the acromion 2, 8
• If ultrasound is used, the medial imaging approach is preferred by radiologists 1

Advanced Imaging

• MR arthrography is rated equally appropriate (rating 9/9) for post-surgical evaluation or when distinction between full-thickness and partial-thickness tears is unclear 7
• MR arthrography is particularly valuable for assessing associated pathologies including rotator cuff tears, pulley lesions, and SLAP lesions 8

Treatment Algorithm

Partial Tears (<50%)

• Conservative management is appropriate for tears <50%: relative rest to decrease repetitive loading, oral NSAIDs 2, 9
• Surgical debridement of surrounding synovitis may be considered if conservative treatment fails 9

Partial Tears (>50%)

• Surgical repair is indicated: divide the remaining tendon and repair the entire tendon as a single unit 9
• Surgical endoscopy can quantify tear extent and provide debridement, but should only be used by experienced surgeons 9

Complete Tears

• Early surgical reattachment to the radial tuberosity is recommended for optimal results 5
• Modified two-incision technique is the most widely used method, though anterior single-incision techniques may be equally effective with proper radial nerve protection 5
• Postoperative rehabilitation requires protected return of motion for the first 8 weeks, formal strengthening beginning at 8 weeks, and return to unrestricted activities including lifting by 5 months 5

Chronic Ruptures

• Surgical reattachment may still benefit patients with chronic ruptures, though proximal retraction and scarring can complicate tendon mobilization and may necessitate tendon augmentation 5

Critical Pitfalls to Avoid

• Never rely solely on ultrasound for diagnosis—its accuracy is less than half that of MRI and it misses partial tears 1, 2, 4
• Failing to distinguish between partial and complete tears leads to inappropriate treatment—this differentiation requires MRI 1, 4
• Missing the diagnosis in partial tears where the tendon remains palpable in the antecubital fossa—maintain high clinical suspicion and obtain MRI 9, 5
• Delaying surgical repair in complete tears—early reattachment provides optimal outcomes 5