Biceps Pathologies

Question 1

Shoulder Bicipital Pathologies:

• Classifications = ?

4

Bicep Pathologies

Answer 1

Shoulder Bicipital Pathologies - Classifications:

(1) Bicipital Tendonitis

(2) Proximal Bicipital Tear

(3) Biceps Tenodesis

(3) Biceps Tenotomy

Question 2

Shoulder Bicipital Pathologies - Characteristics:

• Pain Pattern = ?
• Risk Factors = ?
• Observations = ?
• Examinations = ?

Bicep Pathologies

Answer 2

Shoulder Bicipital Pathologies - Characteristics:

(a) Pain Pattern:

• Anterior/Superior Shoulder Pain
• Possible Painful Arc of motion 60-120d abduction.
• Pain but minimal weakness.
• Pain will be with shoulder flexion NOT abduction.
• Pain worse with activity.

(b) Risk Factors:

• Under 20 up to 40 Years Old
• After 40 typically RTC involvement is co-occurring with impingement
• Overhead activities
• Increase in UE activities

(c) Observations:

• Possible limited scapular upward mobility.
• Superior/Anterior translation of humeral head.
• Kyphotic Posture or limited thoracic mobility.

(d) Examinations:

• (+) Biceps Test
• Upper Cut Test
• Yergason’s test
• Speeds test

Question 3

Shoulder Bicipital Pathologies - Manual Therapy:

• Joint Mobiization = ?
• STM/MFR = ?
• PNF = ?

Bicep Pathologies

Answer 3

Shoulder Bicipital Pathologies - Manual Therapy

(a) Joint Mobiization:

• Inferior/Posterior, Tractional GH Mobilizations.
• AC and SC mobs
• Cervical & Thoracic mobilization
• Hyper or Painful = Grade I/II
• Hypo = Grade III/IV/V

(b) STM/MFR:

• Cross Frictional Pin and Stretch to Biceps, RTC, Pecs/Traps.

(c) PNF:

• PNF diagonal ROM/stretching
• Multiple angle isometrics with humeral head control/centering.
• Contract relax stretching for improved mobility utilizing PNF.
• Increase speed with PNF for quick reversals from muscle groups and multiplanar activities.

Question 4

Shoulder Bicipital Pathologies - Therapeutic Exercise:

Bicep Pathologies

Answer 4

Shoulder Bicipital Pathologies - Therapeutic Exercise:

(a) Motor:

• Scapular mobility for improved upward rotation
• Eccentric shoulder/bicep activities.
• RTC Strengthening endurance/reactivation.
• Isometrics, Theraband isotonics, weights, single plane progressing to multiple plane endurance.
• Scapular Muscular Strengthening
• All Trapezius muscles, serratus, and rhomboids for improved scapular mobility and control.
• Improved mobility of T-spine in all planes especially extension and rotation.

(b) Sensory:

• Body blade
• Rhythmical stabilization
• Humeral head control to prevent anterior and superior migration.
• Undermining/challenging postural stability as progression.

Question 5

What do Bicep Pathologies in shoulder patients sound like in a patient interview?

Bicep Pathologies

Answer 5

Bicep Pathologies in shoulder patients sound like in a patient interview?

• A mix of Labral Symptoms or RTC-like symptoms.
• • Biceps attaches to the top of the labrum so it can lead to labral dysfunction.
• • Bicep Tendonopathy may present similar to RTC pathology.
• Bicep is shoulder flexor so dysfunction with overhead activities.
• Pain in anterior/superior aspect of the shoulder.
• Popping (superficial/anterior not the deep/clunking associated with labrum).
• Lump in arm (older patient).
• Pain with lifting overhead activities in younger adults.

Question 6

Biceps Tendonitis / Biceps Rupture:

• Prevalence = ?

Bicep Pathologies

Answer 6

Biceps Tendonitis / Biceps Rupture - Prevalence:

Question 7

Biceps Tendonitis / Biceps Rupture:

• Symptoms = ?

Bicep Pathologies

Answer 7

Biceps Tendonitis / Biceps Rupture - Symptoms:

Question 8

Biceps Tendonitis / Biceps Rupture:

• DSM/Signs = ?

Bicep Pathologies

Answer 8

Biceps Tendonitis / Biceps Rupture - Signs:

Question 9

Biceps Tendonitis / Biceps Rupture:

• TBC/Special Test = ?

