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Biceps tendon subluxation occurs when the long head of the biceps tendon partially slips out of its normal groove in the shoulder. The biceps muscle, located at the front of the upper arm, has two tendons at the shoulder: the long head and the short head. The long head of the biceps tendon (LHBT) travels through a groove in the humerus (upper arm bone) called the bicipital groove. When the tendon shifts or slips in and out of this groove, it leads to instability and can cause pain, weakness, and other symptoms. The condition frequently appears alongside rotator cuff pathology due to their shared role in shoulder stability and movement.

Biceps tendon subluxation is commonly seen in athletes who perform repetitive overhead motions, such as swimmers, tennis players, and weightlifters, but it can also occur due to traumatic injuries or degenerative changes in the shoulder.

Types of Biceps Tendon Subluxation (Walch Classification)

There are three types of biceps tendon subluxation, based on the extent and location of tendon slippage:

  • Type I: The tendon slips slightly upward due to small ligament tears, but other structures keep it from fully dislocating.
  • Type II: The tendon slips over the edge of its groove, usually because of small tears in nearby stabilising muscles.
  • Type III: The tendon moves in and out of its groove, often due to poor healing after a shoulder fracture.

Signs & Symptoms

The signs and symptoms of biceps tendon subluxation can vary, with severity and duration depending on the extent of the injury and any related shoulder conditions. Common symptoms include:

  • Pain at the Front of the Shoulder: Pain often occurs over the biceps tendon and/or radiates down the upper arm, especially during overhead movements or lifting.
  • Clicking or Popping Sensation: Many people report feeling or hearing a “click” or “pop” when moving the shoulder.
  • Weakness: Reduced shoulder strength, especially during lifting or rotating the arm, is common.
  • Limited Range of Motion: Shoulder movement may be limited, particularly in rotations, due to discomfort or instability.
  • Swelling and Tenderness: There may be visible swelling around the shoulder joint, and the area may feel tender to the touch.
  • Shoulder Instability: The shoulder may feel less secure, especially in positions that involve external rotation and abduction (lifting the arm sideways away from the body).

Causes and Contributing Factors

Biceps tendon subluxation can be caused by various factors that contribute to instability and increased strain on the tendon. Common causes and contributing factors include:

  1. Trauma or Injury: Direct trauma to the shoulder, especially from falls, collisions, or twisting movements, can disrupt the biceps tendon’s position.
  2. Repetitive Overhead Motion: Sports involving repetitive overhead activities, such as swimming, baseball, tennis, and weightlifting, can cause wear and tear on the biceps tendon, leading to subluxation.
  3. Shoulder Joint Anatomy: Individuals with shallow or irregularly shaped bicipital grooves may be at higher risk for tendon subluxation due to less stabilisation of the tendon in its groove.
  4. Rotator Cuff Dysfunction: The rotator cuff muscles and ligaments help stabilise the shoulder. When these structures are weakened, the risk of biceps tendon subluxation increases.
  5. Degenerative Changes: Age-related changes in the shoulder joint and surrounding tendons can lead to fraying and weakening of the biceps tendon, making it more susceptible to slipping out of place.
  6. Shoulder Instability Conditions: Conditions that cause general shoulder instability, such as shoulder ligament laxity, can also increase the risk of biceps tendon subluxation.

Grading of Severity

Biceps tendon subluxation is often associated with other shoulder injuries, particularly rotator cuff tears or tears of the subscapularis muscle. Subluxations are typically classified based on their impact and accompanying injuries, although there is no specific grading system solely for biceps tendon subluxation. An orthopaedic assessment may grade instability as follows:

  • Mild: Minor slipping of the tendon with no associated muscle or tendon tears. Often manageable with conservative treatment.
  • Moderate: Repeated subluxations with some involvement of other shoulder structures, such as minor rotator cuff involvement or partial tearing.
  • Severe: Frequent or constant subluxation, usually with tears in the rotator cuff or subscapularis tendon, which may require surgical intervention.

Prognosis

The prognosis for biceps tendon subluxation depends on several factors, including the severity of the injury, the presence of concurrent shoulder injuries, and adherence to rehabilitation. Many individuals with mild to moderate cases recover well with physiotherapy and lifestyle modifications. However, severe or recurrent subluxations often require surgical repair to restore stability and function.

With proper management, people can return to normal activities within a few months, although full recovery from surgery may take six months or longer. Preventing re-injury is crucial, and long-term rehabilitation exercises may be required to support shoulder stability.

