Dislocation of the long head of the biceps tendon with intact
subscapularis and supraspinatus tendons
M. Lucas Gambill, DO, Timothy S. Mologne, MD, and Matthew T. Provencher, MD, San Diego, CA
A
large body of evidence supports the fact that
subluxation and dislocation of the long head of the
biceps tendon are relatively common findings associated with rotator cuff pathology. Dislocation of the
long head of the biceps is often linked to chronic
degenerative changes seen with impingement syndrome and tears in the rotator cuff, especially the
subscapularis tendon.2 One report states that medial
displacement of the long head of the biceps tendon
can occur in up to 16% of rotator cuff tears.11 Other
authors have reported isolated dislocations of the
biceps tendon without the presence of rotator cuff
tears.3,4,7 However, to our knowledge, there have
been no reports of a medially dislocated long head of
the biceps tendon with intact subscapularis, supraspinatus, and infraspinatus tendons. We report on a
patient with posttraumatic posterior shoulder instability with a medial dislocation of the long head of the
biceps tendon over an intact subscapularis tendon
without evidence of a torn rotator cuff. This injury is
unique in that the subscapularis tendon is not torn,
implying an injury to the tissues of the rotator interval,
likely the coracohumeral and superior glenohumeral
ligaments.
CASE REPORT
A 29-year-old right hand– dominant man presented with
a 2-year history of left shoulder pain and instability. He
reported a traumatic load to the joint sustained when a
teletype machine fell down a stairwell onto his left shoulder,
which resulted in forced adduction and internal rotation of
the limb as he attempted to fend off the heavy device. After
the injury, he complained of persistent pain, popping of the
joint, and frequent nocturnal paresthesias. Despite a trial of
From the Department of Orthopaedic Surgery, Naval Medical
Center San Diego.
The views expressed in this article are those of the authors and do
not reflect the official policy or position of the Department of the
Navy, Department of Defense, or US Government.
Reprint requests: Matthew T. Provencher, MD, Department of Orthopaedic Surgery, Naval Medical Center San Diego, 34800
Bob Wilson Dr, Suite 112, San Diego, CA 92134-1112 (E-mail:
mtprovencher@nmcsd.med.navy.mil).
J Shoulder Elbow Surg 2006;15:e20-e22.
Copyright © 2006 by Journal of Shoulder and Elbow Surgery
Board of Trustees.
1058-2746/2006/$32.00
doi:10.1016/j.jse.2005.09.008
e20
conservative treatment, which included physical therapy
and nonsteroidal antiinflammatory agents, his condition did
not improve.
On initial examination, the patient was found to have no
obvious atrophy or deformity of the shoulder joint. The
range of motion of the shoulder was normal and symmetric
to the unaffected shoulder. The patient was found to have a
positive posterior apprehension test, a positive Speed’s test,
and a positive O’Brien test. In the lateral decubitus position,
he was found to have grade IV posterior translation, with
the humeral head easily subluxated over the glenoid rim,
requiring a reduction maneuver to reduce it. There was
normal anterior translation. There was marked tenderness
in the area of the bicipital groove.
Initial radiographic findings showed a small compression defect in the anterior humeral head. A magnetic resonance arthrogram with gadolinium of the left shoulder
demonstrated a posterior labral tear (Figure 1), a dislocation of the long head of the biceps tendon over an intact
subscapularis tendon, and a normal rotator cuff (Figure 2).
An examination with the patient under anesthesia confirmed the grade IV posterior translation of the humeral
head. Anterior translation was normal.
Diagnostic arthroscopy revealed the long head of the
biceps tendon to have a normal contour, but the tendon was
displaced medially and caudally from the normal path in
the rotator interval. The posterior labrum was torn and
avulsed from the glenoid (Figure 3). The posteroinferior
recess was patulous. The rotator cuff was intact and normal
in appearance (Figure 4). There was tearing of the superior
glenohumeral ligament in the rotator interval. The leading
edge of the subscapularis tendon was normal.
After diagnostic arthroscopy, an arthroscopic posterior
capsulolabral repair was performed with polyester suture
and 3-mm bioabsorbable suture anchors (BioFastak; Arthrex, Naples, FL). At the conclusion of the arthroscopic
portion of the case, a tenotomy of the biceps tendon was
performed with an electrocautery device. An anterior minideltopectoral incision was then made to expose the rotator
interval and bicipital groove. It was noted that the long
head of the biceps tendon was dislocated medially, lying
anterior to the subscapularis tendon (Figure 5). After the
biceps tendon was retracted out of the rotator interval, a
biceps tenodesis was performed with a bioabsorbable interference screw (BioTenodesis Screw; Arthrex). The rotator
interval was advanced laterally and closed with nonabsorbable sutures.
