dolor biceps largo_diagnostico_diferencial_para_tto

journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 55

[ CLINICAL COMMENTARY ]

1Orthopaedic Sports Medicine Fellow, Steadman Hawkins Clinic of the Carolinas, Greenville, SC. 2Director of Qualifications, Proaxis Therapy, Greenville, SC. 3Orthopaedic SportsMedicine Fellow, Steadman Hawkins Clinic of the Carolinas, Greenville, SC. 4Orthopaedic Sports Medicine Physician Assistant, Steadman Hawkins Clinic of the Carolinas,Greenville, SC. 5Orthopaedic Sports Medicine Physician, Steadman Hawkins Clinic of the Carolinas, Greenville, SC. Address correspondence to Dr Steven B. Singleton, 1650Skylyn Drive, Suite 200, Spartanburg, SC 29307. E-mail: [email protected]

RYAN J. KRUPP, MD¹ PT, DPT, SCS² MD³PA-C4 MD, FACS5

Long Head of the Biceps Tendon Pain:Differential Diagnosis and Treatment

he long head of the biceps tendon (LHBT) originatesapproximately 50% from the superior glenoid tubercle and theremainder from the superior labrum, with 4 different variationsidentified.73 The proximal tendon is richly innervated, with

sensory nerve fibers containing substance P and calcitonin gene-related peptide. These substances are responsible for vasodilatationand plasma extravasation, as well as transmitting pain. As the neuralnetwork progresses distally, it becomes more sparse.2 The tendon

As the LHBT then exits the joint andpasses through the rotator interval to theintertubercular groove (often referredto as the bicipital groove), between thegreater and lesser tuberosities, it is sur-rounded by a tendoligamentous sling.The coracohumeral ligament (CHL), su-perior glenohumeral ligament (SGHL),fibers from the supraspinatus, and fibersfrom the subscapularis are the major con-tributors to this sling.34 The CHL arisesfrom its broad, thin origin on the lateralcoracoid base and then divides into 2major bands. One band inserts into theanterior border of the supraspinatus andgreater tuberosity, and the other insertsinto the upper border of the subscapu-laris and lesser tuberosity.15,36 The SGHLarises from the labrum adjacent to thesuperior glenoid tubercle, travels as thefloor of the rotator interval, and crossesunder the LHBT forming a U-shapedsling before inserting into the lesser tu-berosity. The SGHL seems to stabilize theLHBT against anterior shearing forcesproximal to its entry to the groove. Thesubscapularis contributes fibers to theanterior/floor aspect of the sling while fi-bers of the supraspinatus insert into theposterior aspect of the roof.81

Once in the bicipital groove, the ten-don passes under the transverse humeral

receives its blood supply from the ascend-ing branch of the anterior circumflex hu-meral artery, which travels along withthe tendon in its groove in the proximalhumerus. The proximal tendon receivessome arterial supply from labral branches

of the suprascapular artery.3 Moving awayfrom the origin, the tendon is encased ina synovial sheath and is, therefore, intra-articular yet extrasynovial, as it coursesobliquely through the joint and archesover the humeral head.

Though the role of the long head ofthe biceps tendon (LHBT) in shoulder pathologyhas been extensively investigated, it remainscontroversial. Historically, there have been largeshifts in opinions on LHBT function, ranging frombeing a vestigial structure to playing a critical rolein shoulder stability. Today, despite incompleteunderstanding of its clinical or biomechanicalinvolvement, most investigators would agree thatLHBT pathology can be a significant cause ofanterior shoulder pain. When the biceps tendonis determined to be a significant contributor to apatient’s symptoms, the treatment options includevarious conservative interventions and possiblesurgical procedures, such as tenotomy, transfer,or tenodesis. The ultimate treatment decision

is based upon a variety of factors, including thepatient’s overall medical condition, severity, andduration of symptoms, expectations, associatedshoulder pathology, and surgeon preference. Thepurpose of this manuscript is to review currentanatomic, functional, and clinical informationregarding the LHBT, including conservativetreatment, surgical treatment, and postsurgicalrehabilitation regimens.

