Pain, tenderness and inflammation around long head of biceps tendon often caused due to overuse injury among older patients especially older athletes ( 30+ age athletes and old aged patients 60+ age).
Pain often resembles Shoulder impingement syndrome, Rotator cuff tendinopathy.
Occurs more commonly while performing or after sporting activities like lifting, throwing, overhead movement.
In UK prevalence rate of biceps tendon rupture is 0.53/100,000 over 5 years, with male:female ratio 3:1.
Repetitive irritation friction leads to swelling of tendon initially.
Continued irritation, traction, friction makes tendon thicker.
Eventually long term irritation leads to adhesion formation around surrounding structures.
Patients with biceps tendinopathy often complain of a deep, throbbing pain in the anterior shoulder that is intensified when lifting.
Patients are likely to present with a chief complaint of anteromedial shoulder pain The pain is usually localized to the bicipital groove and may radiate toward the insertion of the deltoid muscle or along radial distribution
Pain may be aggravated by overhead reaching, pulling and lifting activities. The pain usually worsens at night when sleeping on the affected shoulder.
Pain with palpation over the bicipital groove is another physical exam finding in patients with biceps tendinopathy. Active elbow flexion may also provoke pain. Cases associated with biceps instability, the patient may complain of an anterior shoulder “clicking” or “popping” sensation associated with throwing motions.
PHYSICAL EXAMINATION AND DIAGNOSIS
Physical examination includes Active And Passive ROM testing, Palpation, Clinical Screening and Specific tests
Biceps Tendon tests
Resisted shoulder flexion with elbow extended and forearm supinated
Positive if pain felt in bicipital groove
Elbow flexed at 90°. Initially pronated
Active Supination and flexion against resistance
Pain at bicipital groove yields positive result
DIFFERENTIAL DIAGNOSIS AND MEASURES
Scales used to measure is
DASH (Disability of Arm, Shoulder and Hand)
Physical therapy has been commonly used for the treatment of tendinopathies, especially eccentric training.
Intervention should include restoration of pain free range of motion, trunk and core stability and ensuring stable scapulothoracic rhythm. Pain free range can be achieved with such activities as Passive Range of Motion, Active Assisted Range of Motion, and mobilization. Painful activities such as abduction and overhead activities should be avoided in the early stages of recovery as it can exacerbate symptoms.
Initial Conservative Management includes application of ice to the affected area for 10-15 minutes, 2-3 times per day for the first 48 hours. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used for 3-4 weeks to treat inflammation and pain
Stretching and strengthening regimes are a common aspects of most therapy protocols. Therapists also use other modalities like ultrasound, iontophoresis, deep transverse friction massage, low-level laser therapy, Hot fermentation.
Supraspinatus Tendonitis is often associated with Shoulder impingement syndrome impingement and inflammation of Supraspinatus Tendon is called Supraspinatus Tendonitis
Mostly affects sports athlete often result from overuse injury with sporting activities like throwing and overhead motion apart from this it also affects age group of 50-60 years with prevalence more in patients with diabetes
Factors affecting listed below
Subdeltoid pain is the most highlighting feature which aggravates with abduction movement Pain also felt while reaching,overhead activity, sleeping on affected shoulder It become worse during night and often disturbs sleep
Painful and limited range of motion and painful arc 70°-120°
Their is anterior instability along with posterior tightness
PHYSICAL EXAMINATION AND DIAGNOSIS
Following physical examination used to evaluate Supraspinatus Tendonitis
Hawkins Kennedy Test
Empty Can Test
Drop Arm Test
Complete description on how to perform following tests along with other important physical examination of shoulder injury is given below
X-ray Radiography shows calcified lesion around Supraspinatus tendon later cases shows degenerative and sclerotic changes Ultrasound reveals thickening of subacromial bursa
AC Joint Injury
Rotator Cuff tear
Biceps Tendinitis or Tendinopathy
MEASURES AND SCALE
Simple shoulder test questionnaire
Oxford Shoulder Score
Medical management includes Corticosteroid injection, NSAIDS that alleviates pain and surgical procedures include subacromial decompression, sometimes acromioplasty, bursal resection. Physiotherapy management includes Rest, Ice, pain relieving modalities like ultrasound, cryotherapy, Electrical Modalities Stimulation. Their are three phases of Supraspinatus Tendonitis management which includes (a) Immobilisation (b) Assitive range of motion (c) Progressive resistance exercise
ROM exercise, Strengthening exercise, Stretching techniques, Isometric exercises, Codmans classic pendullar exercise and Kinesiotaping, soft tissue manipulation like MFR, IASTM are also prescribed and found to be very effective in pain relief and regaining range of motion. Along with these Home exercise programs, self exercise regimes are also advised
It refers to the pain and weakness of rotator cuff musculature Rotator cuff comprises of four main muscles viz. Subscapularis, Supraspinatus, Infraspinatus, Teres Minor responsible for abduction and rotation movement of shoulder
Commonly affects athletes involved in sporting activities like Cricket, Swimming, Throwers etc and it can be age related problem affecting old aged patients their is an incidence of 11.2 cases per 1000 patients per year
CLININCAL PRESENTATION AND PATHOPHYSIOLOGY
Their is a difference between tendinitis and tendinopathy. Tendinitis is an inflammation of tendons whereas tendinopathy is deterioration of tendons. Rotator Cuff tendinopathy is clinically presented with
Pain, Weakness, Loss of strength to bear load aur lift weight on shoulders along with tenderness around shoulder joint painfull overhead movement localised swelling may also be present
PHYSICAL EXAMINATION AND DIAGNOSIS
For Physical examination two clinical tests are performed namely
Empty can test and Hawkins test
Other tests include Modified Belly press test, Palpation, ROM testing the latter two are not so significant In order to see how the tests are performed visit
Other diagnostic tools include ultrasound, radiographs, radionucleotide isotope scan, magnetic resonance imaging (MRI), computed axial tomography (CT), electromyography
Ultrasound reveal partial tear of tendon fibres partial thickened tears and thickened subacromial bursa MRI also reveals rotator cuff tears
Cervical Disc Disease
For measuring extent of rotator cuff tendinopathy VAS score, SPADI (Shoulder pain and disability index) have be adopted extensively by physiotherapist
Physiotherapy is the gold standard treatment for rotator cuff tendinopathy along with Medical Management in majority cases and rarely require surgical intervention if Conservative treatment doesn’t work Medical Management includes NSAIDS, Shoulder immobilisation etc Surgery involves Arthroscopic intervention Physiotherapy treatment includes step wise procedure firstly Stretching, ROM exercises and then Muscle Strengthening exercises for pain management Ultrasound, TENS etc Modalities can be applied Kinesiotaping have shown better result in patients with Rotator Cuff Tendinopathy. Other techniques include