Bicipital tendinitis

[sanagupta]

Hi!
I have patient with 6 months history of stretch in anteriolateral surface of left arm..diagonsed as Bicipital tendinitis.
What r the possible line of treatments ..I m sing US and stimulation
Regards
Sana

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[Physiobase]

Can you explain the mechansim of injury in a bit more detail? If it is a boney insertion issue then you should treat it as such. Sometimes frictions can assist to stimulate more healing by inducing a more sub-acute situation. If it is capsular perhas they should be prevented from going into end of range extension (painful) for a period of time.

Let's discuss the possible injury cause and effect first

[alophysio]

Hi!

More information please!

However, after 6 months of the pain, i doubt U/S or TENS is going to do anything.

Perhaps some eccentric biceps curls in good posture, check and treat the T/S so normal kyphosis present - then scap will be in better position and less tension on the GH joint.

Perhaps check C5 for neck involvement.

Let us know

[sanagupta]

Hi!
thanx for ur replies...there is no history of injury...it was slow onset stretch on anteriorlateral aspect of elbow..MRI revealed mild inflammation at intertubercular sulcus around bicipital tendon.
Sana

[Physiobase]

slow onset stretch

How?8o

[sanagupta]

Hello!
terminology was wrong due to lack of time ,slow onset means that there is no stretch on movement with momentum in abduction...but present wen done slowly at 75 degrees.
Sana

[sdkashif]

Have a look over that information resource for more information.

Therapeutic Exercises- Shoulder and shoulder girdle problems

[ramleo]

Hi,
If there is no history of injuries, We can look into his lifestyle. What is his occupation? IS he an athlete? If he is look into his technique of training, if he did any weights.

If not, As its a chrinic condition, continue the previous physical therapy and Avoid aggravating factors.

Also look for other causes or predisposing factors, such as bony abnormalities, labral pathology, and radiculopathy.

Other Treatment (injection, manipulation, etc.):

Injection with anesthetic and corticosteroid into the biceps tendon sheath.

Myofascial trigger point injections in the parascapular muscles may be beneficial. This technique uses an injection with dilute local anesthetic.

Manipulation may be helpful, especially for first rib abnormalities that contribute to the syndrome.

Lithotripsy is under study for Achilles tendonitis and patellar tendonitis; the results are promising thus far. Studies on bicipital tendinitis are pending.

Educate the patient about using proper body mechanics to prevent recurrent injury (eg, pitching techniques, lifting techniques). Advocate regular stretching before and after exercise.

Cheers.

[sanagupta]

Hello!
Thanx for ur replies.
the patient is from marketing....not an athelete.The current status has changed...after i gave him US in stretched position At Stretch area (elbow)..the stretch has reduced to almost nil may be 5% but the patient complains pain at shoulder at end range abduction and and rotations???
Stretch what so ever is present, is on first rep.
Regards
sana

[neurospast]

I think it is rather strange if there is no obvious onset of the problem. The reason is that in case there is no time of onset the chance of the problem being of muscular origin is marginal. The change of the symptoms might well have to do with the position you have been stretching (nerve stretch? ala Butler?) and not by the use of ultrasound. In cases where the cause is unknown one has to be suspecting nerve involvement and to be honest after a period of 6 months a pure muscular problem would have settled most of the time.
Have you checked the mobility of the spine? Thoracic as well as Cervical? Have you performed the different Upper Limb Tension tests ala Butler? The reason you have to do this is that a malfunction (e.g. impingement) may lead to an inflamation. That would mean you are purely treating symptoms and effect would have his origin within placebo margins.
Cheers

[arkesh_physio]

hi,
i believe Cx involvement should be screened out.it could be due to C5 involvement.
proper postural guidence is very important.
what do the PAIVMS of Cx reveal?

[sanagupta]

hi! thanx for ur valuable replies.can u please tell me what does PAIVMS stands for?
cervical spine is clear with neural tests negative except that on rotations he feels stretch...
At pesent his pain at shulder is improving but at very slow scale and the stretch pain is only on rotations and if i give MF at the stretch area in rotations the pain subside but there is increase in pain at the shoulder.....
Regards
sana

[sdkashif]

A suggested treatment plan will be as follows:

Management: Protection Phase

Control Inflammation and Promote Healing

Use modalities and low-intensity cross-fiber massage
to the site of the lesion. While applying the
modalities position the extremity to maximally
expose the involved region.
Support the arm in a sling for rest.

