Bicipital Tendinitis: And Physiotherapy Exercise

Bicipital Tendinitis 

Biceps tendinitis is inflammation of the tendon around the long head of the biceps muscle.

Biceps tendinitis is a common injury that occurs when the muscles and connective tissues of the arm become inflamed and swollen due to overuse. The biceps muscle is located in the upper arm, and it helps with both flexion and rotation of the shoulder joint. The tendons that attach the biceps muscle to the bones of the shoulder are also susceptible to injury, which can lead to biceps tendinitis.

Overview:

Biceps tendinosis is caused by degeneration of the tendon from athletics requiring overhead motion or from the normal aging process.

Inflam-mation of the biceps tendon in the bicipital groove, which is known as primary biceps tendinitis, occurs in 5 percent of patients with biceps tendinitis.

Biceps tendinitis and tendinosis are commonly accompanied by rotator cuff tears or SLAP (superior labrum anterior to posterior) lesions. Patients with biceps tendinitis or tendinosis usually complain of a deep, throbbing ache in the anterior shoulder. Repetitive overhead motion of the arm initiates or exacerbates the symptoms. 

The most common isolated clinical finding in biceps tendinitis is bicipital groove point tenderness with the arm in 10 degrees of internal rotation. Local anesthetic injections into the biceps tendon sheath may be therapeutic and diagnostic. Ultrasonography is preferred for visualizing the overall tendon, whereas magnetic resonance imaging or computed tomography arthrography is preferred for visualizing the intraarticular tendon and related pathology. 

Conservative management of biceps tendinitis consists of rest, ice, oral analgesics, physical therapy, or corticosteroid injections into the biceps tendon sheath. Surgery should be considered if conservative measures fail after three months, or if there is severe damage to the biceps tendon.

Anatomy and Physiology:

The long head of the biceps tendon rises from the supraglenoid tubercle and the superior glenoid labrum. 

The proximal portion of the long head of the biceps tendon is extrasynovial but intra-articular.
5 The tendon travels obliquely inside the shoulder joint, across the humeral head anteriorly, and exits the joint within the bicipital groove of the humeral head beneath the transverse humeral ligament.
 

The bicipital groove is defined by the greater tuberosity (lateral) and the lesser tuberosity (medial). The biceps tendon is contained in the rotator interval, a triangular area between the subscapularis and supraspinatus tendons at the shoulder (Figure 1). The rotator interval is responsible for keeping the biceps tendon in its correct location.6–8 Because the rotator interval is usually indistinguishable from the rotator cuff and capsule, lesions of the biceps tendon are usually accompanied by lesions of the rotator cuff.

SLAP lesions are often present in patients with biceps tendinitis and tendinosis. The anterosuperior labrum and superior labrum are more likely to tear than the inferior portion of the labrum because they are not attached as tightly to the glenoid.9–13 Additionally, certain conditions that affect the glenohumeral joint may also involve the biceps tendon because it is intra-articular. These may include rheumatologic (e.g., rheumatoid arthritis, lupus), infectious, or other types of reactive or inflammatory conditions.

Symptoms:

Bicipital Tendinitis 

Patients with biceps tendinitis often complain of a deep, throbbing ache in the anterior shoulder. The pain is usually localized to the bicipital groove and may radiate toward the insertion of the deltoid muscle, or down to the hand in a radial distribution.

This makes it difficult to distinguish from pain that is secondary to impingement or tendinitis of the rotator cuff, or cervical disk disease. Pain from biceps tendinitis usually worsens at night, especially if the patient sleeps on the affected shoulder.

Repetitive overhead arm motion, pulling, or lifting may also initiate or exacerbate the pain.9 The pain is most noticeable in the follow-through of a throwing motion.3 Instability of the tendon may present as a palpable or audible snap when range of motion of the arm is tested.

