In a patient with a mild partial‑thickness biceps tendon tear and no palpable bulge, is a simple arm sling adequate or is a rigid splint required?

Management of Mild Partial Biceps Tendon Tears Without Bulge

A simple arm sling is reasonable for mild partial biceps tendon tears without a palpable bulge, as complete immobilization with a rigid splint should be avoided to prevent muscle atrophy and deconditioning. 1

Treatment Approach Based on Tear Severity

For Tears <50% of Tendon Thickness (Mild Tears)

Relative rest with a sling is the appropriate initial management, focusing on reducing activities that reproduce pain while maintaining some controlled movement. 1 The key principle is avoiding complete immobilization, which causes muscle atrophy and deconditioning rather than promoting healing. 1

Specific conservative management includes:

• Relative rest using a sling for symptom control, not rigid immobilization—the goal is to reduce pain-provoking activities while preventing muscle wasting. 1

• Cryotherapy applied through a wet towel for 10-minute periods after activity to reduce pain and swelling. 1

• NSAIDs for short-term pain relief, with topical formulations eliminating gastrointestinal hemorrhage risk. 1

• Eccentric strengthening exercises once acute symptoms improve, as these stimulate proper collagen alignment and have proven beneficial for tendinopathies. 1

Clinical evidence supports this approach: A case series of 21 patients with distal biceps tendinopathy and partial ruptures showed that conservative treatment with splint immobilization (not rigid splinting), oral NSAIDs, and ultrasound-guided steroid injection achieved symptomatic improvement in 16 of 21 cases (76%). 2 Intermittent splinting combined with anti-inflammatory medications showed good results in mild cases. 2

For Tears >50% of Tendon Thickness

Surgical repair becomes the primary recommendation due to high failure rates with conservative management. 1 These larger tears are more likely to fail nonoperative treatment and benefit from surgical intervention. 3, 4

Critical Diagnostic Considerations

The absence of a palpable bulge does NOT rule out a significant tear. In partial tears, the tendon remains palpable, making clinical diagnosis challenging without imaging. 1, 4 This is the key distinguishing feature from complete ruptures where a palpable defect and positive hook test are present.

MRI without contrast is essential for accurate diagnosis, with 86.4% accuracy and superior ability to distinguish partial from complete tears (sensitivity 76%, specificity 50%). 1, 5 The FABS position (flexion-abduction-supination) provides optimal visualization. 1, 5

Common Pitfalls to Avoid

• Do not use rigid splints for complete immobilization in mild partial tears, as this causes muscle atrophy rather than promoting healing. 1

• Do not rely solely on clinical examination to determine tear severity—the tendon remains palpable in partial tears, requiring imaging confirmation. 1

• Do not use ultrasound as primary imaging, as it has only 45.5% accuracy for complete tears and limited ability to detect partial tears. 1, 5

• Do not delay imaging if symptoms persist beyond initial conservative management, as distinguishing <50% from >50% tears is crucial for treatment decisions. 3, 4

Treatment Algorithm Summary

For confirmed mild partial tears (<50%):

1. Simple arm sling for relative rest (not rigid splint)
2. Cryotherapy and NSAIDs for symptom control
3. Progressive eccentric strengthening once acute symptoms resolve
4. Surgical consideration only if conservative treatment fails after 3-6 months 2

The evidence consistently shows that intermittent support with a sling, combined with controlled activity modification, achieves better outcomes than rigid immobilization for mild partial biceps tendon tears. 1, 2