Episode 1: Biceps Tendonopathy

Featured professor:  Skye Donovan | PT, PhD, OCS

Notes by Alexis Lancaster, SPT

What is it

  • A strain of the muscle can be damage to the muscle belly but is usually damage to the tendon
    • Tendon can be ruptured, varying in severity from only a few fibers being interrupted all the way to a complete tendon rupture

Signs and symptoms

  • Pt may come in with pain, can also be weak
    • Pain could limit strength depending on the amount of muscle damage
    • With a lot of muscle damage/tendon damage they will be unable to fire the biceps muscle
  • Point tenderness in the bicipital groove could be the pt’s only symptom
    • More people have proximal pain rather than distal pain (this will be pain at the origin of the muscle
  • Complete rupture: the “Popeye’s Sign”—the muscle will have detached from the bicipital groove and will be balled up in the middle of the upper arm.
    • Pt will say they heard a “ripping” noise, and that they now have a ball in their arm that didn’t used to be there

Anatomy

  • 2 heads
  • The short head of the biceps
    • Origin: coracoid process, Insertion: short head and long head tendons come together and insert into the bicipital aponeurosis on the radius
  • Long head of the biceps
    • Origin: superior glenoid, superior portion of the labrum*, Insertion: short head and long head tendons come together and insert into the bicipital aponeurosis on the radius
      • *Key for differential diagnosis, labrum may be the problem
      • Can be thought of as the 5th muscle of the rotator cuff due to origin anatomy
  • Biceps’ main action is supination, as well as elbow flexion
    • The “wine bottle” muscle: powerful supination (wine opening), elbow flexion (pull the cork out)
  • Innervation: musculocutaneous nerve (C5, C6, C7)
  • Reflex testing: C5

Special tests

  • Speed’s Test (gold standard)
    • Patient in shoulder flexion, some external rotation, elbow extended, full supination
    • PT applies resistance into shoulder extension, patient will resist by flexing shoulder
    • Positive test: pt complains of pain (at the groove or at origin), pt may be weak
    • Supination requires pt to use biceps instead of brachialis or brachioradialis
  • Yergason’s sign
    • Put patient into 90 degrees elbow flexion, in supination
    • PT will try to pull pt into elbow flexion and pronation while patient resists by flexing elbow and supinating forearm
    • Positive: pain
  • Obrien’s test (to differentiate biceps tendinopathy from a SLAP tear)
    • Patient in 90 degrees shoulder flexion, slight horizontal adduction, pronation, internal rotation
    • PT applies resistance downward
    • Positive: pain, possibly a click
      • After: Place patient in supination and apply resistance downward, patient should feel better
      • Pt will have less pain when in neutral forearm position compared to when they are fully pronated, as well

Differential Diagnosis

  • Pain is usually at the origin, so you have to rule out rotator cuff tendons
    • Palpate for bicipital groove between greater and lesser tubercles
      • Biceps sits here
      • Could also be palpating some of supraspinatus at this location
  • Impingement
    • Biomechanics
    • Supraspinatus impingement
    • Subacromial bursa impingement
    • Remember: many pts don’t have a great sense of pain within centimeters, so they may be having subacromial pain (hard to localize)
  • Labral tear
    • Long head of biceps inserts into the superior labrum
  • Gallbladder
    • Referred pain to right shoulder (opposite of heart attack, which is left)
  • Coracoid process will always hurt when palpated
    • 3 muscles attach here: short head of the biceps, coracobrachialis, pec minor
      • MMT’s, ROM for these muscles to determine if it is one of these three muscles  

Causes:

  • Overhead sports
    • Eccentric phase for pitchers
  • Lifting too-heavy of weights
  • Multiple corticosteroid injections in shoulder

Treatment examples:

  • Treat like any other tendinopathy
  • Strengthening
  • Restoration of ROM
  • Pt may be on NSAIDS (decrease inflammation)
  • Postural retraining
    • Biceps may be at a bad angle, pt will overuse it while doing overhead activities
  • Surgery
    • Precautions: no contractions of biceps, stay out of external rotation
      • Relatively the same precautions as rotator cuff surgery

How can it look on the test?

After a SLAP lesion you are seeing a patient S/P @ 1 week, what treatment would you implement

  1. Active ROM into external rotation
  2. Strengthen scapular stabilizers
  3. Joint mobilizations to increase glenohumeral extension
  4. Isometric biceps exercises