46-year-old patient presenting with anterior elbow pain, particularly during flexion and supination. No significant strength loss is reported, suggesting preserved tendon continuity. Examination is limited by restricted pronation and supination.
Ultrasound examination of the anterior elbow demonstrates moderate to severe distension of the bicipitoradial bursa, consistent with bursitis. Mild neovascularization is present within the bursa.
The distal biceps tendon appears thickened and heterogeneous, consistent with tendinopathy. There is moderate neovascularization within the tendon, indicating a degenerative process.
There is suspicion of a partial thickness tear of the distal biceps tendon involving less than 50% of the tendon, based on focal structural irregularity and clinical correlation. The patient reports pain without loss of strength, supporting a partial rather than complete rupture.
At the level of the radial tuberosity, there is cortical irregularity, which likely corresponds to the site of tendon involvement and may reflect chronic traction or degenerative change.
Evaluation is partially limited due to restricted forearm rotation, preventing full visualization of the tendon as it courses into the radioulnar space. As a result, complete assessment of the distal biceps tendon is somewhat limited, and smaller or more proximal abnormalities may not be fully excluded.
1. Final diagnosis
Distal biceps tendinopathy with suspected partial (<50%) tear at the radial tuberosity, associated with moderate to severe bicipitoradial bursitis and mild to moderate neovascularization.
2. Differential diagnosis
Consider isolated bicipitoradial bursitis without tendon tear, or chronic insertional tendinopathy without structural defect. MRI may be helpful if clinical suspicion persists or symptoms do not improve.
3. Teaching points
Bicipitoradial bursitis often coexists with distal biceps tendinopathy and may contribute significantly to pain. Partial tears can be difficult to assess, especially when visualization is limited by restricted forearm rotation. Cortical irregularity at the radial tuberosity is an important secondary sign of chronic tendon pathology.
4. Injury/disease information
Distal biceps pathology typically results from repetitive loading or degenerative change. Partial tears may present with pain but preserved strength. The bicipitoradial bursa can become inflamed due to friction between the tendon and radial tuberosity, especially in the setting of tendinopathy. Imaging limitations should always be acknowledged, and additional modalities such as MRI may be required for full assessment.
Marc is founder of, and trainer at, SonoSkills. SonoSkills is an organization dedicated to MSK ultrasound education. He's also an MSK Sonographer at the Laurentius Hospital in Roermond, the Netherlands.
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