Rupture of the biceps tendon is one of the most common musculotendinous tears. If the biceps has ruptured, patients will describe an audible, painful popping, followed by relief of symptoms. The anterior shoulder may be bruised, with a bulge visible above the elbow as the muscle retracts distally from the rupture point. Risk factors of biceps rupture include a history of rotator cuff tear, recurrent tendinitis, contralateral biceps tendon rupture, rheumatoid arthritis, age older than 40 years, and poor conditioning.9 If a patient has a feeling of popping, catching, or locking in the shoulder, a SLAP lesion may be present. This usually occurs after trauma, such as a direct blow to the shoulder, a fall on an outstretched arm, or repetitive overhead motion in athletes.

The most common finding of biceps tendon injury is bicipital groove point tenderness.


PHYSICAL EXAMINATION:

Many provocative tests (i.e., Yergason, Neer, Hawkins, and Speed tests) have been developed to isolate pathology of the biceps tendonhowever, because these tests create impingement underneath the coracoacromial arch, it is difficult to rule out concomitant rotator cuff lesions.

The Yergason test requires the patient to place the arm at his or her side with the elbow flexed at 90 degrees, and supinate against resistance18 (Figure 2). The test is considered positive if pain is referred to the bicipital groove.

The Neer test involves internal rotation of the arm while in the forward flexed position16. If the patient experiences pain, it is a positive sign of impingement syndrome.

During the Hawkins test, the patient flexes the elbow to 90 degrees while the physician elevates the patient's shoulder to 90 degrees and places the forearm in a neutral position19 (Figure 4). With the arm supported, the humerus is rotated internally. The test is positive if bicipital groove pain is present.


Speed test, the patient tries to flex the shoulder against resistance with the elbow extended and the forearm supinated9,20 (Figure 5). A positive test is pain radiating to the bicipital groove. If any of these tests is positive, it indicates that impingement is present, which can lead to biceps tendinitis or tendinosis.

Advantages and Disadvantages of Radiologic Imaging Studies in the Evaluation of Biceps Tendinitis.

IMAGING STUDY : 

Arthrography (used with MRI or CT to visualize the joint capsule and glenoid labrum)

ADVANTAGES

CT arthrography shows biceps tendon subluxations, ruptures, dislocations, and SLAP lesion
MRI arthrography is preferable for diagnosing biceps lesions and SLAP lesions14 because the agreement between MRI and arthroscopy for biceps lesions is only 37 percent and 60 percent for rotator cuff lesions

DISADVANTAGES

Invasive
Filling of the biceps tendon sheath is unreliable
Sharp images of the tendon may be lost

Ionizing radiation
Bicipital groove view radiography

ADVANTAGES

Shows the width and medial wall angle of the bicipital groove, spurs in the groove, and supertubercular bone spur or ridge
Inexpensive

DISADVANTAGES

Does not show possible intra-articular disorders of the labrum (soft tissue injuries)

MRI

ADVANTAGES

Excellent evaluation of the superior labral complex and biceps tendon

DISADVANTAGES

Partial tears of the biceps tendon are more difficult to detect than complete ruptures
Expensive
Poorly 

Treatment :


CONSERVATIVE:

Biceps tendinitis or tendinosis may respond to analgesia with nonsteroidal anti-inflammatory drugs (NSAIDs).

Physiotherapy Treatment:

Bicipital Tendinitis And Exercise

Ice, rest from overhead activity, or physical therapy. Rehabilitation of an athlete's shoulder involves four phases:

Rest; stretching exercises of the scapula, rotator cuff, and posterior capsule; 

The goal of stretching is to regain a balanced range of motion without stiffness or pain in any position.

Taping Over Biceps Give Great Relief From Pain And Allow Smooth Movement.

Tapping in Bicipital Tendinitis

Strengthening and a progressively difficult throwing program.
The patient may begin exercises after the shoulder is pain-free.

Strengthening Exercise Of Biceps Muscle

Tennis Elbow And Physiotherapy Treatment :

LATERAL EPICONDYLITIS ( TENNIS ELBOW ) :

Tennis Elbow 

Tennis elbow, or lateral epicondylitis, is a painful condition of the elbow caused by overuse.
Tennis elbow is an inflammation of the tendons that join the forearm muscles on the outside of the elbow. The forearm muscles and tendons become damaged from overuse — repeating the same motions again and again. This leads to pain and tenderness on the outside of the elbow.
There are many treatment options for tennis elbow. In most cases, treatment involves a team approach. Primary doctors, physical therapists, and, in some cases, surgeons work together to provide the most effective care.