Level 5. J OrthopSports Phys Ther 2009;39(2):55-70. doi:10.2519/jospt.2009.2802

impingement, rotator cuff, shoul-der, tendinitis, tendinosis

56 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

[ CLINICAL COMMENTARY ]ligament, which bridges the groove. Thisligament is no longer believed to play aprimary role in securing the biceps ten-don, given that most of the stability isprovided by the SGHL and CHL.6,65 Thegroove itself has a mean depth of 4.3mm, with an average medial wall angle of56°.16 After coursing through the groove,the LHBT joins the short head of the bi-ceps to form the biceps muscle belly atthe level of the deltoid insertion.

The function of the LHBT at the shoul-der is controversial and incompletely un-derstood. Stretching from the scapula tothe forearm gives it the potential to havefunction at both the shoulder and elbow.Its contribution to elbow flexion andforearm supination is well established;however, contradictory experimentalproof about its function at the shoulderhas left its role unclear.

Neer53 proposed that the tendon servedas a humeral head depressor and empha-sized the importance of maintaining thetendon for shoulder stability. Andrews etal4 noted that electrical stimulation of thebiceps during arthroscopy led to humeralhead compression within the glenoid. Us-ing a freely hanging arm cadaveric shoul-der model, superior humeral migration wasnoted following LHBT tenotomy,45 thoughthese data have been difficult to interpretdue to difficulties in reproducing physi-ologic tension in the remaining cadavericshoulder girdle. Similarly, superior humer-al migration during active abduction hasbeen noted radiographically in patientswith isolated LHBT tears when comparedto their intact contralateral shoulders.78

However, some evidence exists thatrefutes any major role of the biceps atthe shoulder. In most patients with mas-sive rotator cuff tears and absent LHBTs,either from rupture or surgery, superiormigration of the humeral head is uncom-mon.3 Furthermore, based on electro-myographic studies that have controlledfor elbow motion, no long head of bicepsmuscle activity was measured during ac-tive shoulder motion in patients with in-

tact or torn rotator cuffs.46,83 Given vectoranalysis of the pull of the long head of thebiceps, a humeral head depression rolewould be unlikely in most shoulder posi-tions except in full external rotation.65

Several biomechanical studies per-formed on cadavers have also examinedglenohumeral joint stability in relationto the biceps tendon. Paganini et al59

found contraction of the biceps to limitglenohumeral translation. Rodosky et al63

showed that simulated contraction of thebiceps increases the stability of the gle-nohumeral joint by increasing the shoul-der’s resistance to torsional forces in thecombined abducted and externally rotat-ed position. Additionally, injury to the bi-ceps anchor results in increased strain onthe inferior glenohumeral ligament andincreases anteroinferior glenohumeraljoint translation.58

Though considerable evidence sug-gests that the biceps is not an active sta-bilizer of isolated shoulder motion, theLHBT may still contribute passively toglenohumeral stability. It is possible thatthe biceps serves more as a physical blockto superior and anterior glenohumeraltranslation than as an active contractoragainst translation. Furthermore, activi-ties that require coordinated shoulderand elbow motions may still receive activestabilization from the biceps. Finally, theproprioceptive influence of the LHBT onshoulder stability has yet to be studied.

Understanding the muscle activationpatterns of the biceps during throwingmotions can help treat the overhead ath-lete. Most overhead sports activities, suchas pitching a baseball or serving in ten-nis, are broken down into phases: cock-ing, acceleration, and follow-through.Significant biceps activity is seen afterball release during follow-through as theforearm is decelerated to prevent hyper-extension of the elbow. This eccentriccontraction, transferring large forces tothe biceps anchor, has been postulatedto cause superior labrum anterior-to-posterior (SLAP) tears.4 Others hypoth-esize that SLAP lesions occur not duringeccentric contraction but, rather, through

a “peel-back” mechanism during the latecocking phase of throwing. As the armshifts from resting position to an ab-ducted, externally rotated position, theaccompanying change in the force vectorof the biceps causes a torsional force atthe LHBT insertion. This torsional forcemay “peel back” the biceps anchor awayfrom its insertion, causing progressivefailure over time.12

