Updated: 6/3/2021

Biceps Subluxation

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  • summary
    • Biceps subluxation is a recognized cause of anterior shoulder pain usually associated with a subscapularis tear.
    • Diagnosis can be suspected clinically with anterior shoulder pain made worse with provocative tests and confirmed with MRI studies to evaluate for concurrent subscapularis tear. 
    • Treatment involves an initial trial of NSAIDs, activity modification and physical therapy. Arthorscopic versus open biceps tenodesis/tenotomy with or without subscapularis repair is indicated for recurrent symptoms.
  • Etiology
    • 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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Questions (4)

(SBQ16SM.1) A 55-year-old patient presents with right shoulder pain and weakness after a posterior shoulder dislocation that has not improved with physical therapy. Physical examination reveals significant pain with passive ROM and significant rotator cuff weakness. Figure A is the current MRI of the right shoulder. Which structure is most likely injured based on the current imaging findings?

QID: 211117
FIGURES:
1

Anterior inferior glenohumeral ligament

28%

(422/1520)

2

Coracohumeral ligament

23%

(345/1520)

3

Superior labrum

10%

(148/1520)

4

Infraspinatus tendon

18%

(271/1520)

5

Posterior labrum

21%

(320/1520)

L 5 B

Select Answer to see Preferred Response

(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?

QID: 4828
FIGURES:
1

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

4%

(170/4097)

2

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

76%

(3099/4097)

3

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

7%

(293/4097)

4

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

1%

(60/4097)

5

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

10%

(426/4097)

L 3 B

Select Answer to see Preferred Response

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