CT for Bicep Tear Evaluation: Contrast is Not Needed (But CT Itself is Not Recommended)
CT imaging, whether with or without contrast, is not an appropriate modality for evaluating suspected bicep tendon tears, and you should instead order MRI without contrast or ultrasound. 1
Why CT is Not Appropriate for Bicep Tears
The American College of Radiology explicitly states there is no evidence to support the use of CT (with or without contrast) for the assessment of tendon, ligamentous, or muscle injury in the upper extremity. 1 This applies directly to bicep tendon evaluation, as CT provides:
- No useful soft tissue detail for tendon pathology 1
- No ability to distinguish partial from complete tears 1
- No visualization of associated muscle edema or tendon sheath fluid 1
CT is reserved for bony pathology only - fracture characterization, fragment displacement, and complex fracture patterns. 1
Recommended Imaging Algorithm for Suspected Bicep Tear
First-Line Imaging: MRI Without Contrast
MRI without IV contrast is the gold standard for evaluating bicep tendon tears with the following performance characteristics: 1
- Sensitivity: 92.4% for complete distal biceps tendon ruptures 1
- Specificity: 100% for complete ruptures 1
- Sensitivity: 59.1% for partial tears 1
- Specificity: 100% for partial tears 1
Key MRI findings to identify: 2, 3
- Complete tears: Absence of tendon distally, fluid-filled tendon sheath, antecubital fossa mass, muscle edema
- Partial tears: High signal intensity within tendon, fluid in biceps sheath, tendon thinning or thickening
- Axial images are more valuable than sagittal for accurate grading 2
Alternative: Ultrasound (Operator-Dependent)
Ultrasound is a reasonable alternative if performed by an experienced musculoskeletal sonographer: 1
- Sensitivity: 95% for complete versus partial distal biceps tears 1
- Specificity: 71% 1
- Accuracy: 91% 1
- Performs similar to or slightly better than MRI for distal biceps tears 1
When Contrast IS Needed (Rare Scenarios)
MR arthrography (not CT arthrography) may be considered only in these specific situations: 1
- Remote proximal humeral fracture with persistent pain and suspected rotator cuff tear
- Patient has contraindication to standard MRI
- Not indicated for acute bicep tear evaluation 1
Common Pitfalls to Avoid
Do not order CT for bicep tear evaluation - it wastes time, radiation exposure, and provides no diagnostic value for soft tissue pathology. 1
Do not add IV contrast to MRI for routine bicep tear assessment - noncontrast MRI provides all necessary information. 1
Be aware of MRI limitations for proximal long head biceps tears - standard noncontrast MRI has only 27.7% sensitivity for partial intra-articular tears, though specificity remains high at 84.2%. 4
Ensure proper MRI technique - axial sequences through the distal biceps insertion are critical for accurate grading of injury severity. 2