Pathologic disorders of the LHBT can bedivided into 3 categories: inflammatory/degenerative conditions, instability of thebiceps tendon, and SLAP lesions/bicepstendon anchor abnormalities. The 3 cat-egories of disorders may all present withshoulder pain, though they differ widelyin patient populations and pathogeneses.Though it may be helpful for treatmentpurposes to classify a patient’s particu-lar disorder, there is significant overlapamong the pathologies.LHBT Degeneration As the synovial lin-ing of the biceps tendon sheath is con-tinuous with the glenohumeral joint andintimately related to the rotator cuff,inflammatory conditions affecting anyof these structures can affect the others.Biceps tendonitis, or inflammation of thebiceps tendon, is a misnomer, as is lateralepicondylitis, in that histological inflam-matory changes in the tendon are rarelyseen. Instead, tenosynovitis (inflamma-tion of the tendon sheath) may occur,while changes in the tendon are moreappropriately called tendinosis, as degen-erative changes occur histologically with-out evidence of inflammation.14 It shouldbe noted that the term tendinopathy isalso used throughout the literature as ageneral term for tendon disorders thatare characterized by pain, swelling, andimpaired performance.77 The tendon mayinitially swell, appearing dull and discol-ored, but remains mobile. As the stagesof degeneration progress, the tendonbecomes thickened, irregular, and maybecome scarred to its bed through hem-orrhagic adhesions. When this bicepsdegeneration accompanies subacromial


impingement and rotator cuff disease,this may be termed secondary bicepstendinopathy. In contrast, primary bi-ceps tendinopathy may occur exclusiveof these conditions. In addition, it is ourbelief that degeneration of the tendon fi-bers leads to painful symptoms and mayoccur without any demonstrable changein the gross appearance of the tendon.

“Biceps tenosynovitis” was describedby Neer53 as being caused by subacromialimpingement. The pathology was initiallythought to be limited to the older, rota-tor cuff population, as Murthi et al52 de-scribed it correlating highly with rotatorcuff disease, and Peterssons’60 dissectionof 151 shoulders showed no biceps degen-eration in cadavers from people underthe age of 60.

Relatively recent interests have fo-cused on repetitive motion in overheadathletes contributing to biceps patholo-gy. Crossbody motion, internal rotation,and forward flexion have been shown totranslate the humeral head anteriorlyand superiorly. Thus, while the arm is inthis position during the follow-throughmotion of throwing and hitting, ante-rior structures, like the biceps, are atincreased risk of impingement on thecoracoacromial arch. A tight posteriorcapsule, which is found in many over-head athletes, may further exacerbatethe anterior translation during thesemotions.35 Jobe and Bradley37 describedrepetitive overload to anterior structuresfrom pitching leading to stretching andinjury. Once the anterior structures arelax, subtle glenohumeral instability maycause increased anterior humeral transla-tion and increased anterior impingement.Alternatively, the anterior humeral trans-lation can cause “internal impingement”of the posterior rotator cuff on the pos-terosuperior glenoid labrum during thelate cocking and early acceleration phasesof throwing, when the shoulder is maxi-mally externally rotated and abducted.31

This impingement may result in patho-logical fraying of the posterior rotatorcuff and superior labral biceps anchor. Inaddition, this rotation may lead to inter-

nal shear forces that overcome the bicepsand its anchor, leading to tendon fiberdegeneration or frank anchor failure.LHBT Instability Biceps tendon instabil-ity can vary from subluxation to disloca-tion, and from intermittent to fixed. Thetendon angles 30° to 40° laterally from itsorigin to the bicipital groove; therefore, amedially directed force may displace thetendon into the subscapularis insertion onthe lesser tuberosity.61 These forces are in-creased during repetitive throwing, whenthe arm is in the abducted and externallyrotated position. The soft tissue slingthat secures the biceps within the groovereceives contributions from the CHL,SGHL, and the subscapularis, and mustbe disrupted for the biceps to becomeunstable. Because the tendon most fre-quently subluxes medially, the subscapu-laris tendon insertion and its contributionto the sling are most frequently involved.Although isolated biceps instability hasbeen reported in some young throwers,56

most agree that it is extremely uncommonto find biceps tendon instability withoutsome injury to the rotator cuff.23 Finally,a shallow groove may also predispose thepatient’s biceps tendon to instability.SLAP Lesions/LHBT Anchor Abnormali-ties Snyder et al69 introduced the term“SLAP lesion” to describe a spectrum ofinjuries to the superior labrum and LHBTorigin, and classified the injuries into 4types. Type I lesions involve a degenera-tive fraying of the superior labrum, withthe biceps anchor intact. Type II injuriesare detachments of the biceps anchorfrom the superior glenoid, and are themost common type. Type III is a bucket-handle tear of the superior labrum, withan intact biceps anchor. Type IV lesionsare similar to type III, except that the tearextends into the biceps.

