Ultrasound assessment of distal biceps tendon injuries : Current Orthopaedic Practice

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Ultrasound assessment of distal biceps tendon injuries

Dove, James H. MD; Pasquarello, George J. DO; DaSilva, Manuel F. MD

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Current Orthopaedic Practice 34(1):p 79-81, January/February 2023. | DOI: 10.1097/BCO.0000000000001184
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Distal biceps tendon injuries occur mostly in men aged 40 to 60 yr. The mechanism of failure is eccentric load of the biceps muscle while it is in a flexed position. The diagnosis of a distal biceps tendon rupture often can be made clinically with complete patient history and thorough physical examination. Patients may report a painful “pop” while the elbow is forcibly extended. They will describe pain in the antecubital fossa and weakness in the elbow. On examination, the clinical test described by O’Driscoll et al.1 known as the “hook test” can diagnose complete ruptures, especially when the findings are compared with the uninjured contralateral side. Of note, Devereaux et al.2 combined three clinical tests to identify a complete rupture. By using the hook test, passive forearm pronation, and the biceps crease interval in sequence, they found those tests resulted in 100% sensitivity and specificity when the outcomes of all three were in agreement.2

Despite the information that can be gained from the physical examination, some cases may remain equivocal, and clinicians will use imaging studies to confirm the diagnosis of distal biceps tendon injuries. Radiographs will often appear normal, but ultrasound (US) and MRI provide more information.3–5 MRI is considered the gold standard in diagnosing injuries of the distal biceps tendon; however, the expense must be considered when determining which study to obtain. If ultrasound provides similar information for surgeons, its cost-effectiveness makes it an attractive first option.

Several studies have demonstrated the effective use of ultrasound to diagnose distal biceps tendon injuries; however, ultrasound is operator-dependent.4,6,7 Classically, four different approaches to evaluate the distal biceps tendon exist: anterior, medial, lateral, and posterior. There is no consensus regarding the best approach, but rather, combined use of all approaches help enhance the accuracy of the evaluation.8 Despite this idea, Miller et al.9 reviewed the four different approaches to evaluate the distal biceps tendon using ultrasound and found that readers and operators significantly preferred the medial approach (P<0.001) among the others. Conversely, while describing a new method of ultrasound evaluation of the distal biceps tendon using the crab position, Draghi et al.7 stated that the anterior approach with the forearm pronated was the most commonly used. Obviously, operator preference and experience influence the preferred approach. The crab position places the elbow in flexion and forearm in pronation and allows for coverage of 75% of the elbow in a single position. After the evaluation of the common extensor tendon in the long axis, the transducer is turned 90 degrees and moved distally, allowing a view of the distal biceps tendon in the transverse plane.7 Use of ultrasound to evaluate the distal biceps tendon can be challenging, but using consistent steps and approaches, accurate assessment can be obtained. This article presents a simple and reproducible technique to evaluate the distal biceps tendon using ultrasound. Patient’s images were used after informed consent was obtained from the patient. Institutional review board approval was not required for the description of the authors’ technique.


When using ultrasound to evaluate the distal biceps tendon, the authors prefer to use an anterior approach to the elbow with the patient in a supine position. With the elbow extended, the transducer is first placed longitudinally as seen in Figure 1. The first structure to be identified is the radial head. This initial step allows for appropriate orientation.

Transducer held longitudinally to first identify the radial head.

The forearm is then supinated while the transducer is translated medially. This maneuver helps to reveal the radial tuberosity. The biceps tendon has two insertion points on the radial tuberosity: the long head attaches proximally on the tuberosity, and the short head attaches distally on the tuberosity. The tendon is often easily visualized at this step. In cases in which there is a rupture, the tendon is often retracted, and fluid may instead be seen around the tuberosity.

In the authors’ practice, distal biceps tendon repairs have undergone ultrasound assessments at 6 wk and 12 wk postoperatively to evaluate the healing. This method has been successful at identifying periosteal healing with these simple maneuvers as seen in Figure 2.

