Musculoskeletal Imaging Original Research

Da Gama Lobo et al.

Sonography in Biceps Tendon Tears

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Musculoskeletal Imaging
Original Research

The Role of Sonography in

Differentiating Full Versus Partial
Distal Biceps Tendon Tears:
Correlation With Surgical Findings
Lucas Da Gama Lobo1,2
David P. Fessell1
Bruce S. Miller 1,3
Aine Kelly 1
Jee Young Lee1,4
Catherine Brandon1
Jon A. Jacobson1
Da Gama Lobo L, Fessell DP, Miller BS, et al.

Keywords: biceps, elbow, tendon tear, ultrasound

DOI:10.2214/AJR.11.7302
Received May 31, 2011; accepted after revision
May 18, 2012.
1

Department of Radiology, University of Michigan Hospital,

1500 E Medical Center Dr, Ann Arbor, MI 48109. Address
correspondence to D. P. Fessell (dfessell@med.umich.edu).
2

Present address: Department of Radiology, Mount Sinai

Hospital, Toronto, ON, Canada.

3
Department of Orthopedic Surgery, University of
Michigan Hospital, Ann Arbor, MI.
4

Present address: Department of Radiology, Dankook

University Hospital, Dankook University School of
Medicine, Chungchungnam-Do, Korea.

AJR 2013; 200:158162

0361803X/13/2001158
American Roentgen Ray Society

158

OBJECTIVE. The purpose of this study was to determine the accuracy of ultrasound for
distinguishing complete rupture of the distal biceps tendon versus partial tear and versus a
normal biceps tendon. Surgical findings were used as the reference standard in cases of tear.
Clinical follow-up was used to assess the normal tendons.
MATERIALS AND METHODS. The study population consisted of 45 consecutive elbow
ultrasound cases with surgical confirmation and six cases of a clinically normal distal biceps tendon that underwent elbow ultrasound for suspicion of injury to a structure other than the biceps
tendon. Cases underwent consensus review by two fellowship-trained musculoskeletal radiologists. Tendons were classified as normal biceps tendon, partial tear, or complete tear. The presence
or absence of posterior acoustic shadowing at the distal biceps tendon was also assessed. The ultrasound findings were then compared with the surgical findings and clinical follow-up.
RESULTS. Ultrasound showed 95% sensitivity, 71% specificity, and 91% accuracy for the
diagnosis of complete versus partial distal biceps tendon tears. Posterior acoustic shadowing
at the distal biceps had sensitivity of 97% and accuracy of 91% for indicating complete tear
versus partial tear and sensitivity of 97%, specificity of 100%, and accuracy of 98% for indicating complete tear versus normal tendon.
CONCLUSION. Ultrasound can play a role in the diagnosis of elbow injuries when a
distal biceps brachii tendon tear is suspected.

ears of the distal biceps brachii

tendon are less common than
tears of the proximal long head of
the biceps brachii tendon; however, complete tears are almost always treated
surgically because of loss of strength and
function with nonoperative management [1,
2]. The clinical diagnosis of a complete rupture of the distal biceps brachii tendon can be
straightforward in cases in which there is retraction of the muscle but is more difficult in
cases of nonretracted complete rupture with
an intact lacertus fibrosus, which can prevent
muscle retraction [3, 4]. Less severe forms of
distal biceps brachii abnormality, such as partial tears, tendinosis, and inflammation of the
bicipitoradial bursa, may be difficult to diagnose on clinical grounds. Accurate and timely
diagnosis of complete ruptures of the distal biceps brachii tendon is important because optimal surgical results are achieved within the
first 36 weeks after tear [58].
Both ultrasound and MRI have been
shown to be useful for evaluating the distal
biceps brachii tendon [912]. MRI has shown

findings that strongly correlate with surgical

findings for both partial and complete tears
of the distal biceps brachii [10, 11]. However, MRI is more expensive than ultrasound,
may be less accessible, and is contraindicated
in some patients, including those with aneurysm clips. Ultrasound is less expensive, and
the equipment is widely available. Furthermore, ultrasound enables dynamic examination as well as comparison with the contralateral extremity. In a small series of patients,
ultrasound has been shown to be useful in
the diagnosis of distal biceps brachii tendon
tears, but, to our knowledge, there have been
no published reports of a large patient population with surgical correlation [9, 12]. To determine the role of ultrasound, our study retrospectively compared ultrasound findings
with surgical results for acute biceps tears
and compared ultrasound findings with clinical follow-up for normal tendons.
Materials and Methods
This study was granted exemption by our institutional review board for both approval and patient

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Sonography in Biceps Tendon Tears