ANATOMY: 

Anatomy Of Muscle And Joint

Elbow joint is a joint made up of three bones: upper arm bone (humerus) and the two bones in forearm (radius and ulna). There are bony bumps at the bottom of the humerus called epicondyles. The bony bump on the outside (lateral side) of the elbow is called the lateral epicondyle.
Muscles, ligaments, and tendons hold the elbow joint together.
Lateral epicondylitis, or tennis elbow, involves the muscles and tendons of forearm. Forearm muscles extend wrist and fingers. Forearm tendons — often called extensors — attach the muscles to bone. They attach on the lateral epicondyle. The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

CAUSES:

• Overuse.
• Activities.
• Age.
• Unknown.

PAIN PHASES:

• Phase 0: No pain or soreness. 
• Phase 1: Soreness after activity, usually gone in twenty-four hours.
• Phase 2: Mild stiffness and soreness before activity which disappears with warm-up. No pain during activity, but mild soreness after activity that disappears within 24 hours. 
• Phase 3: Mild/moderate stiffness and soreness plus mild pain during activity which does not alter activity.
• Phase 4: Pain during activity which alters activity.
• Phase 5: Constant pain even at rest.

SYMPTOMS:

• Diffuse achiness.
• Morning stiffness.
• Occasional night pain.
• Dropping of objects/ weak grip strength.
• Pain with palpation of lateral epicondyle.
• Pain with active or resisted extension.
• Pain with grasping objects with the effected hand.
• Pain or tenderness on the outer side of the elbow.
• Pain when you straighten or raise your wrist and hand.
• Pain made worse by lifting a heavy object.
• Pain when you make a fist, grip an object, shake hands, or turn door handles.
• Pain that shoots from the elbow down into the forearm or up into the upper arm.

CONTRIBUTING FACTORS:

• Weak muscles.
• Overuse- playing or working with excessive and repetitive forceful gripping.
• Gripping while extending or twisting of the wrist.
• Racquets/ tools that are too heavy or unbalanced.
• Improper equipment- incorrect grip size, strings too tight.
• poor playing technique- too much wrist action, jerky strokes, poor ball contact.

DIAGNOSIS:

X-rays.
MRI.
EMG.

PHYSICAL THERAPY EXAMINATION:

Examination Of Patient

Cozen's test:

Resistive Tennis Elbow Test:The patient sits with the examiner stabilizing the involved elbow while palpating the lateral epicondyle With a closed fist, the patient pronates and radially deviates the forearm and extends the wrist against the examiner’s resistance”. A positive result would be if there is pain along the lateral epicondyle or objective muscle weakness.

TREATMENTS:

Tapping Technique In Tennis Elbow

Medication: Anti-inflammatory medication helps to reduce pain.
Steroid Inection:  Steroids, such as cortisone, are very effective anti-inflammatory medicines.
Rest: You may have temporarily stop the aggravating activity. A period of rest is most important to allow the injury a chance to heal. You will make the condition worse by continuing the activity that cause the injury, especially if you experience pain. Avoid heavy liftting or carrying opening doors or repeatedly shaking hands.
Ice: Apply cold to your elbow three times a day for 20 to 30 minutes at a time in the early painful stage and for 20 minutes after active use of arm. Protect skin by putting a towel between elbow and the ice bag.
Brace: A counter force brace which is and elastic strap that is worn 1-2 inches below the elbow. This type of brace gives compression to the forearm muscle and helps lessen the force that the muscle transmits to the tendon.
Modalities:
Interferential current.
Ultrasound.
Cold pack.
Laser therapy.

