AJR 2000; 175:1081-1086
© American Roentgen Ray Society
Sonography of Tears of the Distal Biceps Tendon
Theodore T. Miller1,2 and
Ronald S. Adler3
1
North Shore Imaging Associates, P.C., 825 Northern Blvd., Great Neck, NY
10021.
2
Department of Radiology, North Shore University Hospital, 300 Community Dr.,
Manhasset, NY 11030.
3
Department of Radiology and Imaging, Hospital for Special Surgery, 535 E. 70th
St., New York, NY 10021.
Received October 15, 1999;
accepted after revision March 21, 2000.
Address correspondence to T. T. Miller.
Presented at the annual meeting of the American Roentgen Ray Society,
Washington, DC, May 2000.
Abstract
OBJECTIVE. The objective of this study was to describe the
sonographic appearance of tears of the distal biceps brachii tendon.
CONCLUSION. Sonography can reveal complete and partial tears of the
distal biceps tendon, thus providing an alternative technique to MR
imaging.
Introduction
Rupture of the distal tendon of the biceps brachii muscle is rare,
accounting for only 3% of all biceps tendon tears
[1,
2]. Distal biceps tendon
rupture is usually easily diagnosed on physical examination, presenting as a
palpable defect in the antecubital fossa, a palpable mass in the anterior
aspect of the arm corresponding to the retracted tendon, and a weakness of
flexion and supination. Clinical diagnosis may be more difficult, however, in
cases of partial tear or in cases of rupture that are not retracted because of
an intact aponeurosis [2,
3].
MR imaging has been advocated for examination of distal biceps tendon
injuries
[3,4,5],
with a complete tear diagnosed by the absence of the tendon at its insertion,
various degrees of tendon retraction, and edema or hemorrhage in the tendon
sheath. Although MR imaging is the gold standard for the imaging evaluation of
the elbow, sonography is less expensive and more rapidly performed, and the
contralateral normal elbow is readily available for comparison. The purpose of
this study was to describe the sonographic appearances of injuries of the
distal biceps tendons in seven patients.
Materials and Methods
The sonographic examinations of seven men (average age, 51 years; range,
46-62 years), retrospectively collected from two institutions over a 2-year
period, constitute this report. Five patients were recreational athletes, one
was a competitive amateur power lifter, and one was a manual laborer. The
mechanism of injury in all patients was eccentric contraction of the elbow due
to either a sudden flexion jerk of the elbow against a fixed weight or actual
forced extension of the flexed elbow. All patients described a popping
sensation at the time of injury, immediately followed by pain, weakness of
flexion, and swelling.
After physical examination, all seven patients were referred by orthopedic
surgeons for imaging of clinically suspected tears of the distal biceps
tendon; five patients were referred for sonography and two for MR imaging. The
latter two patients agreed to undergo additional sonography, performed without
charge, after the MR examination, with the MR imaging results known to the
radiologist who performed the sonography. One of the five patients referred
for sonography subsequently underwent MR imaging for confirmation of the
findings before surgery. Thus, all seven patients underwent sonography and
three also underwent MR imaging.
We performed sonography in four patients on an HDI 3000 unit (Advanced
Technology Laboratories, Bothell, WA) using a 7-4-MHz linear transducer; this
transducer has a variable frequency that automatically adjusts on the basis of
the focal zone and image depth selected. We then performed sonography in two
patients: one on a Spectra unit (Diasonics, Milpitas, CA) with a 10-MHz linear
transducer and one on a Logic 700 unit (General Electric Medical Systems,
Milwaukee, WI) with a 7.5-9-MHz linear transducer.
The patients were seated facing the operator, with their affected upper
extremity in front of them and their elbow slightly flexed; their forearm was
supinated and supported by the operator. The transducer was on the oblique
plane slightly inferolaterally to the long axis of the forearm for
longitudinal images and perpendicular to the long axis for transverse images
(Fig.
1A,1B).
Dynamic scanning during supination-pronation or flexion-extension was not
performed; however, the patient's forearm was maximally supinated to bring the
tendinous insertion on the radial tuberosity into view. The use of real-time
scanning facilitated optimal visualization of the longitudinal course of the
tendon. The normal distal biceps tendon of the contralateral elbow was scanned
for comparison in four patients.
