Biceps tendon dislocation

Anatomy: The long biceps tendon and its “pulley”

The long biceps tendon originates in the shoulder joint on the upper edge structure of the socket (labrum/SLAP area) and runs through the intertubercular sulcus (biceps groove) of the humerus. It is stabilized by the biceps pulley - an interplay of the upper glenohumeral ligament, coracohumeral ligament and fiber portions of the subscapularis and supraspinatus. This system keeps the string in the groove and prevents it from moving sideways.

• Biceps groove (intertubercular sulcus): bony guide of the tendon
• Transverse humeral ligament/ligament structures: form the “roof” of the groove
• Pulley complex: subtle but important stabilizers
• Close functional relationship to the rotator cuff, especially a. Subscapularis

If there are tears in the pulley or ruptures of the adjacent tendons (especially subscapularis), the LBS can dislocate inwards (medially) out of the groove or repeatedly painfully subluxate (briefly pop out).

What does biceps tendon luxation mean?

Biceps tendon dislocation is the permanent or recurring slippage of the long biceps tendon from its intended path. A distinction is made between:

• Subluxation: the tendon briefly slides over the edge of the groove and springs back again - typical "snapping"
• Dislocation: the tendon lies permanently next to the groove, often medially on the head of the humerus
• Instability: Generic term for recurring jumping with pain under strain

An isolated dislocation is rare. In most cases, there is additional damage, such as to the rotator cuff, pulley or labrum (SLAP lesion).

Causes and risk factors

• Degenerative changes in the pulley complex during overhead work or throwing sports
• Partial or complete tear of the subscapularis (internal rotator) with loss of the anterior tendon guidance
• Acute trauma (fall on outstretched arm, shoulder dislocation)
• Shape variations/flatness of the biceps groove, bony attachments
• Pre-existing inflammation/overload of the LBS tendon
• Age, repeated microtraumas, muscular imbalances of the shoulder blades

People with repetitive overhead loads (e.g. tennis, handball, volleyball, CrossFit) as well as manual workers who do heavy lifting are particularly at risk.

Typical symptoms

• Anterior shoulder pain, often stabbing when rotating movements
• Snapping, cracking or “clicking” in the front shoulder
• Tenderness in the biceps groove, sometimes palpable tendon outside the groove
• Loss of strength, especially during flexion/supination movements of the forearm
• Stress-related complaints, increased at night when lying on the shoulder
• Accompanying signs of a rotator cuff lesion (e.g. weakness in internal rotation)

If the LBS tears completely, a so-called “Popeye” muscle belly can be visible on the upper arm. This is not necessarily the case with a dislocation without a rupture.

Examination and diagnostics

Diagnosis is based on history, clinical examination and imaging tests. It is important to systematically record accompanying injuries.

• Clinic: pressure pain in the gutter, painful rotational movements; special tests (e.g. speed test, Yergason test, belly press/lift-off for subscapularis)
• Ultrasound (dynamic): shows the tendon in and outside the groove, detects subluxation with movement
• MRI/MR-Arthro: Assessment of pulley, rotator cuff, LBS inflammation and labrum
• X-ray: bony changes in the groove, exclusion of other causes

Differential diagnoses include: Biceps tendonitis, SLAP lesion, rotator cuff tendinopathies, subacromial impingement, AC joint osteoarthritis and frozen shoulder.

Conservative therapy: treat gently at first

For many patients, a conservative treatment attempt makes sense. The aim is to relieve pain, calm inflammation and functionally stabilize the shoulder.

• Activity adjustment: temporarily no overhead and throwing loads, no abrupt rotational movements
• Short anti-inflammatory medication as needed (e.g. NSAIDs) – consider individually
• Physiotherapy: strengthening of the rotator cuff and scapular stabilizers, coordination, posterior capsular stretch, posture and technique training
• Cooling in acute phases, warmth in case of muscular tension
• Tape/orthosis depending on the situation as a reminder to protect yourself; rigid immobilization only for a short time
• Targeted injection into the tendon sheath can relieve discomfort; Repeated cortisone injections should be viewed cautiously because of possible tendon weakening

A conservative period of around 6-12 weeks is usual. If there is no stable improvement during this time or if there is relevant accompanying damage (e.g. subscapularis tear), a surgical option should be discussed.

