Summary of the Condition 1,6
Biceps tendinitis is inflammation of the long head of the biceps tendon. This condition is typically seen in the younger, athletic population and is usually caused by repetitive overhead motions. Pain, decreased range of motion, decreased strength, and impaired functional mobility are all common problems for this patient population. Conservative treatment is typically the best option for patients even though surgery can be used in severe cases.
Guide to Physical Therapy Practice 4
The Guide provides two main practice patterns that biceps tendinitis may fall under:
Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation
http://guidetoptpractice.apta.org/content/current
*Take note that the Preferred Practice Patterns are recommendations for treatment; however, these recommendations are very broad and encompass many diagnoses. All treatment mentioned under Patterns 4D and 4E may not be applicable for biceps tendinitis.
-The number of therapy sessions a patient may need is in the range of 6 to 24 visits.
According to The Guide, therapeutic exercise interventions relevant to biceps tendinitis may include but are not limited to:
• Aerobic capacity/endurance conditioning or reconditioning
• Flexibility exercises
• Gait and locomotion training (Arm swing)
• Strength, power, and endurance training for head, neck, limb, pelvic-floor, trunk, and ventilatory muscles
Anticipated goals and expected outcomes relevant to biceps tendinitis may include but are not limited to:
• Joint swelling, inflammation, or restriction is reduced
• Pain is decreased
• Soft tissue swelling, inflammation, or restriction is reduced
• Joint integrity and mobility are improved
• Muscle performance is increased
• Range of motion is increased
• Improved functional limitations
• Ability to perform physical actions, tasks, or activities related to self-care, home management, work (job/school/play), community, and leisure is improved
• Impact on health, wellness, and fitness
Manual Therapy Interventions- massage, mobilization/manipulation, and passive range of motion
Physical Agents- cryotherapy, ultrasound, taping and continuous passive motion (CPM).
Management of Biceps Tendinitis 2,3,5,6
-Initial treatment of biceps tendinitis is non-operative and is intended to relieve pain and decrease swelling. This begins with rest, withdrawal from aggravating activities such as throwing or overhead motion, cryotherapy, nonsteriodal anti-inflammatory drugs (NSAIDs) and progresses to stretching and strengthening exercises. Bicipital tendinitis has shown improvement with stretching and the use of transcutaneous electrical nerve stimulation (TENS). Regaining complete shoulder range of motion and strength of the static and dynamic shoulder stabilizers is achieved through physical therapy.
-Injections are an additional intervention that can be used for pain relief. Subacromial steroid injections can provide pain relief when treating biceps tendinopathy. These injections are usually given to patients with severe night pain or symptoms that fail to resolve after 6 to 8 weeks of conservative treatment.
-TENS (Transcutaneous electrical nerve stimulation) and LEL (Low energy laser) therapy has been successful in reducing pain and improving range of motion for patients with biceps tendinitis. One study suggests that TENS and LEL therapy combined improve pain and ROM at more significant levels than when applied separately.
There are limited studies detailing the conservative management of biceps lesions alone, as they usually occur in combination with other pathologies.
Conservative Management 1,6
Conservative therapy is similar to postoperative biceps rehabilitation. Phase 1 consists of pain management, restoration of full passive range of motion, and restoration of normal accessory motion. Phase 2 consists of active range-of-motion exercises, and early strengthening. Phase 3 involves rotator cuff and periscapular strength training, with an emphasis on enhancing dynamic stability. Finally, the return-to sport phase focuses on power and higher speed exercises similar to sport-specific or work demands. Conservative management of biceps pathology is highly variable among patients, depending on their clinical presentation.
The following protocol is a recommendation for treating the condition conservatively. It was developed with the help of Dr. Richard Hawkins and Howard Head Sports Med in Vail, CO. 1
PHASE 1: ACUTE PHASE
Clinical Modalities as needed
Glenohumeral range of motion:
-Apply appropriate joint mobilization to restrictive capsular tissues
-Implement wand stretching, as indicated
-Supplement with home program: cross arm stretch, sleeper stretch
-Early scapular strengthening
-Begin scapular stabilization with instruction in lower trapezius facilitation
PHASE 2: SUBACUTE PHASE, EARLY STRENGTHENING
Continue with modalities and range of motion as outlined in Phase 1
Begin rotator cuff strengthening
-Sport cord internal/external rotation (30 degrees abduction)
-Sport cord low rows
-Prone I, T, Y, W
-Scaption (Not above 90 degrees)
-Ceiling punch
-Biceps
-Triceps
PHASE 3: ADVANCED STRENGTHENING
Continue with Phase 2 strengthening, with the following additions:
-Resisted PNF patterns
-Sport cord bear hug
-Sport cord reverse fly
-Sport cord IR/ER at 90 degrees abduction for neuromuscular re-education
(External rotation picture shown at right.)