Bicep Pathologies

Answer 9

Biceps Tendonitis / Biceps Rupture - Special Test:

Question 10

Biceps Test = ?

Bicep Pathologies

Answer 10

Biceps Test:

• Biceps Tendon Palpation
• Movement: The clinician palpates
• The origin of the long head of the biceps.
• Assessment: A test is (+) if the palpation reproduces the client’s pain.

Question 11

Upper Cut Test = ?

Bicep Pathologies

Answer 11

Upper Cut Test:

• The patient assumes a standing position.
• The patient is instructed to extend his/her elbow and fully supinate the forearm.
• The examiner, standing in front of the patient, resists shoulder flexion from zero to 60 degrees.
• Positive Test: If the patient localizes concordant pain to the bicipital groove.

Physiotutors Video

Question 12

Yergason’s Test = ?

Bicep Pathologies

Answer 12

Yergason’s Test:

• Primarily a test of the transverse humeral ligament for long head of biceps.
• Pt elbow flexed to 90, forearm pronated.
• Examiner resisted supination, lateral rotation, and in some cases elbow flexion.
• Postive Test: Pain, popping of the biceps tendon with pain.

CR Video

Question 13

Speed’s Test = ?

Bicep Pathologies

Answer 13

Speed’s Test (Biceps or Straight-Arm Test):

• The patient assumes a standing position.
• The patient is instructed to extend his/her elbow and fully supinate the forearm. The examiner, standing in front of the patient, resists shoulder flexion from zero to 60 degrees.
• If the patient localizes concordant pain to the bicipital groove, the test is positive.

CR Video

SP = .61
SN = .32

Question 14

Biceps Pathologies:

• Tendinopathy / Tendonosis = ?

Bicep Pathologies

Answer 14

Biceps Pathologies:

Tendinopathy/Tendonosis:

• Degenerative changes in the collagen matrix, hypercellularity, hypervascularity with an absence of inflammatory cells.
• Realize the connection of the biceps to the superior labrum makes it a potential generator of labral dysfunction (SLAP).

Question 15

Cluster for Biceps = ?

Bicep Pathologies

Answer 15

Cluster for Biceps:

Question 16

Arthroscopic view of bicep pathology

Click to view

Bicep Pathologies

Answer 16

Question 17

Biceps Repairs:

• Biceps tenotomy = ?
• Biceps tenodesis = ?

Bicep Pathologies

Answer 17

Biceps Repairs:

(a) Biceps tenotomy:

• If cosmesis isn’t an important factor the tendon can simply be released.

(b) Biceps tenodesis:

• If the tendon is reattached (biceps tenodesis) then therapy needs to follow the surgeon protocol of 4-8 weeks of protection during the reattachment phase.

Question 18

Rehab for Proximal Biceps Dysfunction = ?

Bicep Pathologies

Answer 18

Rehab for Proximal Biceps Dysfunction:

• PROM, AAROM during the early post-op period.
• • Progress into AROM and then strengthening with avoidance of higher loads until 6 months.
• Scar tissue management manually or with instrument.
• Bicipital tendinopathy will benefit from eccentric loading and biomechanically corrections of the GH joint and scapular rhythms.
• Cross friction, ART, and soft tissue mobilization can assist in healing of the affected tissue.

Question 19

Manual Therapy for Bicipital pathologies = ?

Bicep Pathologies

Answer 19

Manual Therapy for Bicipital pathologies:

• Cross friction to the biceps.
• Rhythmic stabilization PNF activities for control of biceps tendon as well as it’s connection to the labrum.
• Address scapular immobility’s with scapular mobilizations.

Question 20

Take Home message about Bicipital Pathologies

Flip and Read

Bicep Pathologies

Answer 20

Take Home message about Bicipital Pathologies:

(A) Three main types of bicipital pathologies:

• Complete tears of proximal biceps which are fairly rair.
• Long-term dysfunction / impingement / tendinosis of the biceps associated with co-occuring cuff and labral damage.
• Acute bicipital tendonitis as an isolated pathology that will behave similar to acute bursitis only has associated clicking and popping of the biceps tendon.

(b) Treat bicipital pathologies in a similar manner to all other shoulder pathologies by treating the impairments with the only difference being an increase emphasis on shoulder flexion/eccentric shoulder flexion and a shift of the manual therapies to the anterior aspect of the shoulder.