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Fig. 1B. —Photographs of position of sonographic transducer. Transverse image
is obtained by aligning transducer perpendicular to long axis of forearm.
Forearm should be maximally supinated and transducer "heel-toed"
into interosseous space.
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MR imaging was performed on a 1.5-T scanner (Signa Horizon; General
Electric Medical Systems). In two patients T1-weighted spin-echo sequences (TR
range/TE range, 400-600/11-20; matrix size, 256 x 192; field of view,
12-14 cm; slice thickness, 3 mm with no interslice gap; and signal averaged,
1-1.5) and frequency-selective fat-suppressed fast spin-echo sequences (TR
range/TEeff range, 3000-5500/35-57; echo train length, eight;
matrix size, 256 x 192; field of view, 12-14 cm; slice thickness, 3 mm
with no interslice gap; and signals averaged, two) were performed in planes
axial and sagittal to the elbow. In the third patient, an axial fast spin-echo
sequence (TR/TEeff, 4800/32; slice thickness, 4.5 mm) and sagittal
fast spin-echo sequences (4250/34; slice thickness, 3mm; and 4000/32; slice
thickness, 6 mm) were performed with echo train length, eight; matrix size,
512 x 512; field of view, 16; and signals averaged, one.
The imaging criteria for rupture were tendinous discontinuity with or
without retraction, with surrounding hypoechoic fluid on sonography, and
high-signal-intensity fluid on T2-weighted images. Partial tear was diagnosed
with either technique by thickening or thinning of the tendon and contour
irregularity or waviness, but without complete tendinous discontinuity.
The average time from injury to imaging was 8 days (range, 1-21 days), from
imaging to surgery was 8 days (range, 4-14 days), and from injury to operation
was 17 days (range, 5-35 days) (Table
1). Six of the seven patients underwent surgical repairs by their
referring orthopedic surgeons, who were aware of the imaging results. One
patient in whom sonography revealed a partial tear was treated
conservatively.
Results
Four patients had complete rupture of the distal biceps tendon, manifest as
tendinous discontinuity, retraction, and hypoechoic fluid in the gap, all
confirmed surgically (Table 1).
The discontinuity and tendon retraction were best appreciated on longitudinal
images (Figs.
2A,2B,2C
and 3). In the fifth patient,
almost the entire tendon was retracted approximately 5 cm to the level of the
radiocapitellar joint, but a thin strand of tendon appeared to remain attached
to the radial tuberosity on both the MR images and the sonograms (Fig.
4A,4B,4C,4D).
This patient's injury was prospectively reported as an extensive partial tear
bordering on complete rupture, but by the time surgery was performed 12 days
later, the tendon was described by the surgeon as completely ruptured. The
distal biceps tendons in the last two patients were thickened and wavy but
could be traced to their attachments on the radial tuberosities on both
longitudinal and transverse images (Fig.
5A,5B,5C,5D).
These cases were interpreted as partial tears, one of which was surgically
confirmed and the other of which was treated conservatively.
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Fig. 2A. —47-year-old man with surgically proven rupture and retraction of
distal biceps tendon. Longitudinal sonogram of contralateral normal right
elbow shows distal biceps tendon (short arrows) inserting on
bicipital tuberosity (long arrow). Distal aspect of tendon has areas
of decreased echogenicity due to anisotropy. Note radial head (H) and radial
neck (N).
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Fig. 2B. —47-year-old man with surgically proven rupture and retraction of
distal biceps tendon. Longitudinal sonogram of affected left elbow shows torn
and retracted tendon edge (black arrow) with hypoechoic fluid (f) in
gap. Note radial head (H), radial neck (N), and bicipital tuberosity
(white arrow).
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Fig. 2C. —47-year-old man with surgically proven rupture and retraction of
distal biceps tendon. Sagittal fat-suppressed fast spin-echo T2-weighted MR
image (TR/TEeff, 4000/45; echo train length, eight) of affected
left elbow shows torn and retracted tendon (straight black arrow) and
surrounding high-signal-intensity edema and hemorrhage (curved black
arrow). Note capitellum (C), radial head (H), radial neck (N), and
bicipital tuberosity (white arrow).
