Biceps Rupture Workup

Updated: Apr 05, 2022
  • Author: J Michael Wieting, DO, MEd, FAOCPMR, FAAOE; Chief Editor: Milton J Klein, DO, MBA  more...
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Imaging Studies

In most cases, proximal and distal ruptures can be detected based on history and physical examination alone. The mechanism of injury, a history of pain and/or inflammation, and supportive physical findings (as previously discussed) lead to a confident diagnosis in most patients. Several imaging studies can be employed as an extension of the physical examination to rule out other disorders from the lengthy list of possibilities.


Plain radiographs may reveal hypertrophic spurring or bony irregularities that increase the likelihood of biceps rupture and support a clinical suspicion of this diagnosis. Anteroposterior and axillary films are the most useful views for ruling out fractures in this setting.


Arthrography has been used for a long time to evaluate tendon ruptures, but it has several drawbacks, including the following:

  • Invasiveness
  • Need for experienced interpreters of rarely seen images
  • Ionizing radiation
  • Possible confusion with concomitant rotator cuff tears


Ultrasonography of the anterior shoulder can provide a useful and reliable evaluation in many cases and has previously been shown to be superior to arthrography for the examination of the biceps tendons. The use of diagnostic ultrasonography for musculoskeletal indications has received increasing attention due to the availability of ultrasonographic training to non-radiologists. [3, 17, 23]

Studies have indicated that complete rupture or dislocation of the long head of the biceps can reliably be identified through ultrasonography. [23, 24] In a systematic review by Belanger et al, high-resolution ultrasonography demonstrated a pooled positive likelihood ratio (LR+) of 38.0 and a negative likelihood ratio (LR-) of 0.24 for bicipital tendon dislocation, along with an LR+ of 35.5 and an LR- of 0.30 for complete biceps ruptures. [25] However, intra-articular or partial thickness tears, as well as degenerative changes, may be more difficult to detect with ultrasonography. [26]

Smaller, more portable, and less expensive ultrasonography units have likely contributed to the increased use of ultrasonography in the office setting. Other advantages of this modality include the following:

  • Lack of ionizing radiation
  • Painless examination
  • Rapid interpretations
  • Dynamic imaging capability
  • Low cost

Potential disadvantages of ultrasonography include the following:

  • Limited ability to image the intra-articular portion of the tendon, which is the most frequent site of rupture
  • Can be more technically challenging and is highly operator dependent


Magnetic resonance imaging (MRI) provides the greatest anatomic detail from proximal to distal attachment. [27] The major disadvantage is the higher cost of MRI compared with costs associated with other imaging modalities.


Histologic Findings

Nontraumatic tendon ruptures, including those of the biceps brachii, show evidence of advanced degeneration. Changes include hypoxic tendinopathy, mucoid degeneration, lipomatosis, and calcifying tendinopathy. [28] Often, evidence of reduced collagen fiber thickness, decreased crimp angle, and disrupted crimp continuity is also present in tendon rupture.

In symptomatic and asymptomatic patients with rupture (not limited to the biceps alone), a healthy tendon composition rarely, if ever, has been encountered. In contrast, non-ruptured (control) tendon samples have demonstrated a much lower incidence of degenerative change in large study populations. Although the etiology of degenerative changes remains unclear, this group of subjects may be heterogeneous, with multiple factors at work. [28]