MRI Shoulder Without Contrast for Suspected Biceps Tendon Tear
Order an MRI of the shoulder without intravenous contrast as the primary imaging study for suspected biceps tendon tear. 1
Primary Imaging Recommendation
MRI without contrast and ultrasound are considered equally appropriate imaging modalities for evaluating suspected biceps tendon pathology, both rated 9/9 by the American College of Radiology. 1 However, MRI demonstrates superior overall diagnostic performance for biceps tendon tears specifically:
- MRI achieves 92.4% sensitivity and 100% specificity for detecting complete distal biceps tendon ruptures 2, 1
- For partial tears, MRI demonstrates 59.1% sensitivity and 100% specificity 2, 1
- MRI has superior accuracy (86.4%) compared to ultrasound (45.5%) specifically for biceps tendon tears 1
- MRI provides comprehensive evaluation of associated rotator cuff pathology, which is critical since 96.2% of patients with biceps tears also have supraspinatus tears and 47.1% have subscapularis tears 3
Specific MRI Protocol Considerations
- Standard MRI shoulder without contrast is sufficient for most biceps tendon evaluations 1
- For distal biceps tendon tears, consider requesting FABS positioning (Flexion, Abduction, Supination) to optimize visualization 4
- MRI demonstrates tendinosis, partial tears, tenosynovitis, and complete ruptures with high accuracy 1, 5
When Ultrasound May Be Preferred
Ultrasound can be selected as an alternative when:
- Immediate point-of-care evaluation is needed with local expertise available 1
- Concurrent therapeutic injection is planned (ultrasound allows real-time guided injection of anesthetic/corticosteroid) 1
- For distal biceps evaluation specifically, where ultrasound performs similarly to MRI with 95% sensitivity, 71% specificity, and 91% accuracy 2
Critical Pitfall to Avoid
Do not order MR arthrography for biceps tendon evaluation—it is rated 1/9 ("usually not appropriate") and adds no diagnostic value compared to noncontrast MRI for biceps pathology. 1 MR arthrography does not provide additional information for biceps tendon tears or tenosynovitis. 2, 1
Imaging Modalities to Avoid
- CT shoulder without contrast is rated 1/9 and cannot adequately visualize tendon pathology 1
- CT arthrography adds no value for biceps tendon assessment 1
- Plain radiographs should be obtained first only to exclude fractures or bony abnormalities, but cannot visualize the tendon itself 1
Clinical Context for Interpretation
- Focal partial tears at the bicipital groove entrance can be challenging to detect even on MRI, occurring in 100% of cases with focal intrasubstance signal abnormality and only 50% showing tendon enlargement 6
- Proximal long head biceps tears can occasionally mimic pectoralis major ruptures clinically, making imaging essential for accurate diagnosis 7
- Most biceps tendinopathy represents degenerative tendinosis rather than inflammatory tendinitis 5