Initial Management of Biceps Tear with Positive Speed Test
For a patient with a positive Speed test suggesting biceps pathology, obtain plain radiographs first to rule out fractures or bony abnormalities, followed by MRI without contrast (not ultrasound) to distinguish between partial and complete tears, as this distinction determines whether conservative management or urgent surgical repair is needed. 1, 2, 3
Understanding the Speed Test Limitations
The Speed test is highly sensitive (90%) but poorly specific (13.8%) for biceps/labral pathology, meaning a positive test does not confirm a biceps tear but rather indicates the need for further workup. 4 The test has a positive predictive value of only 23-50%, so it frequently yields false positives with various other shoulder pathologies including rotator cuff tears and impingement. 4, 5
Diagnostic Algorithm
Step 1: Plain Radiographs (First-Line Imaging)
- Obtain standard elbow or shoulder radiographs depending on suspected location of injury (distal versus proximal biceps). 1, 2, 3
- Rules out associated fractures, heterotopic ossification, or other bony abnormalities. 6, 1
Step 2: MRI Without Contrast (Preferred Advanced Imaging)
- MRI has 86.4% accuracy compared to only 45.5% for ultrasound in detecting biceps tendon tears. 1, 2, 3
- For distal biceps evaluation, request the FABS view (flexion-abduction-supination) with the patient prone, elbow flexed 90°, shoulder abducted, and forearm supinated—this allows visualization of the entire distal biceps tendon on a single image. 1, 3
- MRI accurately distinguishes partial from complete tears, which is critical for treatment decisions. 2, 3, 7
- MRI also identifies associated pathologies including rotator cuff tears, SLAP lesions, and pulley lesions. 3
Step 3: Consider Ultrasound Only When MRI Contraindicated
- Ultrasound has significant limitations, particularly for detecting partial tears and tendinopathy. 1, 2, 3
- If ultrasound must be used, the medial imaging approach is preferred. 3
Initial Treatment Based on Tear Type
Complete Tears
- Early anatomic reattachment is the goal for complete distal biceps tears, as nonoperative treatment results in loss of flexion and supination strength and endurance. 7
- Surgical repair should be performed urgently (though not emergently) to prevent tendon retraction and optimize outcomes. 2, 7
Partial Tears <50%
- Conservative management is appropriate, including relative rest to decrease repetitive loading and oral NSAIDs. 1, 8
- Alternatively, surgical debridement of surrounding synovitis may be considered. 8
Partial Tears >50%
- Should be treated with division of the remaining tendon and surgical repair of the entire tendon as a single unit. 8
Critical Pitfalls to Avoid
- Do not rely on the Speed test alone for diagnosis—it is sensitive but not specific and requires imaging confirmation. 4, 5
- Do not use ultrasound as first-line advanced imaging—MRI is significantly more accurate and should be the standard. 1, 2, 3
- Do not fail to distinguish partial from complete tears—this distinction fundamentally changes management from conservative to surgical. 2, 7, 8
- Do not delay imaging in suspected complete tears—chronic tears are more difficult to treat due to tendon retraction and poor tissue quality, potentially requiring tendon grafts. 7
Additional Physical Examination Considerations
For distal biceps specifically, the Hook test combined with biceps crease interval measurement provides 94% sensitivity and 100% specificity for acute complete ruptures and should be performed alongside the Speed test. 9 Weakness on active supination has 100% sensitivity for chronic complete ruptures. 9