MRI Protocol for Biceps Injury
Order an MRI of the shoulder (for proximal biceps) or MRI of the elbow (for distal biceps) without contrast, and specifically request the FABS (flexion-abduction-supination) view for distal biceps evaluation. 1, 2
Initial Imaging Sequence
Before ordering the MRI, obtain plain radiographs first to exclude fractures, glenohumeral dislocation, or bony abnormalities that may accompany biceps injuries. 1, 2, 3
- For shoulder/proximal biceps: Order standard shoulder radiographs with minimum 3 views (AP in internal and external rotation, plus axillary or scapular-Y view) in upright positioning 1
- For distal biceps: Order elbow radiographs to rule out associated bony pathology 2
MRI Protocol Specifications
Standard MRI Order
Order "MRI without contrast" as the primary imaging modality, which has superior accuracy (86.4%) compared to ultrasound (45.5%) for biceps tendon pathology. 1, 2, 3
Critical Addition for Distal Biceps
Specifically request the FABS view when evaluating distal biceps pathology:
- Patient positioned prone with elbow flexed at 90°, shoulder abducted, and forearm supinated 2
- This view visualizes the entire distal tendon on a single image and is optimal for detecting complete versus partial tears 1, 2
- Axial MR images are particularly valuable for accurately grading distal biceps tendon injury preoperatively 4
When to Consider Advanced Imaging
Upgrade to MR arthrography in specific situations:
- Post-surgical evaluation 1
- When distinction between full-thickness and partial-thickness tears remains unclear on standard MRI 1
- When assessing associated pathologies including rotator cuff tears, pulley lesions, and SLAP lesions 1
- MR arthrography provides superior assessment of intra-articular pathology compared to non-contrast MRI 1
Alternative When MRI Contraindicated
If MRI is contraindicated or unavailable, ultrasound can be considered as a second-line option, but recognize its significant limitations:
- Substantially lower accuracy (45.5% vs 86.4% for MRI) in detecting complete distal biceps tears 1, 2
- Poor performance in detecting partial tears and tendinopathy 2, 3
- Requires local expertise for optimal results 1
- The medial imaging approach is preferred by radiologists when using ultrasound 1
Common Pitfalls to Avoid
- Never rely solely on ultrasound for definitive diagnosis, as it has significant limitations compared to MRI 1, 2, 3
- Always distinguish between partial and complete tears, which requires MRI accuracy 2, 3
- Don't forget the FABS view for distal biceps evaluation, as standard sequences may miss subtle findings 1, 2
- Avoid CT arthrography as it is inferior to MR arthrography for partial-thickness tears 1