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Fig. 3. —51-year-old man with surgically confirmed ruptured and retracted
distal biceps tendon. Longitudinal sonogram at level proximal to elbow joint
shows retracted tendon edge (arrow) with hypoechoic fluid (f) in gap.
Note brachialis muscle (B). Contralateral elbow was not scanned.
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Fig. 4A. —44-year-old man with retracted tear of most of distal tendon.
Longitudinal sonogram of contralateral normal right elbow shows distal biceps
tendon (short arrows) inserting on bicipital tuberosity (long
arrow).
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Fig. 4B. —44-year-old man with retracted tear of most of distal tendon.
Longitudinal sonogram of affected left elbow shows retracted tendon edge
(black arrow) with thin strand of tendon (small white
arrows) remaining attached to bicipital tuberosity (large white
arrow). Hypoechoic fluid (F) surrounds remaining strand of tendon. Note
trochlea (T).
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Fig. 4C. —44-year-old man with retracted tear of most of distal tendon.
Sagittal fat-suppressed fast spin-echo T2-weighted MR image
(TR/TEeff, 4300/48; echo train length, eight) of affected left
elbow shows torn and retracted tendon (straight white arrow) and thin
strand of remaining tendon (black arrows) with surrounding
high-signal-intensity edema and hemorrhage. Note bicipital tuberosity
(curved white arrow) and trochlea (T).
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Fig. 4D. —44-year-old man with retracted tear of most of distal tendon. Axial
fat-suppressed fast spin-echo T2-weighted MR image (TR/TE, 5000/45; echo train
length, eight) of left elbow shows cross section of thin strand of remaining
distal tendon (arrow) with surrounding high-signal-intensity fluid.
At surgery 12 days later, tendon was completely ruptured.
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Fig. 5A. —57-year-old man with surgically confirmed partial tear of distal
biceps tendon. Longitudinal sonogram of contralateral normal right elbow shows
biceps tendon (thin arrows) inserting on biciptal tuberosity
(thick arrow). Note radial head (H) and radial neck (N).
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Fig. 5B. —57-year-old man with surgically confirmed partial tear of distal
biceps tendon. Longitudinal sonogram of affected left elbow shows thickened
and wavy tendon (thin arrows) inserting on tuberosity (thick
arrow). Note radial head (H) and radial neck (N).
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Fig. 5C. —57-year-old man with surgically confirmed partial tear of distal
biceps tendon. Transverse sonogram of normal right elbow shows tendon
(black arrows) inserting on tuberosity (white arrow). Tendon
is hypoechoic because of anisotropy. Image was photographed reversed to
facilitate comparison with Figure
4D.
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Fig. 5D. —57-year-old man with surgically confirmed partial tear of distal
biceps tendon. Transverse sonogram of affected left elbow shows thickened and
echogenic distal tendon (black arrows) inserting on tuberosity
(white arrow).
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Treatment of two of the seven patients was altered by sonography. In one of
the patients, the initial clinical impression was a partial tear of the distal
biceps tendon, which was instead shown sonographically to be a complete
rupture. The treatment was changed from conservative to operative, and the
rupture was confirmed. In another patient, in whom surgery was planned for a
clinically suspected high-grade partial tear or rupture, sonography revealed a
partial tear with most of the tendon intact. The patient was treated
conservatively with nonsteroidal antiinflammatory medication and physical
therapy and showed improvement at a 1-month follow-up clinical examination (he
was lost to further follow-up). In the remaining five patients, MR imaging of
injury to the distal biceps tendon confirmed the clinical impression and did
not change the treatment.
Discussion
The mechanism of injury of the distal biceps tendon is usually forced
extension against a flexed elbow. The usefulness of MR imaging for evaluating
suspected injury of the distal biceps tendon has been described
[3,4,5],
with a reported accuracy of 100% in 24 patients combined from two series who
had surgical confirmation of partial or complete tears
[4,
5]. Our report cannot address
the accuracy of sonography for the evaluation of distal biceps tendon injury
because of its retrospective nature, the nonblinded sonographic examinations
in two instances, and the small number of patients.
