Introduction
- Brian Armstrong, MPT
- Eric C. Hall, MS, ATC, CSCS
Epidemiology
- •
The proximal biceps tendon is a primary source of anterior shoulder pain.
- •
Proximal biceps tendon injuries are more often present in the older population in conjunction with rotator cuff disease, anterior impingement, or glenohumeral instability.
- •
Isolated proximal biceps tendon injuries are more common in patients 18 to 35 years of age involved in specific sports.
- •
Proximal biceps tendon injuries are more prevalent in males due to the nature of male sports and the general manual labor requirements in the working population.
- •
Tendon rupture is most common in males in their sixth and seventh decades of life.
- •
Several studies demonstrate a low incidence of isolated bicep tendon injuries.
- •
Primary biceps tendinitis accounts for only 5% of all biceps tendon injuries.
- •
The injury typically occurs in sports such as tennis, gymnastics, badminton, squash, volleyball, weight lifting, canoeing, fencing, golfing, boxing, and all sports that require repetitive overhead throwing.
- •
Specific positions in which the injury occurs are pitchers in baseball and softball, quarterbacks in football, javelin throwers, outside hitters in volleyball.
Pathophysiology
- •
The long head of the biceps tendon (LHBT) originates from the superior glenoid rim and the superior labrum. It then exits the glenohumeral joint and passes through the rotator interval, arches over the humeral head and passes through the intertubercular groove ( Figure5-1 ).
FIGURE 5-1
Anatomy of the proximal biceps tendon.
(Redrawn from Krishnan S, Hawkins R, Warren R: The shoulder and the overhead athlete, Philadelphia, 2004, Lippincott Williams & Wilkins.)
- •
The proximal tendon is richly innervated with sensory nerve fibers containing substance P and calcitonin, thus a major reason for a primary source of anterior shoulder pain.
- •
The tendon is stabilized by a tendinoligamentous sling consisting of the coracohumeral ligament, superior glenohumeral ligament, fibers from the supraspinatus, and fibers from the subscapularis ( Figure 5-2 ).
FIGURE 5-2
Anatomy of the tendinoligamentous sling. B , long head of biceps brachii tendon; C , coracohumeral ligament; SSC , subscapularis tendon; SST , supraspinatus tendon; T , transverse humeral ligament.
(Redrawn from Morag Y, Jacobson J, Shields G, et al: MR arthrography of rotator interval, long head of the biceps brachii, and biceps pulley of the shoulder. Radiology 235:21-30, 2005. Available at http://radiology.rsna.org.easyaccess1.lib.cuhk.edu.hk/content/235/1/21.full )
- •
Once in the bicipital groove, the tendon passes under the transverse humeral ligament. The bicipital groove will vary in depth, width, and angle of the walls. A shallow groove may be present in those with LHBT instability.
- •
The function of the proximal biceps tendon is not completely understood and is somewhat controversial. Neer proposed that the tendon depresses the humeral head with contraction. Andrews et al. noted that contraction of the biceps leads to compression of the glenohumeral (GH) joint. Others feel that the tendon may provide passive stability to the joint by acting as a physical block against certain motions.
- •
Neer first described anterior impingement syndrome where subacromial spurs were shown to cause degenerative wear on both the rotator cuff and the biceps tendon .
- •
Proximal biceps tendon injuries can be classified into three different categories:
- •
Tendinopathy: biceps tendinitis, tenosynovitis, and tendinosis
- •
Instability: tendon dislocation and subluxation
- •
Rupture: most often occurring within the bicipital groove
- •
- •
Biceps tendinitis is a common diagnosis but is typically a misnomer because most athletes who are having pain typically have already gone through the inflammation stages and are now experiencing tendon sheath inflammation and tendon degeneration—a tendinosis condition.
- •
Tendinopathies are typically derived from overuse injuries, impingement syndromes, and glenohumeral instability.
- •
Instability of the biceps tendon can result from a tear in the tendinoligamentous sling, a tear in the transverse ligament, or a shallow bicipital groove.