Surgical therapy: individual indication

Surgery is considered if pain persists despite conservative measures, recurrent painful subluxation/dislocation, relevant pulley lesion, or concomitant tendon rupture. The decision depends on age, activity level, accompanying injuries and personal goals.

• Arthroscopic diagnostics and therapy: Assessment of the pulley, LBS, rotator cuff and labrum
• Biceps tenodesis: fixation of the LBS outside the joint (suprapectoral/subpectoral) to avoid rubbing and instability
• Biceps tenotomy: division of the tendon with natural retraction - option v. a. with low functional demands and a desire for shorter rehabilitation
• Accompanying reconstruction: e.g. B. Subscapularis repair, possibly pulley or labrum supplies

Tenodesis usually preserves the strength function of the biceps muscles better than a tenotomy and reduces the risk of a visible “Popeye” sign. A tenotomy may be sufficient for older, less active people who primarily have pain problems. The selection is made after explaining the advantages and disadvantages.

Possible risks of any operation include: Infection, bruising, stiffness, persistent pain, nerve irritation and, with tenodesis, rare failure of fixation. Structured follow-up treatment reduces the risk of complications.

Follow-up treatment and rehabilitation

• Depending on the procedure, use a sling/abduction cushion for 2-4 weeks for protection
• Early functional passive/assistive movements according to plan, avoiding forced external rotation during anterior repair
• No active resistance training of elbow flexion/supination for approximately 6 weeks after tenodesis/tenotomy
• Gradual strength build-up from week 6-8, sport-specific stress from approx. 3-4 months, return to overhead sports often after 4-6 months

The exact timing varies depending on the findings and the combined procedure (e.g. simultaneous rotator cuff reconstruction). The rehabilitation plan is determined individually.

Course, prognosis and everyday life

The prognosis is usually good with targeted therapy. Consistent physiotherapy can significantly reduce symptoms. In the case of structural instability and relevant accompanying damage, surgical stabilization often leads to reliable pain relief and gain in function - without a guarantee. It is crucial to treat the cause (pulley/subscapularis).

• Ability to work: depending on activity; Desk work often early, heavy physical work later
• Sport: Cycling/walking early, equipment training with arms overhead only after clearance
• Relapse prevention: stabilizing training and technical training

What you can do yourself

• Dose the load: no abrupt overhead or throwing movements during the healing phase
• Posture and technique training, especially shoulder blade control
• Regular, pain-adapted strengthening of the rotator cuff and scapula stabilizers
• Ergonomic adjustments in the workplace; Lift loads close to your body
• Heat/cold depending on the phase, easy self-mobilization according to instructions

Prevention: Keep your shoulder stable

• Balanced training of mobility and strength (internal/external rotators, lower trapezius/serratus anterior activation)
• Progressive increase in load, sufficient regeneration times
• Clean technique in overhead sports, use coaching if necessary
• Regular warm-up, posterior capsular stretch
• Early diagnosis of persistent anterior shoulder pain

When should I seek medical advice?

• Persistent anterior shoulder pain or pain at night
• Recurring painful snapping/jumping
• Loss of strength, especially with internal rotation, flexion or supination
• Suspected tear (sudden pain, “Popeye” sign)
• Trauma or acute restriction of movement

Your shoulder treatment in Hamburg

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we clarify anterior shoulder pain in a structured manner. In addition to the clinical examination, we use modern sonography and arrange further imaging if necessary. The treatment is gradual – with a focus on conservative options. Surgical procedures can be considered after careful indication.

A personal conversation helps to take into account your goals, your activity level and any accompanying factors. This creates an individual therapy plan without unrealistic promises – transparent, evidence-oriented and relevant to everyday life.