Patient Education

The environment and habits that provoke the symptoms
must be modified or avoided completely during
this stage.

Maintain Integrity and Mobility of the Soft Tissues

Initiate early motion with passive, active-assistive,
or self-assisted ROM.
Apply multiple-angle muscle setting and protected
stabilization exercises. Of particular importance
in the shoulder is to stimulate the stabilizing
function of the rotator cuff, biceps brachii,
and scapular muscles at an intensity tolerated by
the patient.

Use caution with exercises in this stage to avoid
the impingement positions, which are often in the
midrange of abduction or end-range position
when the involved muscle is on a stretch.

Control Pain and Maintain Joint Integrity.

Use pendulum exercises without weights to cause
pain-inhibiting grade II joint distraction and oscillation
motions.

Develop Support in Related Regions

Teach the patient postural awareness and correction
techniques.
Initiate training of scapular and thoracic posture
using shoulder strapping or scapular taping, tactile
cues, and use of mirrors for reinforcement.
Repetitive practice of correct posture is necessary
throughout the day.
Forward head posture is often related to forward
shoulder posture.

Management: Controlled Motion Phase

Once the acute symptoms are under control, the
main emphasis becomes use of the involved region
with progressive, nondestructive movement and
proper mechanics while the tissues heal. The
components of the desired functions are analyzed
and initiated in a controlled exercise program.
If there is a functional laxity in
the joint, the intervention is directed toward learning
neuromuscular control of and developing
strength in the stabilizing muscles of both the
scapula and glenohumeral joint. If
there is restricted mobility that prevents normal mechanics
or interferes with function, mobilization of
the restricted tissue is performed.

Patient Education

Patient adherence with the program and avoidance
of irritating the healing tissue are necessary. The
home exercise program is progressed as the patient
learns safe and effective execution of each exercise.
Develop a Strong, Mobile Scar
Position the tissue on a stretch if it is a tendon or
in the shortened position if it is in the muscle
belly and apply cross-fiber or friction massage to
the tolerance of the patient.

Follow this with an isometric contraction of the
muscle in several positions of the range and at an
intensity that does not cause pain.

Teach the patient how to self-administer the massage
and isometric techniques.

Improve Postural Awareness

Continue to reinforce proper postural habits. Every
time an exercise is performed, make the patient
aware of scapular and cervical posture with tactile
and verbal reinforcement such as touching the
scapular adductors and chin and reminding the patient
to “pull the shoulders back” and “lift the head”
while doing the shoulder exercises.

Modify Joint Tracking

Mobilization with movement (MWM) may be useful
to modify joint tracking and reinforce full movement
when there is painful restriction of shoulder elevation
because of a painful arc or impingement.

Posterolateral glide with active elevation

• Patient position and procedure: Sitting with the
arm by the side and head in neutral retraction.
Stand on the side opposite the affected arm and
reach across the patient’s torso to stabilize the
scapula with the palm of one hand. The other
hand is placed over the anteromedial aspect of
the head of the humerus.

• Apply a graded posterolateral glide of the
humeral head on the glenoid. Request that the
patient perform the previously painful elevation.
Maintain the posterolateral glide mobilization
throughout both elevation and return to neutral.
Ensure no pain is experienced during the procedure.
Adjust the grade and direction of the glide
as needed to achieve pain-free function.

• Add resistance in the form of elastic resistance or
a cuff weight to load the muscle.
Self-treatment. A mobilization belt provides the
posterolateral glide while the patient actively elevates
the affected limb against progressive resistance
to end range.

Develop Balance in Length and Strength
of Shoulder Girdle Muscles

Design a program that specifically addresses the patient’s
limitations. Typical interventions in the shoulder
girdle include but are not limited to:

Stretch shortened muscles. These typically include
the pectoralis major, pectoralis minor, latissimus
dorsi and teres major, subscapularis, and
levator scapulae.

