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Updated: Feb 21 2024

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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