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Rehab for Bicep Tendon Problems

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Rehab for Bicep Tendon Problems Rehabilitation for Biceps Tendon Disorders and SLAP Lesions 117 capsulitis will suffer long-term ROM defi cits that may arthroscopic release (5); or MUA and arthroscopic last more than 10 years. Clarke et al. (1975) reported hydrodistension (20). During the long-term follow-up that 42% of patients continued to have motion loss (mean 52.3 months) 59% of patients reported hav- after 6 years of follow-up. Likewise, Schaffer et al. ing normal or near-normal shoulders, 35% reported (1992) reported that 50% of patients managed non- persistent mild/moderate symptoms, and 6% still had operatively remained symptomatic during their long- severe symptoms. Persistent symptoms were reported term follow-up, which occurred 2–11 years after their as mild in 94% of patients, with pain being the most initial visit (mean = 7 years). Of these patients, 60% common complaint. Only 6% of patients complained had a measurable restriction of shoulder motion. of severe pain and/or functional loss. Patients with External rotation was the most chronically restricted the most severe symptoms at condition onset had the movement, providing further evidence that the rotator worst long-term prognosis. In general, patients with interval and coracohumeral ligament are particularly comorbid factors, particularly diabetes, hyperthyroid- affected by adhesive capsulitis. Hand et al. (2008) ism, hypothyroidism, hypoadrenalism, Parkinson's tracked outcomes in 269 shoulders affected by pri- disease, cardiac disease, pulmonary disease, or cere- mary adhesive capsulitis who received no treatment brovascular accident, tend to have more severe and (95); physical therapy (55); steroid injection (139); longer lasting symptoms and tend to be more recalci- manipulation under anesthesia (MUA) (5); MUA and trant to treatment. REHABILITATION FOR BICEPS T ENDON DISORDERS AND SLAP LESIONS Geoffrey S. Van Thiel, MD, MBA; Sanjeev Bhatia, MD; Neil S. Ghodadra, MD; Jonathan Yong Kim, CDR; and Matthew T. Provencher, MD, CDR, MC, USN Injuries to the proximal biceps tendon, the distal intraarticular but extrasynovial. It then courses obliquely biceps tendon, and the superior labrum-biceps anterior through the joint and arches over the humeral head at a to posterior (SLAP) tendon complex have long been 30- to 45-degree angle. As the long head exits the joint, recognized as a potential source of pain and disability it passes under the coracohumeral ligament and through when not properly addressed. Disorders of the biceps the rotator interval into the groove between the greater tendon are particularly problematic in overhead ath- and lesser tuberosities (bicipital groove). In the bicipital letes, throwers, and those who do activities of lifting groove it is covered by the transverse humeral ligament overhead. As such, problems with the biceps may lead with contributions from the subscapularis tendon ( Fig. to signifi cant functional disability in both the sport and 3-42 ). Distally, the long and short heads of the biceps work environment. Coupled with an improved under- converge at the midshaft of the humerus then insert standing of anatomy and shoulder biomechanics, on the anterior aspect of the radial tuberosity. In the advances in surgical techniques have resulted in less antecubital fossa the distal tendon blends with the bicip- invasive and more effective management of biceps ten- ital aponeurosis, which helps protect the cubital fossa don disorders and associated SLAP lesions. It is imper- structures and provides an even distribution of force ative that a rehabilitation program mirror these efforts across the elbow. so as to optimize patient recovery both in the nonop- erative and operative setting. The following section Coracoid process will describe the anatomy, examination, mechanism of Coracoclavicular injury, treatment, and rehabilitation for injuries to the Acromion process ligaments proximal and distal biceps tendon and their associated Clavicle structures. Coracoacromial ligament Coracohumeral ligament Rehabilitation Rationale Greater tubercle Normal Anatomy Transverse humeral Biceps (long head) The biceps tendon is one of the few tendons in the body ligament origin to span two joints: the glenohumeral complex and the Biceps brachii tendon elbow. Tension in the tendon, therefore, largely depends (long head) Glenoid Scapula on the position of the elbow, wrist, and shoulder dur- ing muscle contraction. Proximally, the biceps has two Intertubercular groove heads, one of which originates from the coracoid process Humerus (short head) and the other that begins its course from the supraglenoid tubercle and superior labrum (long head). As the tendon travels distally in the glenohumeral joint Figure 3-42 Anterior aspect of the right shoulder showing the tendon it is encased in a synovial sheath and is considered to be of the long head of the biceps muscle and its relationships. 