The SLAP lesion has several proposedcauses. First, such injury may be the re-sult of a shearing mechanism causedby compression of the superior glenoidrim, which occurs during a fall onto anoutstretched arm abducted and flexedslightly forward.23 Second, a tractionmechanism has been suggested, in which

an eccentric firing of the long head of thebiceps muscle causes injury to the supe-rior labrum complex and its attachmentduring the deceleration phase of overheadthrowing.4 Finally, the peel-back explana-tion has also been described.12 When thearm is abducted and maximally externallyrotated, the twisting of the biceps tendonmay result in the peel-back of the an-chor and its subsequent gradual or acutedetachment from the superior glenoid.Further, we speculate that injury to thetendon intra-articular or intertubercularfibers may also occur in association withthe development of a SLAP lesion.

he usual presenting symptom

is pain localized to the anteriorshoulder over the bicipital groove.

Often, the pain may be diffuse or vague,especially when another condition, suchas rotator cuff disease, subacromial im-pingement, or shoulder instability, ispresent. An accurate history includes thedescription of the onset of symptoms, du-ration and progression of pain, history ofa traumatic event, activities that worsenthe pain, and previous treatments andoutcomes. Sensations of instability, pop-ping, and grinding should be noted andqualified to location and arm position.

The following tests are only a small sam-ple of those cited throughout the litera-ture, with no one test offering acceptablesensitivity and specificity. Based on thisfact, the clinician must utilize multipleexam findings in combination with thepatient history, differential injections,and imaging to determine the appropri-ate treatment course.

The shoulder should be inspected forsymmetry with the unaffected side. Acommon finding for biceps tendon painis point tenderness over the bicipitalgroove.65 LHBT pain rotates laterally andmedially, with external and internal rota-tion of the shoulder, respectively; thus it



ing the patient’s arm in the apprehensionposition of 90° abduction while palpat-ing the bicipital groove. Then, upon ap-proaching 90° external rotation, a clunkmay be appreciated near the anterioredge of the acromion, as the biceps ten-don subluxes out of its groove.8

Once these tests have been performed,differential diagnostic injections can behelpful when considering biceps tendonpathology. A subacromial lidocaine injec-tion should not typically provide signifi-cant pain relief when the primary originof pain is from the biceps, unless a rota-tor cuff tear is present. It is important toremember, however, that there is oftenassociated pathology in these conditions,including subacromial bursitis, whichis addressed with this type of injection.An intra-articular injection should helpbiceps anchor pain, but groove pain maysometimes persist if marked inflamma-tion or scarring of the surrounding tissuesprevents infiltration of the anesthetic intothe groove. In such cases, if significantconcern for biceps pathology persists, abiceps tendon sheath injection may be at-tempted with or without the assistance ofultrasound guidance.

Imaging of patients suspected to haveLHBT pathology begins with standardplain radiographs consisting of a true an-terior posterior (AP), axillary, and outletview. Concomitant osteoarthritis, acro-

mial hooks, and acromioclavicular jointlesions can be identified with these views.A special “groove view” may permit mea-surement of the width, depth, and medialwall angle of the biceps groove, and allowevaluation for degenerative changes.16

Ultrasound imaging has the advantageof being inexpensive and noninvasive.Diagnoses of bicipital tendinopathy andruptures can be accurate; however, SLAPlesions can be more difficult to diagnosewith ultrasound.62 The radiologic studyof choice for biceps tendon pathology ismagnetic resonance imaging (MRI). Bi-ceps tendon subluxation with subscapu-laris and rotator interval lesions can bereadily identified with this modality ( -

