Evaluation and Management of Left Biceps Tendon Tear
Initial Diagnostic Approach
Begin with plain radiographs (minimum 3 views: AP in internal and external rotation, plus axillary or scapular-Y view) to exclude associated fractures, glenohumeral dislocation, and bony Bankart lesions, followed by MRI without contrast as the definitive imaging study. 1, 2
Clinical Examination Findings to Assess
- Acute presentation: Painful tearing sensation in the antecubital region (distal tear) or anterior shoulder (proximal tear), with weakness in elbow flexion and forearm supination 3
- Palpable tendon: If the biceps tendon remains palpable in the antecubital fossa, this indicates a partial tear rather than complete rupture 4, 3
- Visible/palpable deformity: "Popeye" deformity of the distal biceps muscle belly suggests complete tear 3
- Specific provocative tests for partial tears or tendinopathy:
Imaging Protocol
MRI without contrast using the FABS view (flexion-abduction-supination position) is the gold standard, with 86.4% accuracy compared to ultrasound's 45.5% accuracy. 1, 2, 6
- FABS positioning: Patient prone with elbow flexed 90°, shoulder abducted, forearm supinated—allows visualization of entire distal biceps tendon on single image 1, 2, 6
- Ultrasound limitations: Can be used when MRI contraindicated (rating 9/9 by ACR when local expertise available), but has poor sensitivity (76%) and specificity (50%) for partial tears and tendinopathy 2, 6
- MR arthrography: Reserved for unclear cases distinguishing full-thickness from partial-thickness tears, or when assessing associated pathologies (rotator cuff tears, SLAP lesions, pulley lesions) 2
Management Algorithm Based on Tear Characteristics
Proximal (Long Head) Biceps Tears
- More common than distal tears 1
- Atraumatic ruptures involve long head in 89% of cases 1
- MRI demonstrates soft tissue abnormalities with high accuracy; can distinguish partial from complete tears 2
- For questionable bursitis or long head biceps tenosynovitis: MRI shoulder without contrast or ultrasound (both rated 9/9 by ACR) 7
Distal Biceps Tears
Partial tears <50%: Conservative management with relative rest and oral NSAIDs, or surgical debridement of surrounding synovitis 6, 4, 8
Partial tears >50%: Division of remaining tendon and surgical repair of entire tendon as single unit 4, 8
Complete tears: Early surgical reattachment to radial tuberosity recommended for optimal results 3
- Modified two-incision technique is most widely used 3
- Anterior single-incision techniques equally effective if radial nerve protected 3
- Long-term outcomes at median 14.7 years show: 98% return to work (85% without restrictions), 91% full elbow flexion strength, 76% full supination strength 9
- Complication rate 24% (infection, rerupture, heterotopic ossification, nerve complications) 9
Postoperative Rehabilitation
- Protected return of motion for first 8 weeks after repair 3
- Formal strengthening begins at 8 weeks 3
- Return to unrestricted activities including lifting by 5 months 3
Critical Pitfalls to Avoid
- Do not rely solely on ultrasound for diagnosis—MRI has significantly superior accuracy for detecting partial tears and tendinopathy 1, 2, 6
- Do not miss the distinction between partial and complete tears—this fundamentally changes management (conservative vs. surgical) 1, 4, 8
- Do not delay diagnosis in partial tears—use biceps provocation test combined with resisted hook test (98% sensitivity) to avoid diagnostic delays 5
- Do not obtain MRI in standard position—FABS view is essential for optimal distal biceps visualization 1, 2, 6
- Consider patient demographics: Typical patient is male, 40-60 years old, dominant extremity, current/former smoker, laborer with traumatic injury during intentional movement 3, 9