Degenerative or traumatic ruptures of the distal biceps tendon are less common than proximal lesions. Distal lesions lead to a significant loss of function with usually considerable discomfort for patients. Therefore, precise diagnostics using operator-dependent high-resolution musculoskeletal ultrasound with illustration of the extent of the affected tendon lesion are important for optimizing patient management. In this article, we discuss the precise highresolution musculoskeletal ultrasound and sonoanatomy of the distal biceps tendon and emphasize its importance for the surgical treatment of tendon lesions. In this review and pictorial essay, we first focus on the description of the precise anatomy and ultrasound anatomy of this clinically important region. Furthermore, we highlight different ultrasound scanning techniques for the correct assessment of the distal biceps tendon. Various approaches for optimal sonographic assessment of the distal biceps tendon have been suggested in the literature: the anterior approach, the lateral access, the medial access and the posterior approach. In the second part of the article, we focus on the evaluation of surgical repair techniques of distal biceps tendon lesions considering the extent of the rupture zone of the distal biceps tendon based on the ultrasound findings. Surgical techniques are explained from the orthopedic surgical point of view.