Postoperatively, the patient used an UltraSling (dj
Orthopedics, Inc, Vista, CA) in neutral rotation for 6
weeks. Therapy was initiated for progressive range of
motion and strengthening after immobilization. At 2
J Shoulder Elbow Surg
Volume 15, Number 6
Figure 1 Axial T2 magnetic resonance arthrogram with articular
gadolinium demonstrating posterior labral tear and dislocation of
long head of biceps tendon over intact subscapularis tendon.
Figure 2 Sagittal T2 magnetic resonance arthrogram with intraarticular gadolinium demonstrating intact supraspinatus tendon and
normal superior labral area.
years postoperatively, he had no pain or complaints of
instability or limited shoulder function. He had a full
range of motion and normal posterior stability. The contour of his anterior brachium and biceps was symmetric
to his contralateral limb. He has subsequently resumed all
prior activities, which included weightlifting, swimming,
baseball, and woodworking.
DISCUSSION
Isolated dislocation of the long head of the biceps is a
rare entity. In most cases, dislocation of the biceps tendon
out of the bicipital groove is usually associated with tears of
the subscapularis tendon or massive rotator cuff tears (or
both).11–13 There are case reports of isolated dislocations
of the biceps tendon3,4; however, these studies were published before the advent of arthroscopy and magnetic resonance imaging. To our knowledge, this is the first case of
a dislocated biceps tendon associated with posterior instability of the shoulder.
Gambill, Mologne, and Provencher
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Figure 3 Arthroscopic picture from anterior portal showing posterior labrum avulsed from glenoid rim.
Figure 4 Arthroscopic picture from posterior portal demonstrating
normal contour of biceps tendon and normal rotator cuff.
The capsuloligamentous structures of the rotator interval
function, in part, to retain the long head of the biceps within
the bicipital groove. The coracohumeral and superior glenohumeral ligaments are believed to be the two most important structures of the rotator interval responsible for
preventing displacement of the long head of the biceps
tendon out of the groove.8,10,13 They function to form a
sling around the tendon, preventing medial dislocation over
the lesser tuberosity. The superior glenohumeral ligament
assists in preventing posterior translation of the humeral
head when the arm is adducted.5 Displacement of the
tendon out of its groove is also associated with rotator cuff
tears. In most cases, complete dislocation of the biceps
tendon is nearly always associated with a tear in the
subscapularis tendon.9 In fact, Warren12 states that the
entity of a subluxating biceps tendon in the absence of
damage to either the lesser tuberosity or subscapularis
tendon is “a diagnosis we are unable to reliably arrive at.”
Similarly, Walch et al11 report, “We have never seen a
subluxation or dislocation with the three tendons (subscapularis, supraspinatus, and infraspinatus) intact.”
e22
Gambill, Mologne, and Provencher
J Shoulder Elbow Surg
November/December 2006
Pathology of the long head of the biceps tendon has
been recognized to play a role in the development of
shoulder pain and dysfunction.6 We have shown a unique
case of a dislocated long head of the biceps tendon over
intact subscapularis and supraspinatus tendons in a patient
with traumatic posterior instability of the shoulder. A dislocation of the long head of the biceps most often involves a
tear of the subscapularis (at a minimum, the upper portion
of the subscapularis) or supraspinatus tendons (or both).
This case illustrates a dislocation of the long head of the
biceps tendon probably resulting from injury to the coracohumeral and superior glenohumeral ligaments and other
soft-tissue structures contained within the rotator interval
sustained after traumatic posterior shoulder instability. It
should serve to emphasize the importance of the tissues in
the rotator interval as restraints to biceps subluxation, as
well as to highlight the potential injury to the rotator interval
in patients with posterior shoulder instability.
REFERENCES
Figure 5 Diagram of medially dislocated biceps tendon with intact
rotator cuff.
We believe that the traumatic injury our patient sustained led to disruption of the rotator interval, allowing the
long head of the biceps tendon to dislocate medially across
the lesser tuberosity and over an intact subscapularis. Some
authors support the circle concept of glenohumeral instability (ie, that translation of the humeral head can occur with
injury to the capsule on one side, but frank dislocation of the
joint requires an insult to both sides).5 Recent biomechanical studies report that the subscapularis is the most important tendon in resisting humeral head subluxation.1 In addition, the coracohumeral and inferior glenohumeral
ligaments, two important structures of the rotator interval,
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respectively.1 Our patient is believed to have had posterior
shoulder instability as a result of a traumatic injury to the
glenoid labrum and rotator interval, specifically the coracohumeral and superior glenohumeral ligaments. This injury
subsequently allowed for medial displacement of the long
head of the biceps tendon over an intact subscapularis.
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