Fig. 134-year-old man with complete biceps brachii tear correctly identified by ultrasound.
A, Ultrasound image with extended FOV shows complete tear with 11 cm of retraction between thin arrow and thick arrow on radial tuberosity. B = biceps muscle, BR =
brachialis muscle, L = lateral epicondyle of humerus.
B, More focused longitudinal ultrasound image shows torn tendon end (white arrows) with posterior acoustic shadowing noted (black arrow).

consent. A retrospective database search of the radiology archive from 2002 to 2009 was completed
to identify patients who had ultrasound evaluation
of the distal biceps brachii tendon. Only those cases with surgical follow-up and no prior surgery on
the distal biceps brachii were included in the final
surgical subject group. An additional six cases of
patients who underwent elbow ultrasound for nonbiceps abnormalities were also identified for inclusion as normal biceps cases. These cases were
scanned for clinical concern for the following abnormalities: ulnar collateral ligament injury (two
cases) and triceps, flexor tendon attachment, lateral epicondylitis, and concern for inflammatory
arthritis (one case each).
One surgical case was excluded because both elbows were scanned but all images were labeled as
only one side. The inclusion criterion for the surgical cases was sonographic evaluation of the distal biceps brachii by one of nine fellowship-trained
musculoskeletal radiologists (214 years of musculoskeletal ultrasound experience) as part of routine
patient care using a commercially available scanner
(Logiq 9, GE Healthcare, with a 6-15 or 7-11MHz
linear array transducer or iU22, Philips Healthcare,
with a 12-5 or 17-5MHz linear array transducer).
In general, the biceps brachii muscle and tendon
were evaluated from the musculotendinous junction
to the insertion at the radial tuberosity. Longitudinal and transverse images were obtained with the elbow in extension or mild flexion. Ultrasound imaging during muscle contraction as well as comparison
with the other side was performed as deemed necessary by the radiologist. Similarly, the use of dynamic scanning of the distal biceps from a medial or lateral approach during elbow flexion was used at the
discretion of the radiologist [13, 14].

All ultrasound images were reviewed in consensus by two fellowship-trained musculoskeletal radiologists with 6 and 13 years of experience
with musculoskeletal ultrasound. One reviewer
had no special knowledge of the ultrasound cases and the other reviewer had not viewed any of
the cases for approximately 6 months. Six elbow
ultrasound examinations with a clinically normal
distal biceps tendon were also included in the consensus review. All distal biceps tendon cases were
viewed in randomized order and assessed as normal, partial tear, or complete tear. A complete distal biceps tendon tear was defined as a full-width,
full-thickness tear. A partial tear was defined as a
partial-width tear, partial thickness tear, or both.
Posterior acoustic shadowing from the distal biceps was also noted to be present or absent in each
case at the consensus review.
Operative reports were retrospectively reviewed
so that each surgical patient was categorized as
having a partial or complete tear of the biceps brachii. Sensitivity, specificity, and accuracy were
determined for distinguishing complete ruptures
from partial tears. Time intervals from imaging to
surgery with partial and complete tears were compared using the Mann Whitney U Test. Length of
clinical follow-up ultrasound was also calculated
for the clinically normal distal biceps tendon group.

Results
The subject group consisted of 45 consecutive patients with both ultrasound of the
distal biceps brachii and subsequent surgical
treatment and six patients with a normal biceps tendon who underwent clinical rather
than surgical follow-up. Of the 45, there were
36 subjects with complete tears, seven with

partial-thickness tears, and none with a normal finding at surgery. All patients in both
the surgical and clinical follow-up groups
were men, with an average age of 44 years
(age range, 1868 years). For the majority of
the surgical cases, the mechanism of injury
was flexion of the elbow against a weight (eccentric contraction). Median time from ultrasound to surgery was 8 days for complete
tears (average, 12 days; range, 390 days)
and 38 days for partial tears (average, 57
days; range, 11132 days), which was significantly different (Mann Whitney U Test, p<
0.001). The average clinical follow-up time
after ultrasound for those with a normal biceps tendon at ultrasound was 182 days.
Of the 38 surgically confirmed complete
tears, ultrasound correctly reported a complete tear preoperatively in 95% (Figs. 1 and
2). In two cases, a complete tear at surgery
was interpreted as a partial tear with ultrasound (Fig. 3). Of the seven partial tears confirmed at surgery, ultrasound correctly identified five (Fig. 4). In two cases, ultrasound
described a complete tear, but a partial tear
was noted at surgery. These results are summarized in Table 1.
In no cases did ultrasound describe a
tear where no tear (partial or complete) was
found at surgery. In no cases did the consensus review identify a normal tendon as torn
(partial tear or complete tear).
Table 2 tabulates the presence of shadowing in complete tears, partial tears, and normal tendons. Shadowing is illustrated in Figures 1 and 5. The sensitivity for shadowing to
indicate complete tear versus partial tear was

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Da Gama Lobo et al.