- •
Ruptures of the biceps tendon typically occur with traumatic events or with an excessive eccentric load. Oftentimes a rupture follows a long course of tendon degeneration and shoulder pain. When a tendon ruptures in this way, it often results in relief of pain.
Intrinsic Factors
- •
Subacromial impingement
- •
Coracoacromial impingement
- •
Anterior glenohumeral instability
- •
Rotator cuff weakness
Extrinsic Factors
- •
Repetitive anterior shear stresses to the shoulder as with the pitching motion, bowling, volleyball, and the tennis swing can lead to stretching of anterior soft tissues, eventually leading to increased glenohumeral instability causing impingement of anterior structures.
- •
Furthermore, increased anterior translation can lead to internal impingement of the posterior rotator cuff, causing fraying of the posterior cuff fibers. Once anterior structures are stretched and posterior cuff fibers are compromised, increased loads are placed on the bicep anchor, possibly leading to a SLAP (superior labrum anterior and posterior) tear.
- •
The term peel-back mechanism is often used to describe the forces on the labrum and proximal bicep tendon with overhead throwing motion. This has been compared to the way one might pull a weed out of the ground by tugging at it in different directions.
- •
With throwing, a large eccentric load is placed through the bicep to decelerate elbow extension speeds of approximately 2200 degrees/second.
Traumatic Factors
- •
Traumatic rupture of the proximal biceps tendon is rare.
- •
Rupture incidents are most common in the middle-aged to older active population with underlying biceps and rotator cuff pathologies.
- •
Mechanisms of injury typically involve high intensity eccentric loads on the biceps muscle and tendon.
- •
Sports that have been found to have the most incidents of biceps tendon ruptures are gymnastics, wrestling, arm wrestling, boxing, and bodybuilding/weightlifting.
Histopathological Findings
- •
Systemic diseases that specifically cause deterioration of a tendon are rare.
- •
Foreign bodies that directly cause tendon deterioration are slightly more common, but represent less than 10% of all tendon injuries.
- •
Overuse injuries are typically the most frequent cause of tendon injuries.
- •
Repetitive intense physical use of a tendon, specifically repetitive eccentric loads, causes continuous microtrauma and does not allow for sufficient rest and recovery between tendon use.
- •
Poor circulation in and around a tendon in conjunction with increased tendon activity can lead to poor oxygenation and tendon nutrition. This explains why a more sedentary subject may be predisposed to tendon injury when participating in infrequent intense physical activity.
- •
Clinical Presentation and Examination
History
- •
Normally there is no specific mechanism of injury, but some sort of repetitive overhead activity will be involved.
- •
Subjects with tendinopathy typically describe difficulty with warming up, a brief period of pain-free activity, increasing pain late with activity, and then stiffness and/or achiness after activity.
Physical Examination
- •
Tendon rupture
- •
Obvious deformity, called a “Popeye” deformity. When the proximal tendon ruptures, the tendon will typically retract distally causing an obvious bulge of muscle tissue, and bruising anteriorly ( Figure 5-3 ).
FIGURE 5-3
Popeye deformity.
(From From Wysocki RW, Verma NN: Distal biceps repair. In Cole BJ, Sekiya JK, editors: Surgical techniques of the shoulder, elbow, and knee in sports medicine. Philadelphia: 2008, Saunders, p. 401, with permission.)
- •
When a rupture occurs, most patients present with initial acute pain from the trauma of the incident, but soon after notice an overall relief of anterior shoulder pain that may have been present from chronic biceps tendon pathology.
- •
- •
Tendon instability
- •
Often presents with an audible or palpable “snap” in a specific arc of motion, such as with turning the steering wheel of a car or moving from an adducted and internally rotated position to an abducted and externally rotated position.
- •
- •
Tendinopathy
- •
Pain is typically located within the bicipital groove and sometimes radiates toward the deltoid insertion. Since most biceps tendinopathies are accompanied by impingement, glenohumeral instability, and/or rotator cuff disorders, the pain is most often diffuse over the anterior shoulder.
- •
Pain is intensified with anterior impingement positions.