Physiotherapy Exercises:

Physiotherapy Treatment in Tennis Elbow

Exercise Of Grip Muscle 

• Resisted wrist extension.
• Resisted wrist flexion.
• Resisted forearm supination and pronation.
• Wrist flexor stretch.
• Wrist extensor stretch.
• Finger extension.
• Hand squeeze.

Strengthening Exercise Using Weight 

Exercise in Tennis Elbow

Wrist range of motion: Bend your wrist forward and backward as far as you can. Repeat 10 times. Do 3 sets.
Forearm range of motion: With your elbow at your side and bent 90 degrees, bring your palm facing up and hold for 5 seconds then slowly turn your palm facing down and hold for 5 seconds. Repeat 10 times. Do 3 sets. Make sure you keep your elbow bent at 90 degrees throughout this exercise.
Elbow range of motion: Gently bring your palm up toward your shoulder and bend your elbow as far as you can. Then straighten your elbow out as far as you can. Repeat 10 times. Do 3 sets
Forearm pronation and supination: Hold a soup can or hammer handle in your hand, with your elbow bent 90 degrees. Slowly rotate your hand with palm upward and then palm down. Repeat 10 times. Do 3 sets.
Wrist extension: Stand up and hold a broom handle in both hands. With your arms at shoulder level, elbows straight and palms down, roll the broom handle backward in your hand as if you are reeling something in using the broom handle. Repeat for 1 minute and then rest. Do 3 sets.
Wrist strengthening.
(1) Wrist flexion: Holding a soup can or hammer handle with your palm up, slowly bend your wrist up. Slowly lower the weight and return to the starting position. Repeat 10 times. Do 3 sets. Gradually increase the weight of the can you are holding.
(2) Wrist extension: Holding a soup can or hammer handle with your palm down, gently bend your wrist up. Slowly lower the weight and return to the starting position. Repeat 10 times. Do 3 sets. Gradually increase the weight of the can you are holding.
(3) Wrist radial deviation: Hold your wrist in the sideways position with your thumb up. Holding a can of soup or . hammer handle, gently bend your wrist up with your thumb reaching towards the ceiling. Slowly lower to the starting position. Do not move your forearm throughout this exercise. Repeat 10 times. Do 3 sets.
Elbow rehabilitation program:
A gradual progression of the exercises is extremely important. Although they may seem easy at first you must follow the enclosed steps closely to prevent an increase or re-aggravation of your symptoms. Before beginning the strengthening exercises you should warm-up your body to a light sweat. Try 3 to 5 minutes of brisk walking, cycling, jogging etc. Do exercises only once a day: more is not better and can re-aggravate your symptoms. Wear the Count’R-Force brace if advised by your therapist or if you experience pain while performing the exercises. Do each exercise at its own rate. You will achieve higher weights faster on some exercises than others. Do each exercise properly and slowly do not work through peavierain.

Stage 1 Exercises:

Keep your elbow bent to 90 degrees. If this is  painful lean forward and bend your elbow even more. Your forearm should be well supported on your thigh or a table.
Begin with no weight, doing 10 to 15 repetitions for each exercise.
Slowly progress the repetitions in sets of 10, every few days as your elbow allows until you are comfortably doing 3 sets of 10 repetitions for 2 consecutive days without increasing your symptoms.
Increase to a one-pound weight (a small can of soup works well). Go back to 10 to 15 repetitions for each exercise.
Slowly work up to 3 sets of 10 repetitions again.
Increase to a two-pound weight and again cut back to 10 to 15 repetitions.
Slowly progress to  3 sets of 10 repetitions.
Continue this gradual progression until you are using a three-pound weight for 3 sets of 10 repetitions without increasing your symptoms.
Progress to next stage as able.

Stage 2 Exercises:

Rubber band and squeeze exercises:
Begin with your elbow bent at your side and progress by performing the exercises with your arm straight out in front of you as able. You should do these two exercises several times a day, every day. It is a good idea to have a ball and rubber band in convenient places like in your car, at your desk, or by the television. Be careful not to overdo these exercises as they can increase your pain.
Ice after exercises.


Related Other Article  :

Bicipital Tendinitis Exercise