Diagnostic Approach for Suspected Torn Biceps Tendon

Imaging Recommendations

The American College of Radiology recommends MRI as the most accurate imaging modality for diagnosing biceps tendon tears, with an accuracy of 86.4% compared to ultrasound (45.5%) for complete distal biceps tears 1, 2, 3
Plain radiographs should be the first imaging study to rule out associated fractures or other bony abnormalities 4
MRI without contrast is the next appropriate imaging study, with superior accuracy and better sensitivity (76%) and specificity (50%) than ultrasound for biceps tendon tears 1, 3
The FABS (flexion-abduction-supination) view is recommended for optimal visualization of the biceps tendon on MRI 1, 5
Ultrasound can be considered as an alternative when MRI is contraindicated, but it has limitations in accuracy, particularly for detecting partial tearing and tendinopathy 3, 6
The medial imaging approach is preferred by radiologists when using ultrasound, with substantial interreader agreement 5

Failing to distinguish between partial and complete tears can be avoided by using MRI, which is crucial for this differentiation 1, 3
Relying solely on ultrasound for diagnosis can lead to inaccurate results, as it has limitations in accuracy compared to MRI 1, 3

MRI demonstrates soft tissue abnormalities in the biceps tendon with high accuracy and can distinguish partial from complete tears, according to the American College of Radiology 7
MR arthrography is rated equally appropriate for post-surgical evaluation or when distinction between full-thickness and partial-thickness tears is unclear, as per the American College of Radiology 7

MR arthrography is particularly valuable for assessing associated pathologies including rotator cuff tears, pulley lesions, and SLAP lesions, although the specific guideline society is not mentioned 7

The American College of Radiology recommends obtaining standard shoulder radiographs with a minimum of 3 views, including anteroposterior (AP) in internal and external rotation, plus axillary or scapular-Y view, to exclude associated fractures, glenohumeral dislocation, and bony Bankart lesions that may accompany biceps injuries 8, 9
Upright positioning is preferred over supine to avoid underrepresenting shoulder malalignment, as suggested by the American College of Radiology 9

The American College of Radiology rates ultrasound as a second-line option when MRI is contraindicated or unavailable, with equal appropriateness (rating 9/9) for long head biceps tenosynovitis when local expertise is available 10
Ultrasound-guided injection of anesthetic/corticosteroid can provide both diagnostic and therapeutic benefit, according to the American College of Radiology 10

The American College of Radiology suggests that MR arthrography provides superior assessment of intra-articular pathology, including SLAP tears and partial rotator cuff tears, compared to non-contrast MRI 9
CT arthrography is inferior to MR arthrography for partial-thickness tears and should only be considered if MRI is contraindicated, as recommended by the American College of Radiology 9