Ultrasound image of periosteal healing (white arrow) around a distal biceps tendon repair. The radius is the solid white structure, proximal is to the left and distal to the right.

Finally, by rotating the transducer 90 degrees, a cross-sectional view of the biceps tendon is obtained. This last step allows for assessment of the tendon architecture, which during follow-up of a distal biceps tendon repair can identify fluid around the tendon. In cases of ruptures, the cross-sectional views can confirm complete rupture of the tendon from the tuberosity. They can also help to assess the degree of retraction of the tendon stump. These simple steps have provided a reproducible way to evaluate the distal biceps tendon in cases of both rupture and in follow-up with tendon repairs.


Ultrasound is a cost-effective and convenient study that has been proven to be accurate in its assessment of the distal biceps tendon.4,7,8 Unfortunately, orthopaedic surgeons do not regularly use ultrasound to evaluate musculoskeletal injuries.10 Because ultrasound is operator-dependent, it is understandable that orthopaedic surgeons would shy away from performing these procedures. A survey of orthopaedic surgeons revealed that 70% of respondents cited lack of experience and 69.5% cited insufficient education as reasons they do not use ultrasound.11 Very little time, if any, exists using ultrasound while undergoing residency training. Whatever ultrasound techniques are acquired by orthopaedic surgeons are often during practice after residency.

Despite the hesitancy for orthopaedic surgeons to use ultrasound, studies have repeatedly shown that orthopaedic surgeons are capable of diagnosing musculoskeletal injuries with ultrasound after a teaching workshop.12,13 Orthopaedists have the distinct advantage of surgical experience lending to a deeper understanding of the relevant anatomy that makes ultrasound a useful tool to evaluate for injuries noninvasively.

Interestingly, a 2017 survey14 of upper-extremity surgeons was performed to evaluate their use of ultrasound for diagnostic purposes and guided injections. The authors found that 43% of respondents had an ultrasound machine in their office, and 51% used ultrasound for diagnostic purposes. They also found a statistically significant difference between access to an ultrasound machine in the office by practice setting and the use of ultrasound for diagnostic purposes by practice setting.14 In other words, those in academic practices had greater access to ultrasound and utilized it for diagnostic purposes.

As surgeons and clinicians, orthopaedic physicians have the opportunity to couple the physical examination with the findings from the ultrasound images. For instance, Iannotti et al.15 revealed that ultrasound assessment after a physical examination was more accurate than a blind interpretation by a radiologist (80% compared with 52%, P<0.001). Ultrasound can be used to enhance a surgeon’s diagnostic accuracy and serves as an important tool.

As stated previously, the authors’ practice has not only used ultrasound to help identify distal bicep tendon injuries, but they also have used it to evaluate the postoperative healing in patients who undergo repair for tendon ruptures. Ultrasound has helped to identify periosteal healing around the repair as early as 6 wk. These patients who show signs of healing could potentially be advanced in their rehabilitation protocol. Historically, patients who undergo distal biceps tendon repairs are immobilized for 2 to 3 wk before any motion is allowed, followed by progressive strengthening program around 6 wk postoperatively.16 The authors recommend immobilization for 1 wk after repair with immediate active range of motion to follow. Patients are counseled to avoid lifting or strengthening exercises until at least week 6. The authors have followed many patients with this protocol with successful outcomes.


Ultimately, ultrasound of the distal biceps tendon appears to be a good alternative to MRI in assessing the integrity of the tendon as long as the operator follows these simple steps. As with all new skills, acquisition and implementation requires consistent practice. With the writing of this technique, the authors sought to provide orthopaedic surgeons with a simple and reproducible way to evaluate the distal biceps tendon. With the use of this technique, injuries of the distal biceps and even postoperative repairs can be assessed quickly and cost-effectively.


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