- •
Abnormal Findings
- •
Point tenderness over the proximal biceps tendon should rotate laterally with glenohumeral ER. This technique is helpful in differentiating between other soft tissue structures that should not move with glenohumeral external rotation (ER).
- •
Positive special tests
- •
O’Brien’s active compression test
- •
Speed’s test
- •
Yergason’s test
- •
Ludington’s test
- •
Lift-off test: test the integrity of the subscapularis
- •
Jobe’s relocation test: test for anterior GH instability
- •
Biceps instability test.
- •
Imaging
- •
Plain-film radiographs: often read as normal in the instance of proximal biceps tendinitis, but may reveal supporting evidence of anterior impingement, glenohumeral arthritis, or a shallow bicipital groove.
- •
Ultrasonography: cost effective and easily tolerated. Very useful in detecting abnormalities of the biceps tendon.
- •
Magnetic resonance imaging: a noninvasive study that is an excellent imaging modality for soft tissue structures. Sometimes used with a contrast dye (invasive) to better evaluate tissue structure.
- •
Arthroscopy: the best method to visually evaluate the integrity of the tendon in vivo
- •
Electrodiagnostic testing: In rare situations, neurological disorders may cause pain that mimics that of a biceps tendon disorder.
Differential Diagnosis
- •
Rotator cuff pathology: specifically with the subscapularis
- •
Positive lift-off test reveals possible subscapularis injury
- •
Weakness and/or pain with resisted ER/IR at 0 degrees of abduction
- •
- •
Glenohumeral instability/labral pathology
- •
Positive Jobe’s relocation test reveals possible glenohumeral instability
- •
Possible history of traumatic injury
- •
Pain with repetitive activities involving extreme end ranges of motion, as with overhead throwing
- •
- •
Subacromial impingement syndrome: Positive impingement tests can result in pain at the anterior shoulder.
Treatment
Nonoperative Management
- •
Conservative treatment
- •
Rest, ice, antiinflammatory medication for evidence of an inflamed tendon
- •
Once acute pain is resolved, physical therapy should be started.
- •
This should involve gradual progressions of ROM exercises, scapular stabilization and movement correction exercises, progressing to posterior rotator cuff stretching and strengthening progressions, general upper body conditioning, then to sport-specific/activity-specific functional progressions.
- •
- •
- •
Steroid injections: sometimes used to facilitate the prescribed rehabilitation program
- •
Subacromial injections: often used to treat both primary and secondary tendinitis. Again, only used when there is evidence of tendon inflammation.
Guidelines for Choosing Among the Nonsurgical Treatment Options
- •
Patient is likely to be compliant with a rehabilitation program.
- •
Patient generally does not require repetitive overhead activity or other repetitive physical activity requiring use of the biceps. Most often middle-aged and older adults.
Surgical Indications
- •
Consistent pain and spasms following a consistent course of physical therapy
- •
Young and physically active patient requiring repetitive elbow flexion, supination, and shoulder flexion activities
- •
Biceps rupture patient to whom cosmetic appearance is important
Guidelines for Choosing Among the Surgical Treatment Options
- •
Age
- •
Physical activity level
- •
Type of physical activity
- •
Value of cosmetic appearance
- •
Compliance probability
Evidence
Multiple-Choice Questions
- QUESTION 1.
Which choice below is not a tendinopathy disorder?
- a.
Tendinitis
- b.
Tendinosis
- c.
Bicep muscle strain
- d.
Tenosynovitis
- a.
- QUESTION 2.
What are common intrinsic factors that lead to biceps tendon injuries?
- a.
Subacromial impingement
- b.
Rotator cuff weakness
- c.
Coracoacromial impingement
- d.
All of the above
- a.
- QUESTION 3.
Which sport below is least likely to play a role in proximal biceps tendon injury?
- a.
Soccer
- b.
Baseball
- c.
Boxing
- d.
Bowling
- a.
- QUESTION 4.
What is a common differential diagnosis for proximal biceps tendon injuries?
- a.
AC sprain
- b.
SLAP tear
- c.
Humeral stress fracture
- d.