Fig. 236-year-old man with complete biceps brachii tendon tear correctly
diagnosed by ultrasound. Ultrasound image of long axis to biceps brachii tendon
shows retracted tendon (arrows) and intervening hypoechoic fluid and hematoma.
RT = radial tuberosity, RH = radial head.

Fig. 353-year-old man with complete biceps brachii tendon tear incorrectly
interpreted as partial-thickness tear by ultrasound. Ultrasound image of long axis
to biceps brachii tendon shows heterogeneous scar tissue (thin arrows) between
torn tendon end (thick arrow) and radial tuberosity (RT).

Fig. 460-year-old man with partial-thickness biceps brachii tendon tear correctly identified by ultrasound.
A and B, Ultrasound images of long axis (A) and short axis (B) to biceps brachii tendon show hypoechoic and thickened short head of biceps tendon (thin arrows) with
sparing of more lateral long head of biceps tendon (thick arrows, B) Degree of thickening and hypoechogenicity and irregularity of deep margin of tendon in longitudinal
plane favored partial tear over tendinosis. RH = radial head, RT= radial tuberosity, L = lateral epicondyle.

97% with accuracy of 91%. The specificity

(four of seven cases) was low and not of great
value given such small numbers. The sensitivity for shadowing to indicate complete
tear versus normal tendon was 97% (37/38)
with specificity of 100% (6/6) and accuracy
of 98% (43/44). The sensitivity for shadowing to indicate partial tear versus normal was
low and not of great value given the small
numbers (3/7). The accuracy of shadowing
to correctly diagnose partial tears versus
normal tendon was also of limited value given the small numbers (9/10 cases).
In all partial tears, the remaining intact fibers
were markedly thickened and hypoechoic with
fluid, debris, or hematoma filling the gap at the
site of the torn fibers. Thirty-four of the 38 cases of complete rupture were surgically treated
with anatomic reinsertion of the distal biceps
brachii tendon to the radial tuberosity using a

160

single anterior incision (20 cases) or the BoydAnderson two-incision technique (14 cases).
The two-incision technique uses a small incision at the radial tuberosity and a small incision
more proximally. The torn tendon is tunneled
through the soft tissues from the proximal to
the distal incision. Four cases of complete tear
were treated with a biceps tenodesis to the brachialis tendon muscle. Six of the seven patients
with a partial tear were treated with anatomic
reinsertion (five patients with the single incision and one with the two-incision technique).
The other partial tear was treated with biceps
tenodesis to the brachialis. Five orthopedic
surgeons performed the 45 surgeries, with two
surgeons performing 37 of the 45 studies.
Discussion
Distal biceps tendon tears tend to occur in
middle-aged men and are usually of traumat-

ic origin. The mechanism of injury often involves large force acting against resistance
from a flexed elbow, such as in weightlifting
or gymnastics [68, 11]. Accurate diagnosis is important because prompt surgical repair of complete tears is optimal. Our results
show that ultrasound can differentiate complete versus partial tear with 95% sensitivity, 71% specificity, and 91% accuracy. The
presence of posterior acoustic shadowing has
been shown to have a high correlation with
complete rupture of the Achilles tendon [15].
This was also seen in the current study, with
shadowing showing high sensitivity (97%),
specificity (100%), and accuracy (98%) for
complete tear of the distal biceps tendon tears
versus a normal tendon (Figs.1 and 5). The
high specificity suggests that lack of shadowing can help exclude a complete tear. Further
study with a larger number of healthy tendons

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Sonography in Biceps Tendon Tears

TABLE 1: Ultrasound Findings Compared With Surgical Findings in Partial
and Complete Tears
Surgical Findings

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Ultrasound Findings

Complete

Partial

Total
38

Complete

36

Partial

Total

38

45

TABLE 2: Shadowing at Ultrasound

Surgical or Clinical Follow-Up Findings
Ultrasound Findings
Shadowing

Complete

Partial

Normal

Total

37

40

No shadowing

11

Total

38

51
Fig. 558-year-old man
with complete distal
biceps rupture correctly
identified by ultrasound.
Longitudinal ultrasound
image shows torn and
markedly retracted and
redundant tendon (thick
arrow) with marked
posterior shadowing
from torn tendon end
(thin arrows).