-Push-up progression
-Begin 2 arm plyometric exercises, advance to 1 arm exercises
-Weight training:
-Keep hands within eyesight, keep elbows bent
-Minimize overhead activities
-No military press, upright rows, or wide grip bench press
PHASE 4: RETURN TO ACTIVITIES
-Continue with Phase 3 program
-Re-evaluation with physician and therapist
-Advance to return to sport program, as motion and strength allow
Postoperative Management 1
The following protocol is a recommendation for Biceps Tenotomy post-operative rehabilitation. It was developed with the help of Dr. Richard Hawkins and Howard Head Sports Med in Vail, CO. 1
PHASE 1: PASSIVE
-Pendulums to warm-up
-Passive range of motion
Week 1
-Full passive elbow flexion/extension
-Full passive forearm supination/pronation
-Full passive shoulder range of motion
-Seated scapular retractions
PHASE 2: ACTIVE
-Pendulums to warm-up
-Active range of motion, with terminal stretch to prescribed limits
Week 2
-Full active range of motion, lawn chair progression (Shown at lower right. Lawn chair active range-of-motion progression from supine to sitting. The patient is progressed through increasingly upright positions to gradually increase the effect of gravity on the shoulder)
-Active elbow flexion and extension, full range of motion allowed
-Active forearm supination/pronation, full range of motion allowed
PHASE 3: RESISTED
Pendulums to warm-up and continue with Phase 2
Week 3
-Sport cord internal rotation at 30 degrees abduction
-Sport cord external rotation at 30 degrees abduction
-Prone I, T, Y, W
-Sport cord standing forward punch
-Sport cord low rows
-Sport cord bear hugs
-Bicep curls
-Resisted supination/pronation
-Weight training
Week 4
-Keep hands within eyesight, keep elbows bent
-Minimize overhead activities (No military press, upright rows, or wide-grip bench)
Return to Activities:
Computer: 1-2 weeks
Golf: 4 weeks
Tennis: 8 weeks
The following protocol is a recommendation for Biceps Tenodesis post-operative rehabilitation. It was developed with the help of Dr. Richard Hawkins and Howard Head Sports Med in Vail, CO. 1
PHASE 1: PASSIVE
-Pendulums to warm-up
-Passive range of motion
Week 1
-Full passive elbow flexion/extension
-Full passive forearm supination/pronation
-Full passive shoulder range of motion
-Seated scapular retractions
PHASE 2: ACTIVE
-Pendulums to warm-up
-Active range of motion, with terminal stretch to prescribed limits
Weeks 1-6
-Full active shoulder range of motion: lawn chair progression
-Active elbow flexion and extension: full range of motion allowed
-Active forearm supination/pronation: full range of motion allowed
PHASE 3: RESISTED
-Pendulums to warm-up and continue with Phase 2
Week 7
-Sport cord internal rotation at 30 degrees abduction
-Sport cord external rotation at 30 degrees abduction (Shown at right.)
-Prone I, T, Y, W
-Sport cord standing forward punch
-Sport cord low rows
-Sport cord bear hugs
-Bicep curls
-Resisted supination/pronation
-Weight training
Week 8
-Keep hands within eyesight, keep elbows bent
-Minimize overhead activities (No military press, upright rows, or wide-grip bench)
Return to Activities:
Computer: 4 weeks
Golf: 8 weeks
Tennis: 12 weeks
References
1. Krupp RJ, Kevern MA, Gaines MD, Kotara S, Singleton SB. Long head of the biceps tendon pain: Differential diagnosis and treatment. J Orthop Sports Phys Ther. 2009;39(2):55-70. doi: 10.2519/jospt.2009.2802.
2. Ryu JH, Pedowitz RA. Rehabilitation of biceps tendon disorder in athletes. Clinics in Sports Medicine. 2010 Apr;29(2):229-46.
3. Ozdincler, Arzu Razak. Effects of TENS and LEL on pain and functional performance of patients with shoulder pain. Journal of Medical Science. 2005 Oct-Dec. 5 (4): 328-332.
4. American Physical Therapy Association. Guide to physical therapist practice. Second edition. American physical therapy association. Phys Ther. 2001;81(1).
5. Burkhead WZ, Arcand MA, Zeman C, Habermeyer P, Walch G. The biceps tendon. The Shoulder. Vol. 2. 2004:1059-1119.
6. Durham B, Ho S. Bicipital tendonitis treatment and management. Medscape Website. Available at:http://emedicine.medscape.com/article/96521-treatment. Accessed December 1, 2011
