Best Biceps Tendinitis Treatment In Delhi NCR.
What Does Biceps Tendinitis Mean?
Inflammation of the tendon surrounding the long head of the biceps muscle is known as biceps tendinitis. Rotator cuff tears lesions frequently coexist with biceps tendinitis. Primary tendonitis is an isolated tendon inflammatory condition that has no pathologic effects on the shoulder. Tendinosis (degeneration of tendon’s collagen) is a better term to describe this secondary degeneration of the biceps tendon since it lacks a real inflammatory component.
Biomechanics
The insertion of the biceps brachii lies near to the axis of the elbow, making it a mobility muscle. When the elbow is flexed between 80° and 100°, the biceps moment arm is at its biggest. When the elbow is fully extended, the biceps smaller arm causes most of the muscular force to be translated into the compression of the joint. Beyond a flexion of 100 degrees, the translatory force is directed away from the elbow joint and functions as a dislocating or distracting force. Due to two joint muscle, the biceps’ function is influenced by the location of the shoulder. The muscles capacity to produce torque is reduced if elbow flexion is performed with the shoulder flexed fully and the forearm supinated. The elbow joint angle affects the activation of the biceps during concentric and isometric contraction but not during eccentric and isokinetic contraction. Biceps’ EMG activity rose during gradual supination and fell during pronation. When the forearm is supinated or at a position halfway between supination and pronation, the biceps brachii are active during unresisted elbow flexion in both concentric and eccentric contractions, but not when the forearm is pronated. All forearm postures where the resistance is greater than the weight of the limb result in the biceps contracting.
Etiology
- Primary bicipital tendinitis is much less common
- Secondary associated shoulder pathologies include:-
- Rotator cuff tendinitis and Chronic Rotator Cuff Tendinopathy
- Subscapularis injuries
- LHB tendon instability/dislocation (seen in association with subscapularis injuries/tears)[5]
- Direct or indirect trauma
- Inflammatory conditions
- Internal impingement of the shoulder (“Thrower’s” shoulder)
- External impingement/Subacromial impingement syndrome
- Glenohumeral arthritis.
Clinical Features
- The gradual, non-traumatic development of anterior shoulder discomfort
- Exacerbation of symptoms while overhead activities
- shoulder pain that travels down the front arm
- When the proximal biceps is unstable, clicking or audible popping can be heard.
- Pain during sleeping and at rest
- History or contemporary jobs of manual/physical work, including baseball, volleyball, and other overhead sports.
Diagnosis
- Subjective Assessment – history taking
- Objective Assessment –
- Palpation: Pain with palpation over the bicipital groove (which is most felt in 10° of internal rotation) is a common physical finding for patients with biceps tendinopathy.[8]
- Range of Movement (ROM): Testing of cervical, shoulder and elbow AROM should all be completed as well as PROM of shoulder and elbow.
- Strength Testing: Strength testing of shoulder, elbow and wrist should all be completed to ensure no significant weakness of other structures. There may also be associated rotator cuff weakness.
- Provocative tests: If any of these tests is positive, it indicates that impingement is present, which can lead to biceps tendinopathy. No validated cluster of diagnostic tests is currently available for ruling in or out biceps tendinopathy specifically. Therefore, these tests should be used to help guide the diagnosis.
- Yergasons test: Yergason’s test requires the patient to place the arm at his or her side with the elbow flexed at 90 degrees, and supinate against resistance. The test is considered positive if pain is referred to the bicipital groove.
- Neers test: involves internal rotation of the arm while in the forward flexed position. If the patient experiences pain, it is a positive sign of shoulder impingement syndrome or sub acromial pain syndrome.
Differential diagnosis
- Differential Diagnosis of Anterior Shoulder Pain:-
- Acromioclavicular joint pathology
- Adhesive capsulitis
- Cervical spine pathology
- Glenohumeral osteoarthritis
- Glenohumeral instability
- Humeral head osteonecrosis
- Sub-acromial Impingement syndrome
- Rotator cuff tears
- Superior labrum anterior-posterior lesions (SLAP)
- Pulley lesions
Physiotherapy Management
Physical therapy management of proximal biceps tendon injuries typically consists of three phases:-
- phase one (restoration of full PROM, pain management, and restoration of normal accessory motion)
- phase two (AROM exercises and early strengthening)
- phase three (rotator cuff and periscapular strength training, with a focus on enhancing dynamic stability)
- For athletes, a return to sport phase is initiated upon completion of the rotator cuff and periscapular strength training phase 2.