Strengthen and train the scapular stabilizers.
These typically include the serratus anterior and
lower trapezius for posterior tipping and upward
rotation and the middle trapezius and rhomboids
for scapular retraction. It is important that the patient
learns to avoid scapular elevation when raising
the arm. Therefore, practice scapular depression
when abducting and flexing the humerus.
Strengthen and train the rotator cuff muscles,
especially the shoulder lateral rotators.

Develop Co-Contraction, Stabilization, and Endurance
in the Muscles of the Scapula and Shoulder
Isolate the scapular muscles in open-chain positions
(side-lying, sitting, supine) and apply alternating
isometric resistance to protraction/
retraction, elevation/depression, and upward/
downward rotation so the patient learns to stabilize
the scapula against the outside forces.

Combine scapular and glenohumeral patterns
with the humerus in various positions of flexion,
abduction, and rotation and apply alternating isometric
resistance while the patient holds against
the changing directions of the resistance force.

Closed-chain stabilization is performed with the
patient’s hands fixated against a wall, a table, or
the floor (quadruped position) while the therapist
provides a graded, alternating isometric resistance
or rhythmic stabilization. Observe for abnormal
scapular winging. If it occurs the scapular
stabilizers are not strong enough for the demand;
so the position should be changed to reduce the
amount of body weight.

Increased muscular endurance by increasing the
amount of time the individual holds the pattern
against the alternating resistance. The limit is
reached when any one of the muscles in the pattern
can no longer maintain the desired hold. The
goal at this phase should be stabilization for approximately
3 minutes.

Modify Joint Tracking

Mobilization with movement (MWM) may be useful
to modify joint tracking and reinforce full movement
when there is painful restriction of shoulder elevation
because of a painful arc or impingement110.

Posterolateral glide with active elevation

• Patient position and procedure: Sitting with the
arm by the side and head in neutral retraction.
Stand on the side opposite the affected arm and
reach across the patient’s torso to stabilize the
scapula with the palm of one hand. The other
hand is placed over the anteromedial aspect of
the head of the humerus.

• Apply a graded posterolateral glide of the
humeral head on the glenoid. Request that the
patient perform the previously painful elevation.
Maintain the posterolateral glide mobilization
throughout both elevation and return to neutral.
Ensure no pain is experienced during the procedure.
Adjust the grade and direction of the glide
as needed to achieve pain-free function.

• Add resistance in the form of elastic resistance or
a cuff weight to load the muscle.
Self-treatment. A mobilization belt provides the
posterolateral glide while the patient actively elevates
the affected limb against progressive resistance
to end range.

Develop Balance in Length and Strength
of Shoulder Girdle Muscles

Design a program that specifically addresses the patient’s
limitations. Typical interventions in the shoulder
girdle include but are not limited to:

Stretch shortened muscles. These typically include
the pectoralis major, pectoralis minor, latissimus
dorsi and teres major, subscapularis, and
levator scapulae.

Strengthen and train the scapular stabilizers.

These typically include the serratus anterior and
lower trapezius for posterior tipping and upward
rotation and the middle trapezius and rhomboids
for scapular retraction. It is important that the patient
learns to avoid scapular elevation when raising
the arm. Therefore, practice scapular depression
when abducting and flexing the humerus.
Strengthen and train the rotator cuff muscles,
especially the shoulder lateral rotators.

Develop Co-Contraction, Stabilization, and Endurance
in the Muscles of the Scapula and Shoulder
Isolate the scapular muscles in open-chain positions
(side-lying, sitting, supine) and apply alternating
isometric resistance to protraction/
retraction, elevation/depression, and upward/
downward rotation so the patient learns to stabilize
the scapula against the outside forces.

Combine scapular and glenohumeral patterns
with the humerus in various positions of flexion,
abduction, and rotation and apply alternating isometric
resistance while the patient holds against
the changing directions of the resistance force.

Closed-chain stabilization is performed with the
patient’s hands fixated against a wall, a table, or
the floor (quadruped position) while the therapist
provides a graded, alternating isometric resistance
or rhythmic stabilization. Observe for abnormal
scapular winging. If it occurs the scapular
stabilizers are not strong enough for the demand;
so the position should be changed to reduce the
amount of body weight.