Treatment

Treatment options for biceps tendon subluxation aim to relieve pain, restore tendon stability, and improve shoulder function. Treatment approaches can vary depending on the severity of the injury and the individual’s activity level. Physiotherapy plays a central role in conservative treatment and postoperative recovery.

Physiotherapy

Physiotherapy plays a central role in managing and rehabilitating biceps tendon subluxation, aiming to restore stability, reduce pain, and address underlying weaknesses that contribute to instability.

Key aspects of the physiotherapy approach include:

  • Rotator Cuff Strengthening: Exercises target the shoulder’s stabilising muscles, essential for joint stability.
  • Scapular Stabilisation: Focusing on shoulder blade control helps minimise strain on the biceps tendon.
  • Biceps Tendon Control: Using controlled, slow-loading exercises strengthens the tendon’s support structures.
  • Range of Motion (ROM) Exercises: Gentle stretching restores shoulder flexibility safely.

For athletes, physiotherapists tailor these exercises to optimise overhead mechanics, correcting movement patterns that contribute to tendon stress. Conditions like scapular dyskinesia (abnormal shoulder blade movement), GIRD (restricted shoulder rotation), and poor core stability are often addressed to reduce strain on the biceps tendon.

In some cases, additional techniques like dry needling may be used to improve muscle function and reduce discomfort, although evidence is still emerging on its effectiveness.

Conservative (Non-Surgical) Treatment

For mild to moderate cases, non-surgical approaches generally include:

  • Rest and Activity Modification: Avoiding strain-inducing movements allows the tendon to stabilise.
  • Ice and Anti-inflammatory Medications: Ice packs and NSAIDs reduce inflammation and pain.

In select cases, corticosteroid injections may be offered to ease inflammation. These, however, are used sparingly to avoid weakening tendon tissues.

Surgical Treatment

Surgery may be necessary for severe, recurrent subluxations unresponsive to conservative care. Surgical options include:

  • Biceps Tenodesis: Reattaches the tendon outside the bicipital groove, relieving tendon strain and restoring stability.
  • Biceps Tenotomy: Removes the tendon’s attachment, reducing pain but potentially leading to a “Popeye” deformity.
  • Rotator Cuff Repair: Addresses associated rotator cuff tears to improve overall stability.
  • Soft Tissue Reconstruction: Repairs damaged ligaments or the joint capsule to stabilise the shoulder.

After surgery, physiotherapy is crucial for recovery, focusing on:

  • Immobilisation: Protecting repaired structures initially with a sling.
  • Gradual ROM Exercises: Restoring flexibility through controlled movements.
  • Strengthening: Rebuilding strength in stabilisers like the rotator cuff and scapular muscles.
  • Return-to-Activity Training: Progressively preparing the shoulder for daily or sports movements, especially for athletes.

Prevention of Biceps Tendon Subluxation

Preventing biceps tendon subluxation involves strengthening the shoulder and maintaining flexibility. Key strategies include:

  • Shoulder Strengthening: Focus on building up the rotator cuff and scapular muscles to support stability.
  • Proper Mechanics in Sports: Athletes, especially those in overhead sports, should work with trainers to ensure safe throwing or lifting techniques.
  • Regular Stretching: Keeping shoulder and chest muscles flexible, including stretching the pectoralis and rotator cuff muscles, can help prevent muscle imbalances.
  • Gradual Training Increases: Avoid sudden increases in intensity or weight during exercise to reduce strain on the shoulder.

Regular physiotherapy assessments are beneficial for early detection of shoulder instability, especially in athletes and older adults.

Information is provided for education purposes only. Always consult your physiotherapist or other health professional.

References

Maalouly, J. et al. (2020) ‘Biceps tendon subluxation associated with isolated greater tuberosity fracture and Bony Bankart lesion without a hill-sachs lesion: A case report and review of the literature’, Trauma Case Reports, 28, p. 100310. doi:10.1016/j.tcr.2020.100310.

Sohn, H. J., Cho, C. H., & Kim, D. H. (2023). Bilateral dislocation of the long head of biceps tendon with intact rotator cuff tendon: A case report. World journal of clinical cases, 11(26), 6304–6310. https://doi.org/10.12998/wjcc.v11.i26.6304

Varacallo M, Seaman TJ, Mair SD. Biceps Tendon Dislocation and Instability. [Updated 2023 Nov 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534102/