Fitzgerald et al. [4]
reported that MR imaging altered the treatment in eight of 21 patients in
their series. In our series, two of seven patients had their treatment altered
by the sonographic findings, with treatment changed from conservative to
surgical in one and vice versa in another. The imaging appearances of our
other five patients confirmed the surgeons' decisions to operate rather than
to alter treatment. If our series had been larger and had patients with
equivocal physical findings, sonography might have been more influential in
treatment.
Complete rupture is manifest on both sonography and MR imaging as the
absence of the distal tendon from its insertion site, with various amounts of
tendon retraction and fluid in the gap
[4,
5]. The amount of tendon
retraction is best assessed on the sagittal images
[4]. Le Huec et al.
[3], in a series of 10 patients
with distal tendon rupture assessed on MR imaging, reported that a tendon
retraction of less than 8 cm correlated with an intact aponeurosis, whereas a
retraction of more than 8 cm indicated a torn aponeurosis. Our experience was
different because two of our patients had a retraction of less than 8 cm on
sonography and MR imaging but had a torn aponeurosis at surgery
(Table 1).
Lozano and Alonso [6]
described the sonography of a single patient with distal biceps tendon injury.
Although the appearance in their patient was similar to that of our patients,
with tendinous discontinuity, edema, and hemorrhage in the tendon gap, the
authors of that report stated that the tendinous discontinuity was best
appreciated on the axial images; in contrast, we believe that longitudinal
scanning is better for showing tendon discontinuity and estimation of the
amount of tendon retraction because both the torn retracted tendon edge and
the radial tuberosity can be depicted on a single image.
The MR imaging literature suggests that partial tears of the distal tendon
are best assessed in the axial plane, revealed by abnormal intratendinous
signal intensity and either thinning or thickening of the tendon, depending on
the severity of the injury [4,
5]. Conversely, in our two
patients with partial tears, the thickening and altered echogenicity of the
tendon were appreciated in both the axial and longitudinal planes, whereas the
irregular contour was only appreciated longitudinally. Fitzgerald et al.
[4] stated that the assessment
of tendon thickness on MR imaging is based on the reviewer's experience with
normal biceps tendons, but with sonography, the presumably normal
contralateral elbow is available for comparison. When dealing with an intact
but thickened distal tendon, we cannot make a distinction between mild
interstitial partial tear and degenerative tendinosis with either technique;
however, in the clinical setting of acute pain after the typical mechanism of
injury, one may suspect a partial tear. An irregular or wavy contour
sonographically further suggests a partial tear.
An advantage of sonography is its ability to optimize the imaging plane
with real-time scanning to best display tendon abnormality, particularly the
irregular longitudinal profile of the partially torn tendon. When scanning
axially at the tendinous insertion, the forearm should be maximally supinated
to bring the bicipital tuberosity of the radius to a level as superficial as
possible, and the linear transducer may be "heel-toed" or pressed
into the interosseous space. Sonography should be performed in both
planes.
A limitation of sonography is its dependence on the skill and experience of
the operator, but the patient's contralateral elbow may be used as a guide to
the normal appearance. A potential pitfall on the axial image is the
hypoechoic appearance of the distal tendon at its insertion because of
anisotropy [7] (Fig.
5A,5B,5C,5D),
mimicking an absent retracted tendon. However, in a true case of rupture,
fluid will be present in the region and the adjacent soft-tissue planes may be
distorted. Turning the transducer longitudinally can verify or deny the
rupture. The hypoechoic distal tendon can be differentiated from a distended
bicipitoradial bursa by the tendon's ability to be tracked proximally in the
axial plane or by its elongation in the longitudinal plane. Moreover, the
bicipitoradial bursa lies between the biceps tendon attachment and the radial
head, and, if distended, will be visualized lateral to the biceps tendon
attachment and anterior to the radius
[8].
In summary, sonography showed both partial tears and retracted ruptures of
the distal biceps tendon in a small group of patients. Larger series
investigating the accuracy of sonography of this rare injury are necessary to
determine if sonography can be used either for screening of suspected distal
biceps tendon injury or for people who cannot undergo MR imaging.
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Abstract
Introduction