Increased muscular endurance by increasing the
amount of time the individual holds the pattern
against the alternating resistance. The limit is
reached when any one of the muscles in the pattern
can no longer maintain the desired hold. The
goal at this phase should be stabilization for approximately
3 minutes.

Progress Shoulder Function

As the patient develops strength in the weakened
muscles, develop a balance in strength of all shoulder
and scapular muscles within the range and tolerance
of each muscle. Increase coordination between
scapular and arm motions; dynamically load
the upper extremity within tolerance of the synergy
with submaximal resistance. Improve muscular endurance
and develop control from 1 to 3 minutes.

Management: Return to Function Phase

As soon as the patient has developed control of posture
and the basic components of the desired activities
without exacerbating the symptoms, initiate
specificity of training toward the desired functional
outcome.

Increase Muscular Endurance

Increase repetitive loading of defined patterns from
3 to 5 minutes.

Develop Quick Motor Responses to Imposed Stresses
Increase the speed at which the stabilization exercises
are applied.

Initiate plyometric training in both open- and
closed-chain patterns if power is needed.

Develop Function

Progress to specificity of training; emphasize timing
and sequencing of events.

Progress eccentric training to maximum load.
Simulate desired functional activities, first under
controlled conditions, then under progressively
challenged situations using acceleration/deceleration
drills.

Assess the total-body function while doing a desired
activity and modify any component that
causes faulty patterning.

Educate the Patient

Inform the patient of the time frames for healing and
any exercises and activities that can be done. Instruct
the patient on how to progress the program
when discharged as well as how to prevent recurrences.

[alophysio]

Hi

PAIVMs are Passive Accessory Intervertebral Movements
PPIVMs are Passive Physiological Intervertebral Movements
PAMs are Passive Accessory Movements

Good luck

[arkesh_physio]

passive accessory intervertebral movements(PAIVMS)

[sanagupta]

hi!
thanx for help.i tried as advised but it did not help much....at present the status has changed to pain in External rotation at shoulder...it seem something like PA shld now. but i m unable to understand the reason for his pain at shoulder....please help
sana:rolleyes

[arkesh_physio]

hi,
pls screen out the Cx again properly,bcz finding out the cause is imp first.
by the way whats his occupation,whether he does overhead activities frequently?
chk out 4 capsular pattern involvement.
i suggest a reassessment of the patient & don't rule out the psychological factor.
hoping a reply soon.
Regards,
ark..

[sanagupta]

Hi!
Cervical spine is clear with no significant finding. his work involves supervision so no overhead activity..unsure og psycological part
Sana

[arkesh_physio]

hi.
so u have screened out the Cx.
what do the spl tests of shldr including tests for instability reveal?
if u r not sure about it u can go for a MRI..

[sanagupta]

Hi!
The MRI only showed Bicipital tendinitis..special tests all negative now..
only problem that persist now is, as soon as he lifts his arm up..forward reach position there is pain 3/10 .if continues doing movement pain goes...
Help..how to go about now..
Regards
Sana

[alophysio]

Hi.

Try some scap stabillisation with "core activation" through the T/S (multifidus).

If he is getting pain on initiation of movement, it is usually because there is not a stable position for the joint to transfer the load therefore the tendon/stressed structure is bearing the load.

Try also some eccentric bicep curls without the concentric part (i.e. get the other hand to help lift the weight up). Then gradually move the weight further away with gradually less elbow flexion until you have the eccentric version of bringing your arm dwon from FF. Focus particularly on the last few degrees where he gets his pain. The eccentric exercise should help his control and stability and allow him to load up more than he can with concentric exercise.

Let us know how he goes

[arunja]

Hi

I dont think that its a Bisceps tendinitis, if the injury was the result of lateral tension , check for the ligaments or capsule. If so stimulation is not effective for strains or sprains. If its localised pain , laser will be effective along with ultrasound.

[syaz_uitm]

it is interferential therapy is an effective tretment for a patient with bicipital tendinitis?what else i can do for my patient with bicipital tendinitis?and can all of you try to help me in finding the articles for the treatment in bicipital tendinitis that can be used as evidence based for my case study presentation..