Biceps tendon subluxation occurs when the long head of the biceps tendon (LHBT) slips partially out of its normal groove in the upper arm bone. This tendon runs through the bicipital groove of the humerus, and when the stabilising structures are weakened or injured, the tendon can shift in and out of place. This leads to pain, clicking, weakness, and reduced shoulder function.
The condition often develops alongside rotator cuff or subscapularis injuries due to their shared role in stabilising the shoulder. It is most common in athletes who use repetitive overhead movements, such as swimmers, tennis players, and weightlifters, but can also result from trauma or age-related degeneration.
Physiotherapy for biceps tendon subluxation is the cornerstone of recovery, aiming to restore shoulder stability, improve tendon control, and prevent recurrence.
Key Facts
- The long head of the biceps tendon is particularly prone to subluxation due to its position in the bicipital groove.
- Subluxation commonly coexists with rotator cuff and subscapularis tendon tears.
- Physiotherapy is first-line treatment, while surgery is reserved for severe or recurrent instability.
Risk Factors
- Participation in overhead sports
- Occupations requiring repetitive lifting
- Poor shoulder blade control (scapular dyskinesis)
- History of rotator cuff injury
- Age over 40 (degenerative changes)
- Joint hypermobility
Symptoms
- Pain at the front of the shoulder, radiating down the arm
- Clicking, popping, or snapping sensation with movement
- Weakness, especially when lifting or rotating the arm
- Limited range of motion, particularly in external rotation
- Tenderness over the bicipital groove
- Feeling of shoulder instability
Aggravating Factors
- Overhead movements such as serving in tennis or swimming strokes
- Heavy lifting or pressing exercises
- Sudden twisting or jerking of the arm
- Throwing and throwing sports (e.g., baseball, cricket)
- Poor posture with rounded shoulders
- Rapid increase in training load
Causes
Biceps tendon subluxation can occur due to a combination of structural weakness, injury, and repetitive strain.
- Trauma: Falls, collisions, or twisting injuries may stretch or tear stabilising ligaments and muscles.
- Repetitive overhead motion: Sports like tennis, swimming, or weightlifting place chronic stress on the tendon.
- Anatomical variation: A shallow or irregular bicipital groove reduces the tendon’s stability.
- Rotator cuff or subscapularis tears: These muscles normally help secure the tendon; when torn, instability increases.
- Degenerative changes: Age-related tendon weakening and fraying can contribute.
- Shoulder laxity: People with naturally loose ligaments are more prone to tendon instability.
How Is It Diagnosed?
Diagnosis begins with a thorough clinical history and physical examination. A physiotherapist or orthopaedic specialist will ask about pain patterns, sports or work demands, and history of trauma.
On examination, pain and clicking with resisted shoulder movements, particularly external rotation, may indicate tendon subluxation. Special tests such as the Yergason’s or Speed’s test may reproduce symptoms.
Investigations & Imaging
- Ultrasound
- Dynamic assessment of the biceps tendon slipping out of the groove.
- MRI
- Provides detailed evaluation of the biceps tendon and associated rotator cuff tears.
- X-ray
- Assesses for bony abnormalities in the bicipital groove or post-fracture changes.
Grading / Classification
- Walch Type I
- Minor upward slip, tendon remains contained by surrounding structures.
- Walch Type II
- Tendon slips over the edge of its groove, usually due to partial subscapularis involvement.
- Walch Type III
- Tendon repeatedly dislocates in and out of its groove, often linked with poor fracture healing or major tears.
Physiotherapy Management
Exercise
Physiotherapy exercises for biceps tendon subluxation target the rotator cuff and scapular stabilisers, which play a critical role in tendon stability. Examples include:
- External rotation strengthening with resistance bands
- Scapular retraction and depression exercises (e.g., rows)
- Controlled biceps strengthening in mid-range positions
- Stretching of tight chest and posterior shoulder muscles
Activity Modification
Physiotherapists guide patients in modifying or avoiding aggravating activities, such as heavy pressing or repeated overhead lifting, until stability improves. Gradual return-to-sport programs are used for athletes.
Manual Therapy
Joint mobilisation and soft tissue release can help improve shoulder movement and reduce compensatory muscle overactivity.
Postural Retraining
Correcting rounded shoulder posture and improving scapular positioning reduces strain on the biceps tendon.
Heat & Ice
Ice in the acute phase can reduce pain, while heat may be used for chronic stiffness.
Education
Education on movement strategies and home exercise compliance is essential for long-term recovery and prevention.
Other Treatments
- NSAIDs and ice for pain management
- Corticosteroid injections to reduce inflammation in select cases (used cautiously to avoid tendon weakening)
Surgery
Surgical management may be necessary for recurrent or severe biceps tendon subluxation, particularly when associated with rotator cuff or subscapularis tears. Common procedures include:
- Biceps tenodesis – Reattaches the tendon outside the groove to reduce instability.
- Biceps tenotomy – Releases the tendon, reducing pain but sometimes causing a “Popeye” deformity.
- Rotator cuff repair or capsular reconstruction – Performed if concurrent injuries are present.
Physiotherapy is critical after surgery, beginning with immobilisation, followed by progressive range of motion, strengthening, and functional retraining.
Prognosis & Return to Activity
The prognosis depends on the severity of tendon instability and associated injuries. Mild cases often resolve with physiotherapy within 8–12 weeks. Athletes with moderate instability can usually return to sport within 3–6 months. Severe cases requiring surgery may need up to 6–12 months for full recovery.
Complications
- Chronic pain and instability
- Progression to tendon dislocation or rupture
- Rotator cuff degeneration
- Reduced ability to participate in sport or overhead work
Preventing Recurrence
- Regular rotator cuff and scapular strengthening exercises
- Proper warm-up and mobility work before sport
- Correct lifting and throwing techniques
- Avoiding sudden training load increases
- Posture correction and ergonomic advice
When to See a Physio
- You experience shoulder pain with clicking or popping
- You feel instability or weakness, especially during overhead movements
- Pain interferes with sport or work activities
- Conservative rest has not improved symptoms within 1–2 weeks
- You have a history of rotator cuff or shoulder injuries