Biceps Tendon Dislocation and Instability

What is Biceps Tendon Dislocation and Instability?

The long head of the biceps tendon (LHBT) in the shoulder is a common source of pain. It’s often connected to rotator cuff issues. LHBT injuries can range from inflammation or deterioration of the tendon to instability and even partial or complete ruptures.

Looking at the anatomy, the LHBT is an average of 9cm long. It originates, or starts, at two main locations: halfway down the backside of the shoulder and on a bump on the shoulder blade called the supraglenoid tubercle. As the tendon moves down the upper arm, it gets narrower before it meets the short head of the biceps tendon in the middle of the upper arm. After moving across the front of the elbow, the tendon then attaches to a little rough area on the bone of the forearm and the soft tissue on the inner side of the forearm.

The LHBT is known to cause pain in the front of the shoulder due to repeated pulling, rubbing, and twisting. It is located inside the shoulder joint but outside the protective sheath, making it prone to inflammation. Certain chemicals in this region of the tendon can cause blood vessels to widen – a process which could play a role in chronic issues with the LHBT.

The bicipital groove is a landmark that sits between two points on your upper arm bone and it helps to keep the LHBT in place. The shape and size of this groove can vary and may contribute to pain and instability of the LHBT.

Other important parts of the shoulder that help guide the LHBT are the soft tissues which act like a pulley system. This includes muscles (the subscapularis and supraspinatus) and ligaments (the coracohumeral ligament and the superior glenohumeral ligament). All these components create a sort of tunnel for the LHBT to run through in the upper arm.

There’s a debate over whether the CHL is just a part of the shoulder joint capsule or its own distinct structure. Studies have found links between a thickened CHL and limited shoulder movement, especially in cases of a stiff, painful condition called adhesive capsulitis.

Historically, the transverse humeral ligament was thought to assist in the stability of the LHBT. However, this ligament is no longer seen as significant in providing stability and its existence as a distinct structure is controversial. Some recent studies suggest that it may play a role in generating pain in the front of the shoulder though.

When it comes to shoulder stability, the exact role of the LHBT is somewhat controversial. It was once believed that the tendon helped to keep the shoulder stable but newer research opposes this theory. It seems that in most healthy individuals, the LHBT plays only a minimal role in the stability of the shoulder and its main function is turning the forearm up and aiding in bending the elbow.

What Causes Biceps Tendon Dislocation and Instability?

The problems related to the upper part of the biceps muscle, or proximal biceps, can be categorized into three main groups: biceps instability, inflammation, and injury-related problems.

Biceps Instability

Repeated strain or sudden injury can cause the biceps to become unstable or move out of its usual location. While the shape of the bone at the top of the arm can play a part in how stable the biceps is, other important aspects that maintain stability are several ligaments and tendons around the shoulder. These structures form a sort of protective circle around the shoulder, giving it stability. Damage to one or more of these structures can lead to the biceps becoming unstable. Sometimes these structures can tear away from the bone causing varying levels of instability.

Inflammatory Conditions

‘Biceps tendonitis’ is a term used to describe an inflammation condition that most often affects the biceps as it moves through a groove in the top part of the arm bone. Repeated inflammation can lead to tendinitis (inflamed tendons) and severe tendon problems.

Inflammation often occurs because there are other related or preceding problems in the shoulder. The biceps tendon is exposed to the same forces that commonly cause damage to the rotator cuff (a group of muscles and tendons that provide shoulder stability). This means that they often have associated conditions. Other associated issues can include shoulder impingement (a condition where shoulder structures are compressed during motion) and arthritis of the shoulder joint.

Primary inflammation of the biceps tendon is much less common compared to secondary cases (those caused by another condition). The causes for primary inflammation are not well understood compared to those causing secondary inflammation. Some younger athletic patients can have primary biceps tendonitis, with common sports associated including baseball, softball, and volleyball. Certain medical conditions can cause internal damage to the tendon leading to spontaneous rupture, a condition that is often noticed by a bulge in the upper arm often referred to as a ‘Popeye’ deformation.

Traumatic Pathologies

Injury related issues can often overlap with those related to bicep instability. They can include tears to specific parts of the shoulder, complete ruptures and injuries caused by direct or indirect trauma like a penetrating wounds, or injuries that can cause damage to the tendons in various fracture patterns of the top part of the arm.

A tendon rupture usually happens either where the muscle connects to the tendon or near the origin of the tendon of the bicep at the shoulder. Just like with bicep tendinitis, most ruptures are associated with other shoulder problems, with the most common being rotator cuff injuries. The cause of secondary rupture is understood to be the loss of protection of the rotator cuff for the biceps tendon. Primary ruptures are much less common, and occur at a similar rate to primary bicep tendonitis (around 5% in both cases).

