If you have ever experienced shoulder pain, you will know firsthand just how debilitating it can be. Assessing and correcting shoulder pain can represent a significant challenge to both the patient and the chiropractor, due to there being a large number of pieces in the healthy shoulder puzzle.

In this post, I am going to explain the causes and solutions for a commonly overlooked cause of shoulder pain  – the subluxated (slipped) biceps tendon, a problem that I frequently see in practice.

The Shoulder Joint Is A Hot Bed For Problems

The shoulder joint, known as the glenohumeral joint, is by design an unstable ball and socket type joint. It is created this way to afford you a lot of mobility and dexterity for your arms, but if anything disturbs its normal alignment or strength then pain and injury can fairly easily follow.

There are four main rotator cuff muscles which afford stability to the shoulder joint: Teres Minor, Subscapularis, Infraspinatus, and Supraspinatus.

As well as 15 further muscles that can also create problems with shoulder stability and function if they go wrong.  To make things even more tricky, here are some other important factors that can affect the health of the shoulder:

  • Your posture – rounded shoulders and forward head position can increase the mechanical stress on the joint
  • Spinal alignment – vertebral subluxation complexes in the cervical and thoracic spine can affect the normal reflexive firing patterns of all shoulder muscles.
  • Nutritional deficiencies/problems
  • Wrist/elbow problems can cause upstream issues in the kinematic chain.
  • The alignment of the biceps tendon
  • The smaller acromioclavicular, sternoclavicular joints
  • The scapulothoracic joint.
  • The strength of the surrounding ligaments, labrum and joint capsule.
  • Problems internally within the joint cartilage.
  • Lifestyle factors

This list is by no means exhausted, and each point there could have a long sub-list of potential problem areas. Each of these muscles, for example, can be influenced by

  • Injuries at their origin or insertion
  • Trigger points
  • Fascia tightening and restriction
  • Strain injuries
  • The nervous system (linking directly back into the spine in most cases)
  • The acupuncture system
  • Neurolymphatic and neurovascular reflexes
  • The craniosacral system
  • Nutritional problems – including multiple common deficiencies in B12, Folic Acid, Magnesium and Calcium to name a few.
  • Immune/histamine problems caused by food allergies and environmental toxins, or chronic infections
  • Underlying systemic inflammation
  • Problems with metabolism
  • Anaerobic or aerobic system deficiency/excess
  • Old unhealed injuries to the ligaments, tendons, joints, bones and surrounding muscles

This list is also not exhaustive. With so much to consider when assessing a shoulder problem, it is no surprise that problems with the biceps tendon are often overlooked in the care of shoulder pain.

What Is A Slipped Biceps Tendon

The biceps muscle attaches to the humerus bone via tendons; there is one in the elbow and two at the shoulder. One of the attachments at the shoulder is known as the “long-head,” which is a thin tendinous structure that runs through a groove at the front of the shoulder before entering the shoulder joint. The transverse ligament covers this groove and holds the biceps tendon in place.

The likelihood of the biceps tendon slipping out of this groove is increased if the transverse ligament becomes loose, injured or ruptured, which it commonly does. Usually, it will slide medially (towards the chest) and get lodged on the other side of the groove, where it causes pain and a multitude of functional problems. When this happens, there is often an associated partial or complete tear of the subscapularis tendon.

Occasionally, the soft tissue restraints from the rotator cuff muscles that maintain the position of the long head of biceps tendon can become injured and allow the tendon to slip out of place. The two most common muscular weaknesses that I find predisposing to this are the infraspinatus and teres minor muscles. These muscles are commonly predisposed to injury through daily activity, sports, and forward rounded postures.

Interestingly the field of Applied Kinesiology shows that the infraspinatus and teres minor muscles are related to the thyroid gland hormonal imbalances, which are also increasingly common these days. A link that I often see in my chiropractic practice.

A regular report from patients is that they just wake up with the pain, having been sleeping on that side and further rolling the shoulder joint inwards, applying pressure to the tendon in the direction of weakness. One of the giveaway signs of a slipped biceps tendon is not being able to lie on the involved side at night without aggravating the pain.

