Acute Phase
Rehabilitation Program
Physical Therapy
The initial goals of the acute phase of treatment for bicipital tendinitis are to reduce inflammation and swelling. Patients should restrict over-the-shoulder movements, reaching, and lifting.
Patients should apply 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. The degree of immobilization depends upon the degree of the injury and the patient's discomfort. Most authors agree that prolonged immobilization tends to result in a stiff shoulder.
Physical therapy plays a minor role in the treatment of acute bicipital tendinitis; however, some authors recommend daily weighted, pendulum stretch exercises for uncomplicated and mild cases of acute bicipital tendinitis. Use of transcutaneous electrical nerve stimulation (TENS) has been reported with some success.
Phonophoresis and iontophoresis are examples of methods that are used to deliver steroids into inflamed tissue without an injection. Phonophoresis uses ultrasound, whereas iontophoresis uses electrical repulsion to transport medicines through the skin. In order to deliver an effective steroid concentration, the target area should be superficial, and serial application is necessary.
Medical Issues/Complications
It is important to realize that performing analgesic and steroid injections into the bicipital groove is not without risk. Use care to avoid direct injection into the long head of the biceps tendon itself because this can result in direct trauma to — and may lead to atrophy and/or rupture of — the tendon. Other complications from injections include postinjection infection and inflammatory reaction. In order to exclude a possible missed differential diagnosis, radiographic imaging should be considered if no improvement occurs after treatment.
Consultations
Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.
Other Treatment
A local injection of an anesthetic and steroid can be given in the bicipital groove. A combination of 2-3 mL of anesthetic with 1 mL of methylprednisolone (Depo-Medrol; Pfizer Inc, New York, NY) is typically recommended 3-6 weeks after the acute injury. A repeat injection can be performed 4 weeks later if the symptoms have not decreased by 50%. Caution is indicated with additional injections or with patients older than 40 years because there is an increased risk of biceps tendon rupture from repetitive injections. Restrict lifting and overhead activities by the patient for 30 days after the injection.
Recovery Phase
Rehabilitation Program
Physical Therapy
Physical therapy and rehabilitation are directed toward restoring the integrity and strength of the dynamic and static stabilizers of the shoulder joint while restoring the affected shoulder's ROM, which is critical for most athletes.
The goal of the recovery phase is to achieve and maintain full and painless ROM. Weighted, pendulum stretch exercises are combined with isometric toning. These exercises are recommended 3 times per week throughout the recovery phase. Passive stretching with ROM exercises removes residual shoulder stiffness. The uninvolved shoulder can be used as a standard comparison to achieve symmetric ROM.
Occupational Therapy
Although a rehabilitation program should improve strength and flexibility, adding an interval program can help restore normal joint arthrokinematics. Interval tennis and baseball programs have been developed for highly competitive athletes as these individuals recover from bicipital tendinitis. The patient progresses in a series of steps and stages, with the goal of returning safely to competition without reinjury. The progression of therapy is dependent upon a gradual, painless increase in activity without excessive fatigue.
Medical Issues/Complications
Failure to recognize concomitant injuries with bicipital tendinitis could result in delayed healing and damage from inappropriate treatment. Physical therapy for shoulder injuries or a misdiagnosed injury may aggravate other conditions in the elbow and neck.
Consultations
Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.
Other Treatment (Injection, manipulation, etc.)
Weighted, pendulum swings should begin with moist heat application to the shoulder on the affected side, followed by therapy with 5- to 10-lb weights, which are held lightly in the hand. The shoulder muscle should be relaxed and the arm kept vertical and close to the body. The arm is allowed to swing back and forth, no greater than 1 inch in any direction. Note: This exercise is not appropriate for patients who have shoulder separation or strain, upper back strain, or neck strain.
Maintenance Phase
Rehabilitation Program
Physical Therapy
The maintenance phase concentrates on the patient developing increased strength and endurance on the affected side. This phase can begin as soon as patient discomfort is effectively controlled and should continue for at least 3 weeks after the pain has completely resolved. When performing strengthening exercises, it is safer for the individual to start out with low tension, followed by a gradual increase in force, because flare-ups can occur.
The patient continues isotonic and isokinetic stretching and is allowed limited participation in sports activities. Monitor the patient and adjust his/her activities as progress allows. Note: Conditioning and proper throwing techniques are important for certain athletes because improper mechanics may result in tissue fatigue and damage.
Surgical Intervention
Surgical intervention is not recommended for bicipital tendinitis if the patient is making a slow and gradual improvement. Surgical treatment is only indicated after a 6-month trial of conservative care is unsuccessful. Although good results have been reported with arthroscopic decompression, acromioplasty with anterior acromionectomy is the standard surgical treatment for bicipital tendinitis. The biceps tendon does not generally undergo tenodesis unless severe attritional wear or eminent rupture is found. [7, 27] No attempt is made to repair biceps tendon ruptures older than 6 weeks.
Tenodesis is not recommended when it is believed that the tendinitis is reversible. Specific indications for tenodesis of the biceps long head include the following [7, 27] :
-
Greater than 25% partial-thickness biceps tendon tear
-
Severe subluxation from the bicipital groove
-
Disruption of the associated bony or ligamentous anatomy of the groove itself
-
Biceps tendon atrophy greater than 25%
-
Failure of surgical decompression
Growing evidence has shown a shift from routine tenodesis to a more individual approach, with considerations such as physiologic age, activity level, expectations, and specific combinations of shoulder pathology as important factors. [7] Although new repair techniques continue to be developed, the preference is for preservation of the biceps-labral complex rather than routine surgery. When surgery is performed for bicipital tendinitis, the procedure is typically performed through an open anterior incision. Variations of this surgery include arthroscopic techniques and open exposures with suture anchors through the subclavian portal. Subpectoral biceps tenodesis has proven to be an effective procedure to relieve pain and maintain function. [28]
Consultations
Consider orthopedic consultation if the patient's symptoms persist longer than 2 months or if biceps tendon rupture occurs.
-
Biceps muscle and tendons.