can help confirm these findings. Shadowing

has poor sensitivity for partial versus normal
tears (43%) because four of seven partial tears
in our study did not show posterior acoustic
shadowing from the torn tendon. Because only
a portion of the tendon is torn with a partialthickness tear, shadowing is more variable.
Our findings suggest a lack of shadowing on
ultrasound does not reliably exclude a partial
tear. More study is needed with a greater number of partial tears.
Seiler et al. [16] studied the potential sites
of biceps brachii tears on the basis of anatomic and CT studies to identify causes of
tendon tears. They hypothesized that a combination of mechanical impingement and arterial supply was the primary cause of tears.
There are three vascular zones within the
distal biceps brachii with proximal zone 1
supplied by the brachial artery and distal
zone 3 supplied by the posterior recurrent artery. Zone 2, approximately 2 cm proximal
to insertion, represents a relatively hypovas-

cular zone. During pronation, the proximal

radioulnar space is reduced by half. Thus
mechanical impingement during rotation
and a relatively hypovascular region (zone 2)
may contribute to tendon tears.
In several small studies, MRI has shown a
strong correlation with surgical findings for
both partial and complete tears of the distal
biceps brachii tendon [10, 11]. Using MRI,
Fitzgerald et al. [11] studied 21 patients with
clinically suspected injury of the distal biceps tendon, and they identified 12 complete
distal biceps tears, four partial tears, one brachialis tear, and one ganglion. Surgical correlation was performed in 15 patients, with
100% agreement between MRI and surgical
findings. MRI findings led to changes in clinical treatment plans in 38% of patients. Falchook et al. [10] studied distal biceps injuries
with MRI. Complete tendon rupture was diagnosed in 10 patients and partial tears in six.
Nine patients had surgical correlation, and
the MRI findings were confirmed at surgery.

Ultrasound has also shown a similar high

correlation with surgical findings in several small series of distal biceps brachii tears.
Belli et al. [9] examined 25 patients with
clinically indicated distal biceps tendon ruptures. Ultrasound noted 17 of 18 full-thickness tears, with 14 of the 18 having surgical
confirmation [9]. Using ultrasound, Miller
and Adler [12] examined seven patients for
distal biceps abnormalities. Ultrasound correctly diagnosed four of the five surgically
confirmed complete tears. Two partial tears
were correctly diagnosed using ultrasound,
one of which was surgically confirmed [12].
Our larger series of 45 patients shows sensitivity of 95% for the sonographic detection of
complete tears and accuracy of 91% for diagnosing tears as complete versus partial. There
were two cases in which a complete tear was
interpreted as a partial-thickness tear at ultrasound. Scar tissue was described at the site of
the tendon tear in the operative report of one
of these cases and may have been mistaken at
ultrasound for intact tendon fibers.
Because only seven surgically confirmed
partial tears were found at surgery in our
study, we cannot draw strong conclusions regarding the accuracy of ultrasound for identifying partial tears. The time interval between
ultrasound and surgery for partial tears had
a median of 38 days and was significantly
greater than the median time of 8 days for
complete ruptures. This also limits evaluation because interval healing or further tearing could take place if there is an extended
time period between ultrasound and surgery.
The recommended treatment for complete
and high-grade partial tears of the distal biceps is surgical repair because it is known
that patients treated with conservative management lose approximately 30% of flexion
strength and 40% of supination strength [2,
8, 17]. This corresponds with our data because the median time from ultrasound to
surgery for complete tears was 8 days versus
38 days for partial tears. Nonoperative management of complete tears is usually recommended only to elderly patients with low-demand activities who are also not concerned
by cosmetic considerations (e.g., a mass in
the upper arm due to tendon retraction) [17].
Limitations of this study include its retrospective nature. Surgery was used as the standard of reference for the majority of cases and
introduces bias; however, the direct visualization of the tendon at surgery is a stronger
reference standard than clinical follow-up.
The small number of partial tears and nor-

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Da Gama Lobo et al.

mal tendons also limits statistical evaluation.
Further study is needed with larger numbers
of partial tears and normal tendons. An additional limitation is the multiple radiologists and surgeons involved in this retrospective study. This could introduce some level of
variability in the sonographic and surgical interpretations. Such variability, however, provides a more accurate picture of the range of
interpretations and accuracy that would be
seen in an average clinical practice.
In conclusion, in a series of 45 surgically confirmed cases, ultrasound has shown
95% sensitivity, 71% specificity, and 91% accuracy in the diagnosis of complete tears of
the distal biceps brachii tendon versus partial tears. The presence of posterior acoustic
shadowing can help indicate a complete tear
(sensitivity, 97%) versus both partial tears
and normal tendons. However, lack of shadowing does not reliably exclude a partial tear.
Ultrasound can play a role in the diagnosis of
elbow injuries in which distal biceps brachii
tendon tear is suspected.
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