Sometimes the long head of biceps tendon does not fully slip out of the groove, but the weakness of the external rotators (teres minor, infraspinatus, posterior deltoid) allows the humeral head to turn medially (inwards) and the tendon pushes against an injured or ruptured transverse ligament, which is painful.

What Are The Symptoms Of A Slipped Biceps Tendon

  • A “clunk” when turning the arm inward or outward.
  • Pain in the front of the shoulder.
  • Pain can refer down into the biceps muscle.
  • Symptoms associated with rupture or injury of the subscapularis tendon, including pain in the front of the shoulder and pain with internal rotation (placing the hand behind the back).
  • A catching pain in the front of the shoulder as the arm is raised or lowered through a certain section of its range of motion. Usually at around 80-90 degree of abduction (side raising).

How As A Slipped Biceps Tendon Diagnosed?

There are several exam findings suggestive of a problem with the biceps tendon, whether that is tendonitis, rupture, or slipping. The most common findings are a pain in the front of the shoulder, tenderness to pressure along the tendonous groove and pain and weakness when the shoulder is tested into internal rotation.

Applied kinesiology muscle testing is the most useful and accurate tool in diagnosing this problem. By challenging the biceps tendon and aggravating the problem a weakness can be ‘induced’ into a previously strong muscle, thus indicating the nature of the underlying problem.

Orthopaedic tests such as ‘Speeds’ test (pain on internal rotation) or ‘Yergasons’ Test (pain or clunking when the patient attempts to turn their palm upwards with their elbow held against their side) also have some merit, although they can sometimes fail to pick up the problem.

Diagnostic imaging such as MRI scanning allow for visualisation of a displaced biceps tendon, and often also reveals pathology to the subscapularis tendon as well. MRI is static, however, so if the tendon only slips when the shoulder is moved, then it may not reveal the problem.

Ultrasound can be useful for diagnosing a functional slipping tendon, as the tendons response to shoulder movement can be visualised in ‘real time’.

How Is A Slipped Biceps Tendon Treated?

The treatment will depend upon the severity of the problem. Often conservative approaches with AK,  Chiropractic and lifestyle modifications is enough to allow it to heal.

There is a safe, gentle, soft tissue procedure which AK Chiropractors use to relocate the tendon within its groove. Often surrounding problems with the rotator cuff muscles and correction of any biomechanical problems within the cervical or thoracic spine is also required.

Rest, ice and natural anti-inflammatory strategies are also advised.

Very severe cases may require surgery to correct.

How Soon Can You Return To Sport and Your Normal Activities?

Again everyone is different. With a conservative, natural, AK Chiropractic approach most patients are pain-free and functional within six weeks of commencing care.

As with any soft tissue injury 3-6 weeks of rest as well as a gradual reintroduction of complex movement and rehabilitation. is recommended.

Accurate Functional Assessment Is The First Place To Start

I began this post explaining the highly complex nature of the shoulder joint. In my experience diagnostic imaging and standard orthopaedic tests are limited in their ability to diagnose the full scope of most shoulder problems. Since the underlying cause to shoulder pain problems will only reveal themselves under functional assessment.  Each shoulder muscle needs to be tested individually yet considered under the context of the whole system.

Applied Kinesiology assessment is the most through functional approach for diagnosing functional problems and finding the underlying cause(s) to many shoulder pains and problems.

Relief and improvements in function are often rapid and dramatic, as shown in the case below.

I am here to help.

 

Live In Alignment

&

Thrive At Life

 

Richard Gliddon

AK Chiropractor

SpineCentral

 

References

  • Gill TJ, McIrvin E, Mair SD, Hawkins RJ. Results of biceps tenotomy for treatment of pathology. J Shoulder Elbow Surg 2001; 10:247-9.
  •  M. Lucas Gambill, DO, Timothy S. Mologne, MD, et al., Dislocation of the long head of the biceps tendon with intact subscapularis and supraspinatus tendons.  J Shoulder Elbow Surg, 15(6):e20-2 · November 2006
  • O’Donoghue DH. Subluxing biceps tendon in the athlete. Clin Orthop Relat Res 1982:26-30
  • Walch G, Nove-Josserand L, Boileau P, Levigne C. Subluxations and dislocation of the tendon of the long head of the biceps. J Shoulder Elbow Surg 1998;7:100-8