Biceps strain at MTJunction

[Jerram]

Background:
I am a neurologic PT with a minimal amount of orthopedic experience. I just wanted to share my story b/c I want get feedback on what my Ortho doc told me today as my treatment moves forward. I am 35 y/o with no hx of arm injury.

While working with a significantly debilitated MS patient about 7 weeks ago, I strained my biceps, triceps, and a portion of the rotator cuff (subscapularis from what my and my PT can best tell). Well, no diagnostic testing was done, I was referred to OP PT with official diagnosis (from the occupational medicine doctor at my hospital) of "biceps/triceps strain". In case you're wondering how I strained opposing muscles, it was simply a case of maximum isometric cocontraction while I tried to keep this poor woman from pushing herself (and me!) on to the floor.

Anyway, I had formal therapy for about 5 weeks with mixed results. The triceps seems pretty resolved, I still have very mild subscapularis pain at insertion. What is most troubling to me and my therapist is the lack of progress with the biceps. This was always my worst pain. I have regained full ROM with little to no pain but can't lift more than about a pound or tolerate yellow t-band exercises without pain. I've had iontophoresis, kinesiotaping, daily ice, and BID naproxen for to help control inflammation. I returned to the MD and reported my persistent biceps pain. I implored her to order an MRI, almost positive that I had to have a minor tear that just couldn't heal. An MRI was done 3 days ago and was looked at by 2 different radiologists who both agreed that the tendon was intact, including at the musculotendinous junction where my worst pain is. There is little to no local edema and no major scarring.
The Orthopedic specialist (very prominent and works with major league baseball players frequently, so I trust his opinion) told me today that its just a bad strain and that when these occur at the MTJ they tend to take a long, long time to heal. He encouraged me to plug away, confident that my tendon is intact. He told me to let the pain be my guide and continue use of ionto and/or naproxen if I think its helping me to tolerate treatment. He also encouraged me to have Active Release Techniques done if my therapist was skilled in it. (I don't know much about this)

So, I ask you: Does this sound like a plan going forward? What ever happened to exercise in a pain free range or exercise progression once pain free tolerance is established? Again, I'm not an orthopedic therapist but I just don't want to push too hard...or not enough. Any other interventions you can think of?

Did I mention that I'm still working full time? I'm limited to patients that require min assist or less as a precaution. But its kind of a pain in the #$% for me and my staff to work around.

Thanks in advance for your feedback!
I'm fairly new to the board and look forward to giving some of my own in areas I think I can contribute.

Jeremy

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[ginger]

Just get your physio to mobilise your cervical spine and there is a very good chance you will normalise the whole scenario. These kinds of problems commonly arise with exertion , where protective behaviour at your spine will cause ongoing referred pain. Sounds like your triceps got better by themselves , despite treatment.

[iliastolos]

Hi all!
Jeremy, I’m a bit confused about your signs and symptoms. You say that you have pain at the MT joint but the MRI doesn’t show anything there. At least that’s what I get from what you said. Moreover, the MD says that you have a bad strain. A bad strain would definitely be shown at an MRI, unless the strained area was not scanned at all. Please define the scanned area.
Secondly, you didn’t mention which MT joint is involved. Is it the distal one (at the elbow) or the proximal one (at the shoulder)? Remember that biceps has two tendons both at the shoulder and the elbow. And which motion is limited? Is it shoulder flexion/abduction/internal rotation/scapular elevation with shoulder externally rotated? Or is it elbow flexion/supination? And how about other motions at the shoulder or elbow? How about coupled motions as well? Furthermore, you said subscapularis was also involved. How’s its function now?
As for cervical assessment and/or treatment, I would suggest an assessment first, since the problem hasn’t resolved yet.
If you could give us more info about the initial assessment, MRI findings and current clinical situation, we could help more.
ilias

[iliastolos]

Jerram,
I must admit I'm still a bit confused. Since the proximal arm was scanned, no conclusion can be made radiographically about the distal part. Secondly, having pain at max ER at about the area of subscapularis insertion could also be that other structures might be involved, like glenohumeral ligaments or the capsule (maximally stretched at maximum ER). Since at onset you had pain with resisted ER and subscapularis is an internal rotator, it couldn't be involved. Perform manual muscle test for subscapularis (arm at the back and resisted IR) to rule this out. Infraspinatus and teres minor, both external rotators, could be involved, but again these attach to the greater tuberosity, not the lesser. And they are not the only external rotators. Therefore, shoulder rotation is kind of confusing concerning symptoms and area of pain.
A comment about biceps brachialis... biceps is a strong forearm supinator, stronger than elbow flexor. So, its muscle test should be focused on supination first (from full pronation to full supination with elbow flexed at 70-90 degrees) and elbow flexion then. At the shoulder joint, it flexes and slightly internally rotates it. So, if during shoulder flexion, ER and forearm supination you get pain at the anterior shoulder, then it could be biceps. With IR and pronation, you should feel less pain since it's anterior band of deltoid that works harder. Check again these movements (supination with elbow flexion-classical manual muscle test for biceps-, shoulder flexion with ER shoulder and supinated forearm-for biceps- and with IR shoulder and pronated forearm-for anterior deltoid) and inform us of the symptoms and area of pain.
ilias

[ginger]

I'd say you do have at least one "radicular"symptom, pain. when you "cleared "the neck,did you attempt passive movements of spinal facet joints unilateraly ? or was this with just active movement?. Most referred pain events will be missed if only active movements are tested, the lack of other nerve related symptoms is not an indicator for the prospect I suggest here of somatic referred pain to your bicep. The only way to discover the presence of these common neurlagias is to treat them as if present, by unilateral mobs , in this case , to C56. This can also be done AP.
Are you familiar with a method known as traction rotations ?

[iliastolos]

Jerram,
My fault about scanned area, I read 'proximal biceps region to the mid arm', not forearm as is correct. About biceps, forearm supination is performed by the radial attachment and the muscle as a whole, not long or short head. Therefore, there won't be any difference in pain intensity at the elbow if the problem is at the shoulder. There will be a difference at the shoulder though. So, assuming that the long head is involved and not the short, testing of supination won't clarify which head is injured. Testing of shoulder will do. I hope this was what you asked...
ilias