Diagnose please :)

[King]

Hi there,

For about 2 weeks now i have had this pain around my biceps brachii area on my left arm. It just came on one day when i was playing basketball, it is a sudden very sharp pain which comes on during external rotation of the shoulder while flexed to 90degrees. All movements are fine however if i start the movement in external rotation i can only get to 90degrees before the pain kicks in

Thanks for reading

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[ginger]

Have someone do AP glides on C5 in supine, this stands a good chance of reproducing neuralgia in the bicep, should the most common cause be present. Have him/her continue till the pain has gone to both C5 and the bicep. You will have an insight into the proposition that you have protective behaviour in your cervical spine with somatic referred pain as a result. This is by far the most likely and happily ,the easiest to fix.

[Physio Dace]

I'd be highly surprised that C5 mobs would eas the pain with shoulder external rotation - but who knows stranger things have happened - My knowledge of facet joint and disc somatic referral patterns (from early research) suggests the cervical spine doesn't refer in that way unless its a radiculopathy and then its usually more lateral than Kings area and lots of other signs would exist.

King is the pain aggravated when external rotation reaches 90deg or immediately when the shoulder is externally rotated. And by flexing the arm to 90deg is that to the front to side. At this point is sounds like a shoulder pathology but more info would be needed. Can you carry heavy things without pain; can you sleep on that shoulder; can you press on the pain with your finger; any noises with shoulder; can you reach up your back ok; can you do a push up or press up from a chair using your arms. etc etc.

[King]

Hi there Dace

the pain seems to come on just when i hit around 90 with external rotation, carrying heavy things brings on a very slight ache but not the sharp pain it presents normally with.

It is painful to sleep on that shoulder but bearable, press ups feel fine, on palpation theres no noticeable areas of tenderness, hand behind back and lift off fine, hawkins kennedy -ve.

Not too sure what you meant bu this bit "And by flexing the arm to 90deg is that to the front to side"

Thanks for the help

[Physio Dace]

Sorry I meant is it only painful when you externally rotate to 90deg in 90deg shoulder flexion or only in 90deg abduction. Not sure whether you were a health professional or not so tried to keep it simple.

Does isometrically contracting into internal rotation at the limit of your external range increase or decrease the pain? Any pain on internal rotation isometric test? Is it tender inferior to or on the coracoid process or over bicipital groove?

[King]

It is painful in both abduction and flexion at 90 degrees when externally rotated and seems to be in a painful arc between 90-140 degrees.

Isometric contraction seems to limit the pain, however concentrically contracting from full ext rot to int rot increases the pain.

Around those landmarks i cant feel any painful areas.

Forgot to mention went to see the Doc, he said i had ruptured one of my biceps heads. However wouldn't this show a lack or strength/ increase of pain during flexion?

[victorlo1]

I would probably just see a doctor about that :P

[Physio Dace]

Interestingly the complete long head of bicep tears I have seen have been mostly pain free. Weakness of elbow flexion and/or in supination would be the most affected as well as flexion with straight arm aka speeds test; complete proximal ruptures are evident by a large round mass over the anterior arm where the muscle had retracted distally - looks swollen/deformed - surgery for this needs to be done quite quickly after the injury. If that is not the case then its most likely a partial tear of the tendon or possible muscle belly (may also be a sprain/rupture of the transverse humeral ligament) - palpation should give the most clues as to where the pathology lies - most special tests for the biceps lack specificity. Ultrasound can pick up any lesions within biceps however once again they are subject to moderate to low specificity. MRI = gold standard.