Stingers
- a.
- QUESTION 5.
Which treatment below is often considered when conservative treatments for primary biceps tendinitis have failed?
- a.
Sling
- b.
Postural correction
- c.
Static stretches
- d.
Tendon sheath injection
- a.
Answer Key
- QUESTION 1.
Correct answer: C (see Pathophysiology )
- QUESTION 2.
Correct answer: D (see Pathophysiology )
- QUESTION 3.
Correct answer: A (see Epidemiology and Extrinsic Factors )
- QUESTION 4.
Correct answer: B (see Differential Diagnosis )
- QUESTION 5.
Correct answer: D (see Nonsurgical Treatment Options)
Nonoperative Rehabilitation of Long Head of Biceps Tendinitis/Tendinosis
- Brian Armstrong, MPT
- Eric C. Hall, MS, ATC, CSCS
- •
Nonoperative treatment should be based on the recognition and accurate classification of the biceps pathology.
- •
Differential diagnosis is critical to a successful outcome–tendinitis vs. tendinosis
- •
Patient should follow an individual criterion-based rehabilitation program with attention placed on response to treatment in terms of changes in pain, swelling, or motion.
- •
Any comprehensive rehabilitation program following biceps injury should focus on restoring dynamic stability to the shoulder.
Phase I (Weeks 1 to 3): Acute Phase
Treatment for Pain/Swelling
- •
Clinical modalities as needed:
- •
Disposable iontophoresis patch ( Figure 5-4 ).
FIGURE 5-4
Disposable iontophoresis patch.
(Empi Medical, St. Paul, MN).
- •
Electrotherapy: low-frequency transcutaneous electrical nerve stimulation
- •
Ultrasound (biceps tendinosis)
- •
Laser
- •
Phonophoresis
- •
- •
Cryotherapy: ice massage
- •
Oral pain medications as needed
- •
Subacromial injection
- •
Heat (biceps tendinosis)
- •
Rest
- •
Patient education:
- •
Withdrawal from aggravating activities
- •
Avoidance of reaching and lifting overhead
- •
Proper posture during sitting/sleeping
- •
| PHASE I (weeks 1 to 3) | PHASE II (weeks 4 to 8) | PHASE III (weeks 6 to 12) | PHASE IV (weeks 10 to 16) |
|---|---|---|---|
|
|
|
|
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Apply glenohumeral, sternoclavicular, and scapulothoracic joint mobilizations to restrictive capsular tissues (grades I/II/III).
- •
Manual glenohumeral joint range of motion
- •
Thoracic and cervical spine mobilizations/manipulations
Soft Tissue Techniques for Biceps Tendinosis
- •
Cross-friction massage
Stretching/Flexibility Techniques for the Musculotendinous Unit
- •
Rope-and-pulley
- •
Wand stretching, passive range of motion, flexion and external rotation ( Figure 5-5 )
FIGURE 5-5
Wand flexion, wand ER at 0° of abduction, and wand ER in the scapular plane.
- •
Posterior capsule stretching—cross-arm stretch or sleeper stretch
- •
Self-stretches-upper trapezius, levator scapulae, and pectoralis minor stretching
- •
Biceps tendinitis—frequent bouts of light range-of-motion/stretching/flexibility exercises during inflammatory stage
Other Therapeutic Exercises
- •
Leg strengthening exercises
- •
Low-intensity cardiovascular conditioning activities such as Stairmaster, stationary bike riding, running in the pool, elliptical (without use of upper extremity), or treadmill walking.
- •
Core stability exercises
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Early scapular strengthening, scapular stabilization with emphasis on low/mid trapezius.
- •
Modified isometrics: arm below 90° and abduction 45°
Neuromuscular Dynamic Stability Exercises
- •
Utilize biofeedback to increase neuromuscular control of scapular musculature.
