Biceps Subluxation - Shoulder & Elbow

Introduction

A recognized cause of shoulder symptoms usually associated with a subscalaris tear
Pathophysiology
- most commonly associated with
  - subscapularis tears
    - most common associated pathology
  - disruption of the biceps sling

Anatomy

Biceps tendon anatomy
- originates off supraglenoid tubercle and superior labrum
- stabilized by the biceps sling which is comprised of
  - fibers of the subscapularis
  - supraspinatus
  - coracohumeral
  - superior glenohumeral ligaments
Function
- acts as dynamic stabilizer
- involved in movement such as shoulder flexion, abduction
Complete glenohumeral anatomy

Presentation

Symptoms
- anterior shoulder pain
- may have sensation of clicking
Physical exam of shoulder
- strength
  - due to the association with subscapularis tears, strength of the subscapularis muscle should be performed
- biceps provocation tests
  - Yergason's test
    - anterior shoulder pain with resisted forearm supination with the arm at the side and the elbow flexed to 90 degrees.
  - Speed's test
    - anterior shoulder pain with resisted shoulder flexion with the shoulder flexed at 90 degrees, elbow in full extension and the palm facing upwards"
  - palpable click
    - may be produced with arm abduction and external rotation
      - occurs when tendon subluxes or dislocates out of groove

Imaging

Ultrasound
- can give dynamic test of bicep instability
MRI
- can show increased T2 signal, and displacement out of the bicipital groove
- coincides with subscapularis tears
  - decreased angle between the long head biceps to glenoid during arthroscopy has been associated with biceps tendon subluxation

Treatment

Nonoperative
- NSAIDS, PT strengthening, and steroid injections
  - indications
    - initial management
  - technique
    - direct steroid injection in proximity, but not into tendon
Operative
- arthroscopic vs open biceps tenotomy vs tenodesis
  - indications
    - reserved for refractory cases for bicep pathology
  - technique
    - performed with or without subscapularis repair
    - can test instability intra-operatively

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(OBQ13.193) A 62-year-old woman presents with chronic shoulder pain. On physical exam, she has anterior shoulder pain and her symptoms are reproduced with provocative testing of the biceps including supination against resistance and forward flexion of the shoulder against resistance. Internal and external rotation are painful, but her range of motion is intact. Shoulder radiograph and MRI images are shown in Figures A-E. Which of the following statements is true regarding the patient's condition? Review Topic | Tested Concept

QID: 4828

FIGURES:

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Her clinical examination is most consistent with a SLAP tear, which should be repaired.

(143/3354)

Her biceps pathology is due to her partial tearing of her subscapularis

75%

(2517/3354)

She has isolated degenerative biceps tendonosis and an injection may cure her symptoms

(256/3354)

She has end-stage rotator cuff arthropathy and should consider a reverse total shoulder arthroplasty

(44/3354)

Her subacromial impingement is causing her biceps tendon sheath to be inflamed

10%

(349/3354)

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