Risk Factors and Frequency for Biceps Tendon Dislocation and Instability

Instability of the Long Head Biceps Tendon (LHBT) usually happens alongside other shoulder problems. When the LHBT becomes constantly inflamed, the soft tissue pulley system, a part of your shoulder that helps keep everything in place, can get damaged. This can cause the LHBT to move out of place or even dislocate. While this is the closest situation to primary LHBT instability, most researchers agree that LHBT instability is usually due to a primary injury to the soft tissue pulley system (including parts of your shoulder like the subscapularis and supraspinatus) or secondary to fractures of the upper arm that can affect the integrity of the bicipital groove – a groove in your arm bone where the bicep tendon lies.

Signs and Symptoms of Biceps Tendon Dislocation and Instability

When assessing patients for shoulder pain, especially those who present with symptoms that suggest instability in the long head of the biceps tendon (LHBT), doctors perform a comprehensive examination. This usually starts with procuring a complete history that includes the background of the injury, the patient’s employment, past surgeries, and injuries related to the neck or shoulder. In addition, they perform physical examinations to rule out any neck or shoulder pathologies. Now let’s go over a detailed rundown of the examination process:

Cervical Spine/Neck Exam

In this examination, doctors analyze the neck posture, symmetrical muscle structure, tenderness, and range of motion. The tests in this collection include Spurling’s maneuver, myelopathic testing, reflex testing, and a comprehensive neurovascular exam. The objective is to rule out any accompanying neck condition that might be causing shoulder discomfort.

Shoulder Exam

Doctors carefully observe the shoulder and check for symmetry, posture, and muscle bulk. They additionally assess any skin conditions and carry out range of motion tests. If they suspect issues in the long head of the biceps tendon causing trouble, they look for symptoms like extensive bruising and Popeye deformity.

Provocative Examinations

These are explicit physical exams that target the bicipital groove or the area near the supraglenoid tubercle where the LHBT originates. It could involve the Speed’s test, Uppercut test, or Yergason test. All of these tests aim to induce pain or detect rotary instability through specific maneuvers. If any of these tests result in patient-reported pain, further diagnosis happens to gauge the severity of the instability. Other provocative tests can also be run based on symptoms, such as the AC joint or the glenohumeral labrum tests.

Rotator Cuff Muscle Testing

There are several muscles around the shoulder joint known as rotator cuff muscles. These include the Supraspinatus, Infraspinatus, Teres Minor, and Subscapularis. Doctors use specific tests like strength testing, External rotation lag sign, Hornblower’s sign, and the bear-hug test to determine if there’s an issue with any of these muscles.

External Impingement/SIS

There are several maneuvers that doctors use to diagnose shoulder impingement syndrome. These are called Neer impingement sign, Neer impingement test, and the Hawkins test.

Internal Impingement

To diagnose internal impingement, doctors use a test known as the Internal impingement test. In this test, the doctor moves the patient’s shoulder into a certain position to see if it induces pain.

If doctors suspect any of these issues, they will run the corresponding checks to ensure an accurate diagnosis. The tests listed here are just a few of the many potential evaluations that healthcare professionals can conduct to understand the source of shoulder pain.

Testing for Biceps Tendon Dislocation and Instability

If you’re experiencing ongoing or sharp pain in the shoulder, your doctor will likely order imaging tests. These give a clear view of your shoulder’s structure and can help figure out what’s causing your pain.

One common test is a radiograph, also known as an X-ray. For these images, doctors generally opt for a view known as the “Grashey” view. This particular angle, which requires you to rotate a bit from the camera, allows doctors to measure the gap between your shoulder blade and arm bone. This gap typically measures between 7 and 14 millimeters and can provide clues about potential shoulder problems, including arthritis.

Ultrasound imaging is another useful tool for diagnosing shoulder pain. This kind of imaging is dependent on the person operating the scanner and is highlighted as a quick and cost-effective option. Ultrasound can identify common problems such as swelling of the tendon, the protective sheath around the tendon, and any surrounding fluid. A dynamic examination, where you move your shoulder during ultrasound, can give even more detail. However, the accuracy of ultrasound for diagnosing specific conditions varies.

Magnetic Resonance Imaging, or MRI, can provide even more detail about your shoulder’s health. These scans not only assess potential injuries to different parts of the shoulder but also evaluate associated shoulder conditions. For instance, the position of the shoulder’s tendon in relation to the biceps can indicate if there’s a dislocation. Given MRI can be less reliable in identifying specific shoulder injuries, a direct visualization technique such as shoulder arthroscopy is also needed. MRI scans can also show other conditions like inflammation of the shoulder bursae, or fluid-filled sacs, and problems with the joint connecting the collarbone and shoulder blade.