Milestones for Progression to the Next Phase
- •
Restoration of full passive range of motion
- •
Restoration of normal accessary motion
- •
Decreased signs of inflammation: no discomfort at rest and no warmth felt upon palpation
- •
Good tolerance of Phase I program
Phase II (Weeks 4 to 8): Subacute Phase, Active Range of Motion, Early Strengthening
Treatment for Pain/Swelling
- •
Cryotherapy, ice massage
- •
Clinical modalities as needed
- •
Continue activity modification, modification of aggravating activities
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Progressive glenohumeral, scapulothoracic, and sternoclavicular joint mobilizations as needed (grades II/III/IV)
- •
Manual glenohumeral range of motion
- •
Pectoralis stretching
Soft Tissue Techniques for Biceps Tendinosis
- •
Transverse friction massage
Stretching/Flexibility Techniques for the Musculotendinous Unit
- •
Active assisted to active range of motion exercises
- •
Flexion, abduction, external rotation and internal rotation
- •
- •
Self-stretches for anterior, posterior, and inferior capsule
- •
Rhomboid and latissimus dorsi stretching
Muscle Activation of Primary Muscles Involved
- •
Submaximal bicep curls with dumbbells (eccentric for biceps tendinosis )
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Begin rotator cuff strengthening
- •
Theraband-internal rotation and external rotation
- •
Scaption
- •
Prone I,T,Y,W ( Figure 5-6 )
FIGURE 5-6
Prone I/T/Y/W exercise with scapular retraction.
- •
- •
Submaximal triceps kickback
- •
Dumbbell forearm exercises
- •
Scapular protraction/retraction exercises
Neuromuscular Dynamic Stability Exercises
- •
Initiate neuromuscular control exercises:
- •
Scapular stabilization with submaximal proprioceptive neuromuscular facilitation (PNF)
- •
Diagonal I (DI) and diagonal II (DII) PNF pulley
- •
Scapular clock ( Figure 5-7 )
FIGURE 5-7
Scapular clock to promote neuromuscular reeducation (12 o’clock/3 o’clock/9 o’clock).
- •
Milestones for Progression to the Next Phase
- •
Restoration of normal active assisted range of motion
- •
No symptoms during activities of daily living
- •
Improved muscular performance
Phase III (Weeks 6 to 12): Progressive Exercise Stage
Treatment for Pain/Swelling
- •
Cryotherapy as needed
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Aggressive joint mobilizations, if needed
Stretching/Flexibility Techniques for the Musculotendinous Unit
- •
Continue self-capsular stretching
- •
Aggressive wand ROM in all planes
Other Therapeutic Exercises
- •
Initiate upper body ergometer for endurance
Muscle Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Advance biceps dumbbell strengthening
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Initiate isotonic dumbbell strengthening program
- •
Side-lying external rotation
- •
Prone extension and horizontal abduction in external rotation
- •
Standing scaption and flexion
- •
- •
Scapular strength: push-up progression and rowing
- •
Initiate “Thrower’s 10” program
Neuromuscular Dynamic Stability Exercises
- •
Advance shoulder/scapular PNF
- •
Initiate shoulder and scapular rhythmic stabilizations ( Figure 5-8 ).
- •
Isometric to dynamic
- •
Slow to fast
- •
Multiple direction
FIGURE 5-8
Rhythmic stabilizations at 90/120/60° of flexion.
- •
- •
Manual scapular resistance ( Figure 5-9 )
FIGURE 5-9
Manual side-lying scapular resistance.
- •
Standing body blade ( Figure 5-10 ).
- •
Can initiate PNF patterns
FIGURE 5-10
Bodyblade at 90° of abduction/adduction and 90° of flexion/extension to promote neuromuscular dynamic stability.
- •
Milestones for Progression to the Next Phase
- •
Full, nonpainful ROM
- •
No pain or tenderness
- •
Continued improved muscular performance
Phase IV (Weeks 10 to 16): Advanced Strengthening/Return to Activity Phase
Treatment for Pain/Swelling
- •
Cryotherapy as needed
Techniques for Progressive Increase in Range of Motion
Stretching/Flexibility Techniques for the Musculotendinous Unit
- •
Self-capsular stretching to maintain capsular mobility/ROM
Other Therapeutic Exercises
- •
Initiate upper body gym strengthening program (modified to avoid positions of impingement).