118 Shoulder Injuries Innervation of the biceps muscle is via the branches is localized to the proximal biceps tendon with resisted of the musculocutaneous nerve (C5). Blood supply is pri- shoulder forward fl exion with the forearm supinated. marily provided by the ascending branch of the circum- This pain should be decreased if the same maneuver is fl ex humeral artery but is augmented by the suprascapular done with the forearm in pronation. artery proximally and the deep brachial artery distally. SLAP lesions can be more diffi cult to discern. Functionally, the biceps acts as a strong forearm A complete examination for both rotator cuff pathol- supinator and a weak elbow fl exor. However, it is ogy and instability must be completed fi rst. Often the more active in fl exion of the supinated forearm than patient will have positive Neer and Hawkins shoulder in fl exion of the pronated forearm. Although contro- impingement signs , which can be nonspecifi c indica- versial, it is also hypothesized that the long head aids tors of shoulder pathology. The O'Brien active com- in the anterosuperior stability of the humeral head by pression test is often reported to be relatively specifi c resisting torsional forces at the shoulder and prevent- for superior labral lesions. For this test, the shoulder ing humeral migration; particularly evident during the is positioned in 90 degrees of fl exion, slight horizon- vulnerable position of abduction and external rota- tal adduction, and internal rotation. The test is consid- tion seen in overhead athletes. Furthermore, as dem- ered positive when, on resisted shoulder fl exion, the onstrated by EMG analysis, biceps contraction plays patient experiences deep or anterior shoulder pain that a prominent role during the cocking and deceleration is decreased when the maneuver is repeated with the phases of overhand and underhand throwing. shoulder in external rotation. Overall, physical exam- ination fi ndings often do not reveal a specifi c pain generator and other techniques must be used. History and Physical Examination Differential diagnostic injections can be helpful in evaluating biceps tendon pathology. A subacromial lido- Proximal Biceps and Superior Labrum caine injection will relieve symptomatology if rotator The proximal biceps tendon and the associated supe- cuff disease is present, but it will not relieve pain with rior labral complex must be evaluated independently isolated biceps pathology. A shoulder intra- articular of the distal biceps, given the signifi cant differences injection can decrease pain from the superior labral in mechanism of injury, evaluation, and treatment. In complex, but bicipital groove discomfort can often per- fact, pathologic lesions of the proximal biceps and supe- sist if marked infl ammation or scarring prevents infi l- rior labral complex can be extremely diffi cult to diag- tration of the anesthetic into the groove. In these cases, nose, with a multitude of potential sources for anterior direct injection into the biceps groove and sheath can shoulder pain confounding the clinical picture. be diagnostic. Evaluation of proximal biceps pathology The most common presenting symptom of any biceps can be complex and the patient history, physical exami- problem in the shoulder is pain. With isolated biceps nation, and diagnostic injections must be combined to pathology, this is usually localized to the anterior shoul- further clarify the pain generator. der and the bicipital groove. However, the picture is less clear if the superior labrum is involved. In this case, pain can occur in the anterior or posterior aspect of the Distal Biceps shoulder with the patient often complaining of “deep” Patients with complete distal biceps tendon ruptures pain. Diffuse discomfort can also occur if another con- usually report an unexpected extension force applied to dition also is present, such as rotator cuff disease, the fl exed arm. Commonly, there is an associated sud- subacromial impingement, acromioclavicular joint den, sharp, painful tearing sensation in the antecubital arthrosis, or shoulder instability. Thus, an accurate his- region of the elbow. The intense pain subsides in a few tory is essential and includes a description of the onset hours and is replaced by a dull ache. Weakness in fl ex- of symptoms, duration and progression of pain, history ion is often signifi cant in the acute rupture; however, of a traumatic event, activities that worsen the pain, and this can dissipate with time. Weakness in supination previous treatments and outcomes. A SLAP tear is also is less pronounced and can depend on the functional associated with sensations of instability, popping,
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