MR Arthrography (MRA) is another imaging modality that’s especially effective for spotting soft tissue injuries. In this method, a dye is injected into the joint before the MRI to give a clearer picture. Specific findings on an MRA scan can suggest various injuries or conditions. For instance, the displacement of the shoulder tendon in relation to other shoulder components can suggest certain soft tissue injuries. However, MRA isn’t the only necessary evaluation for these conditions as advancements in imaging and exploratory surgery play a significant role in identifying these injuries.

Treatment Options for Biceps Tendon Dislocation and Instability

The first step in treating instability in the long head of the biceps tendon (LHBT) is usually non-surgical. This typically involves resting and changing activities that could worsen the condition, along with taking anti-inflammatory medications. However, if the instability is severe, especially in younger, active people or manual laborers, surgery might be necessary.

Physical therapy is often part of the treatment process. It is important that the therapist identifies any related shoulder issues that could be contributing to the problem. The therapy will usually focus on strengthening the shoulder and improving balance, especially for athletes or those who use their arms overhead frequently. Stretching, specifically of the shoulder muscles, might also be beneficial. In some cases, dry needling, a procedure using fine needles to stimulate specific points in the body, may be an option.

Injections may be used for a variety of LHBT issues, including subtle instability. However, there’s no consensus on the best location for the injection, whether it be under the shoulder blade, within the joint, or in the groove of the bicep, nor the precise way it should be administered. It’s important to note that injecting directly into the bicep tendon could potentially lead to tendon rupture. An ultrasound-guided injection may result in a higher accuracy rate.

If non-surgical treatments are not successful, surgery might be needed. The decision to proceed with surgery could depend on a number of factors such as whether symptoms persist despite non-surgical treatment attempts, the degree of LHBT instability, and whether other shoulder injuries are present.

There are a variety of surgical options depending on specific patient circumstances. Cutting and releasing the bicep tendon (biceps tenotomy) may be recommended, particularly if the tendon is damaged. One disadvantage could be persistent pain after surgery if the tendon is tightly stuck to surrounding tissue. Another surgical option is biceps tenodesis, which involves anchoring the bicep tendon in a different location. This method could be favoured in younger patients, athletes, manual laborers, or those who are concerned about how their arm could look post-operation. Regardless of the surgical option chosen, ensuring the optimal tension on the bicep muscle is important in the procedure.

Another surgical option involves reconstructing the area of the shoulder where the bicep tendon sits. In some cases, this may improve symptoms associated with bicep irritation or instability. Alternatively, there’s a method where the bicep tendon is transferred to a different part of the shoulder, potentially leading to less pain and a better cosmetic outcome.

What else can Biceps Tendon Dislocation and Instability be?

There are numerous health conditions that can cause shoulder pain. These are categorized into several major groups:

• Impingement issues – external problems or subcoracoid issues, some of which can be attributed to calcific tendonitis, and internal ones, which include shoulder lesions, shoulder rotation problems, conditions common in young athletes such as “Little League Shoulder”, and tears in the posterior labrum of the shoulder joint.
• Rotator cuff Pathology – problems related to tears of the rotator cuff tissue, ranging from partial to full thickness. This can also include rotator cuff atrophies, often seen in older adults.
• Degenerative issues – conditions that are wear-and-tear related such as degenerative joint disease, glenohumeral arthritis, a condition referred to as “frozen shoulder” or adhesive capsulitis, tissue death due to poor blood flow or avascular necrosis (AVN), and unusual grating or cracking sound originating from the joint called scapulothoracic crepitus.
• Proximal biceps problems – this group includes conditions like the dislocation of the bicep tendon, often associated with certain shoulder injuries. It can also include inflammation or damage to the bicep tendon.
• Conditions related to the AC (acromioclavicular) joint – this can be a shoulder separation, a condition termed as distal clavicle osteolysis, or inflammation of the AC joint which is known as AC arthritis.
• Instability conditions – these include one-way instability often linked to an event or dislocation, in any direction – backwards, forwards or downwards. Also, there can be instabilities in multiple directions, along with associated injuries to the shoulder joint’s cartilage ring called the labrum.
• Neurovascular conditions – health situations relating to your nervous system or circulatory systems. An example includes nerve damage (suprascapular neuropathy) that may occur alongside a cyst near the shoulder joint. Other examples are “scapular winging” where the shoulder blade protrudes out unnaturally, inflammation of nerves in the arm (brachial neuritis), a group of disorders that cause pain and tingling in the arm and hand known as thoracic outlet syndrome (TOS), and quadrilateral space syndrome which impacts the blood flow in the shoulder.
• Other conditions – these include abnormal movement of the shoulder known as scapulothoracic dyskinesia, a condition where the upper part of the shoulder blade (acromion) isn’t completely fused, rips in key muscles like the pectoralis major, deltoid, latissimus dorsi, and fractures (could be fresh or due to long-standing deformity, improper healing, or failure to heal).