- •
Minimize overhead activities
- •
Keeps hands within eyesight
- •
Muscle Activation of Primary Muscles Involved in Injury Area or Surgical Structures
- •
Continued advancement of biceps strengthening
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Advance isotonic rotator cuff dumbbell program
- •
Push up progression
Neuromuscular Dynamic Stability Exercises
- •
Advance scapular PNF exercises
- •
Resisted PNF patterns
- •
Advance rhythmic stabilization in all planes
Plyometrics
- •
Initiate plyometric exercises ( Figure 5-11 )
- •
Duplicate the explosive dynamics of overhead athletes
- •
Progress from 2-arm to 1-arm
FIGURE 5-11
Plyometric weighted ball toss against wall in 90/90 position.
- •
Sport-Specific Exercises
- •
Initiate Interval Functional Progression Program:
- •
Throwing
- •
Golf
- •
Tennis
- •
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Full, nonpainful ROM
- •
No pain or tenderness
- •
Satisfactory clinical exam
- •
Satisfactory strength evaluation (manual muscle testing and/or isokinetic testing 5% to 10% greater than nondominant side)
- •
Adequate dynamic stabilization and muscular endurance as measured by isokinetic testing and closed kinetic chain (CKC) functional testing for sport-specific actions to analyze muscle performance and activation characteristics
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or Other More Invasive Intervention
- •
No improvement after 3 to 6 months of a comprehensive rehabilitation program
- •
Plateau in recovery at an undesirable level of function
Transition to Performance Enhancement: Tips and Guidelines
Before transitioning to performance enhancement, the patient must have met criteria to return to play during the rehabilitation progression. An interval sport program that progressively applies more forces to the healing structures and gradually returns the athlete to full athletic competition as quickly and safely as possible must be completed. For sport-specific rehabilitation programs to be successful, the entire body must be reeducated in a stepwise fashion to perform the various activities related to the sport.
Performance Enhancement and Beyond Rehab: Training/Trainer and Optimization of Athletic Performance
- •
Maintenance program
- •
Flexibility exercises, self-capsular stretches
- •
Isotonic exercises, rotator cuff/total arm strengthening (TAS)
- •
Theratubing exercises, IR/ER 90/90 position, D2 PNF pattern
- •
Serratus pushups
- •
- •
Optimize specific sport/occupational biomechanics to performance.
- •
Continue enhancing strength and conditioning parameters that improve power and performance related to activity.
- •
Need for a supervised and structured off-season, preseason, and in-season training regime.
Specific Criteria for Return to Sports Participation
- •
Full, nonpainful ROM
- •
Satisfactory clinical exam and isokinetic strength test
- •
Clearance from MD
- •
Adequate dynamic stabilization and muscular endurance as measured by isokinetic testing and sport-specific CKC testing
- •
Completion of interval sport program or functional progression to sport/activity
Evidence
Multiple-Choice Questions
- QUESTION 1.
During what phase of rehabilitation do you begin active assisted/active range of motion exercises?
- A.
Phase I
- B.
Phase II
- C.
Phase III
- D.
Phase IV
- A.
- QUESTION 2.
What must be achieved for progression to Phase IV?
- A.
Full, nonpainful ROM
- B.
No, pain or tenderness
- C.
Satisfactory clinical exam
- D.
All the above
- A.
- QUESTION 3.
When treating biceps tendinosis during what phase of rehabilitation is it appropriate to begin cross-friction massage?
- A.
Phase I
- B.
Phase II
- C.
Phase III
- D.
Phase IV
- A.
- QUESTION 4.
Which exercise would be inappropriate to perform upper extremity strengthening in the gym during phase IV rehabilitation?
- A.
Eccentric bicep curls
- B.
Triceps kick backs
- C.
Military bench press
- D.
Scaption
- A.
- QUESTION 5.
During what phase of rehabilitation would it be appropriate to initiate the upper body ergometer for endurance?
- A.
Phase I
- B.
Phase II
- C.
Phase III
- D.
Phase IV
- A.
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