Phase 1
PRECAUTIONS
- Avoid overloading the biceps tendon
- Avoid exercises and activities that increase pain and/or swelling
- Avoid anterior humeral head translation
- TREATMENT RECOMMENDATIONS
Patient education
- Nature of the condition
- Activity modification
- Postural awareness
- Work ergonomics
- Understanding the importance of compliance with the home exercise program(HEP)
Manual therapy
- Soft tissue massage (STM)
- Myofascial release (MFR) to adjacent tissues, as needed
- Joint mobilizations
- Grades I and II
- Taping, as needed
ROM/flexibility
- PROM/AROM
- Stretching to adjacent tissues, as needed
- Posterior capsule
- Cross body stretching
- Sleeper stretch
- Latissimus stretch
- Self MFR
- Foam rolling
- Lacrosse ball
- Thoracic spine mobility
Neuromuscular re-education
- Postural training
- Scapulohumeral rhythm training
- Bilateral
- Proprioception
- Rhythmic stabilization
- Bilateral
- Closed chain
Strength
- Peri-scapular
- Focus on mid and lower trapezius facilitation
- Rotator cuff
- Isometrics, as tolerated
- Lower extremity (LE)/core strengthening
- No limits on LE or core workouts that do not affect the injured shoulder
Functional training
- Scapular plane
- < 90° shoulder elevation, unloaded
Modalities
- Cryotherapy
- Laser
- Blood Flow Restriction Training (BFR)
Phase 2
Patient education
- Nature of the condition
- Activity modification
- Postural awareness
- Work ergonomics
- Understanding the importance of compliance with HEP
Manual therapy
- STM
- MFR to adjacent tissues, as needed
- Cross-friction over biceps tendon
- Joint mobilizations
- Grades III and IV
- Taping, as needed
ROM/flexibility
- PROM/AROM
- Stretching to adjacent tissues, as needed
- Posterior capsule
- Self MFR
- Foam rolling
- Lacrosse ball
Neuromuscular re-education
- Postural endurance training
- Scapulohumeral rhythm training
- Proprioception
- Rhythmic stabilization
- Open kinematic chain (OKC)
- Close kinematic chain (CKC)
Strength
- Progress Peri-scapular
- Proprioceptive neuromuscular facilitation (PNF) patterns
- Rotator cuff
- Isometrics
- progressive resistive exercises (PREs)
- Biceps
- Isometrics – eccentric – concentric
- Sagittal plane elevation
- LE/core strengthening
- No limits on LE or core workouts that do not affect the injured shoulder
Functional training
- Scapular – forward flexion and abduction
Modalities
- Cryotherapy
- laser
- BRF
Phase 3
Patient education
- Nature of the condition
- Activity modification
- Postural awareness
- Work ergonomics
- Understanding the importance of compliance with HEP
Manual therapy
- Stretching to adjacent tissues, as needed
- Self MFR, as needed
Neuromuscular re-education
- Scapulohumeral rhythm training
- Unilateral, multiplanar
- Proprioception
- Rhythmic stabilization
- OKC
- CKC
- Added resistance, perturbations
- PNF patterns
Strength
- Progress PREs
- Increasing intensity
- Full kinetic chain exercises
Functional training
- Multiplanar
o > 90° shoulder elevation, with load
Modalities:
- laser
- BFR
Phase 4:
Patient education
- Gradual return to play
Neuromuscular re-education
- Multiplanar
- Dynamic
Strength
- Biceps
- Biceps contraction from an elongated position
- High velocity, explosive exercises
- CKC exercises
Plyometric
Sports specific exercises
- Thrower’s Ten Program
- Advanced Thrower’s Program
Functional training
- Full kinematic chain exercises
Cardiovascular conditioning
- Upper body ergometer, bicycle
- Increased resistance
- Swimming