What to expect with Biceps Tendon Dislocation and Instability

Patients with ongoing severe symptoms, such as feelings of instability, and known issues with the upper arm biceps tendon, are suitable for two kinds of surgical procedures: tenotomy and tenodesis. In cases of severe instability or actual displacement of the tendon, tenodesis is usually chosen over tenotomy.

When comparing these two procedures in the case of long head of the biceps tendon (LHBT) pathologies, research shows a high level of satisfaction from patients post-surgery, as judged by reports of pain and overall outcomes over the long term. A 2017 study involving over 100 patients who had undergone these surgical procedures showed more than 90% of them were either satisfied or very satisfied with the results. Additionally, 95% of patients said they would willingly undergo the same surgery again. Similar positive outcomes are seen in studies of patients undergoing biceps tenodesis over the long term. It’s noted that for most patients, there’s no noticeable difference between tenotomy and tenodesis in terms of strength recovery in the elbow flexion and forearm supination.

Possible Complications When Diagnosed with Biceps Tendon Dislocation and Instability

The following is a list of common surgical complications after the procedures of Biceps Tenotomy and Biceps Tenodesis, along with their approximate rates:

Biceps Tenotomy:

• “Popeye” Deformity — 10% – 70%
  • Patients dissatisfied due to the deformity — less than 5% to 10%
• Muscle spasm or cramping — 15% to 25%
• Biceps pain — 10% to 20%
• Residual weakness:
  • Mild — Up to 30%
  • Moderate to severe — 10% to 15%

Biceps Tenodesis:

• Residual anterior shoulder or groove pain — rate is under debate. Some reports have claimed a 45% revision surgery rate for persistent pain post-procedure.
• A 2015 study, on the other hand, disputes these rates by reporting a much lower 4.1% revision surgery rate as per data from 1083 patients who were followed up for 136 weeks on average. Specifically, only 0.4% of revisions were directly caused by issues with the biceps tenodesis.

Cosmetic deformity, Muscle Spasms, and Biceps Pain:

• “Popeye” deformity: 5% – 10%
• Muscle spasm or cramping: 5% – 10%
• Biceps pain: 5% – 10%

Recovery from Biceps Tendon Dislocation and Instability

For patients who have undergone a Biceps Tenotomy, here are the typical steps for their recovery:

* They usually need to use a sling for 1 to 2 weeks
* From the second week onwards, they can begin a range of motion exercises, and they no longer require the sling
* Strengthening exercises can start from the fourth week

When it comes to returning to work or regular activities:

* Light work can generally be resumed after 3 to 4 weeks following the operation
* If the patient’s job is physically demanding, returning full time can take anywhere from 1 to 3 months post-surgery
* Normal, unrestricted activities can usually be picked up again between the third and fourth month after the operation

For those who have had a Biceps Tenodesis, here’s a guide on the sequence of their recovery:

* Sling use is recommended for about 3 to 4 weeks post-surgery
* The initial recuperation period includes gentle elbow movement exercises and exercises to strengthen the grip
* It’s best to steer clear of resisted elbow bending and turning the forearm upwards until about six weeks into recovery
* Full movement of the shoulder, both active and passive, is the target to achieve by six weeks.

On the subject of getting back to work or their regular activities:

* Light work can usually be resumed after 3 to 4 weeks post-surgery
* If the individual’s job involves heavy physical work, a full return can take from 2 to 4 months after the procedure
* The majority of patients are able to return to unrestricted activities between the third and fourth month following the surgery

Preventing Biceps Tendon Dislocation and Instability

It’s important to teach patients about the different causes and potential related issues tied to problems with the biceps near the shoulder. Patients should be made aware of any issues with the long head of the biceps tendon (LHBT), especially if it’s linked with other known shoulder problems. For instance, if a patient has a rotator cuff injury, they should understand there might also be a biceps tendon injury.

Particularly with older patients, they should be told that the procedure they’re planning for – the tenotomy or tenodesis – might not necessarily take place. By having this kind of conversation before surgery, the patient’s expectations after the operation can be appropriately managed.