). Associated tears of the rotator cuffare also best defined by MRI. MRI alsohas a reported 98% sensitivity, 89.5%specificity, and 95.7% accuracy for detec-tion of SLAP lesions.17

reatment of suspected LHBT

tendinopathy begins with first at-tempting to make an accurate di-

agnosis of the primary pathology. Aspreviously discussed, this can be difficultto determine, given the multiple condi-tions, including rotator cuff disease, in-stability, impingement, and SLAP lesions,which often accompany disorders of thebiceps tendon.1,3,6,72 Initial treatment ofboth primary and secondary bicipitaltendinopathy is nonoperative and be-gins with a period of rest and withdrawalfrom aggravating activities, ice, a courseof anti-inflammatory medication, andformal physical rehabilitation. There arelimited studies detailing the conservativemanagement of biceps lesions alone, asthey usually occur in combination withother pathologies. A Cochrane review33

looked at 26 different studies involvingphysical therapy for shoulder conditionsand concluded that there is some role formobilization and exercise in the manage-ment of rotator cuff disease; but none ofthese studies specifically evaluated themanagement of biceps pathology in isola-

can be differentiated from painful super-ficial structures, like the anterior deltoid,which do not move with arm rotation.Assessment of shoulder range of motionshould be performed and compared tothe contralateral side. Overhead throw-ers may have a loss of internal rotationin their throwing arm, which can be anormal finding in this population. If anormal total arc of motion is maintainedby an associated increase in external rota-tion, then the internal rotation deficit isless likely to be a contributing problem.LHBT pathology itself can lead to lossof shoulder range of motion, similar towhat is seen with rotator cuff tendinopa-thy. Neer and Hawkins signs will often bepositive. The rotator cuff should be testedfor strength, which may be normal in theface of isolated biceps disease.

Glenohumeral joint stability testingis particularly important to perform inthe athlete. The crank test and the load-and-shift test may be used. Subtle gle-nohumeral joint instability in the athletemay not produce a feeling of pendingsubluxation during apprehension testing,but may reproduce the pain that occursduring athletic activities.31 Yergason’s testof resisted supination causing anteriorshoulder pain may be specific for bicepspathology but tends to lack sensitivity.18

Speed’s test is considered positive if painlocalized to the proximal biceps area iscaused by resisted shoulder forward flex-ion with the forearm supinated. O’Brien’sactive compression test can be used tohelp detect superior labral pathology.For this test, the patient elevates the armto 90° and adducts the arm 10° to 15°,with the elbow in full extension and thearm internally rotated so that the thumbis pointing to the floor. The patient thenresists downward pressure applied bythe examiner. The palm is then fully su-pinated and the patient resists downwardpressure again. A positive test for labralpathology is “deep” shoulder pain in thethumb-down position, relieved in the su-pinated position.55

LHBT instability can be difficult to di-agnose. One common test involves plac-

Magnetic resonance imagingdemonstrating rupture of the subscapularis tendonwith instability of the biceps tendon.


tion. This review also evaluated the use oftherapeutic ultrasound and laser therapyin the treatment of these conditions andcould not find any evidence to supporttheir utilization.33

The first consideration for nonopera-tive biceps rehabilitation is to establisha causal relationship between physicalimpairments and biceps pathology. It isthen necessary to develop a treatmentplan specifically designed to address theimpairments. The patient is advancedthrough the phases of rehabilitation,with particular attention paid to pa-tient response to treatment in terms ofchanges in pain, swelling, or motion. Thepatient progresses through phases simi-lar to postoperative biceps rehabilitation( ). Phase 1 consists of painmanagement, restoration of full passiverange of motion, and restoration of nor-mal accessory motion. Phase 2 consistsof active range-of-motion exercises, andearly strengthening. Phase 3 entails rota-tor cuff and periscapular strength train-ing, with a strong emphasis on enhancingdynamic stability. Finally, the return-to-sport phase focuses on power and higher-speed exercises similar to sport-specificdemands. Conservative management ofbiceps pathology is highly variable amongpatients, depending on their clinical pre-sentation. Some patients will presentwith near full passive and active shoulderrange of motion and be ready to begin re-sistance training on their first visit. Con-versely, individuals with acute injuriesor acute irritation of the biceps tendonmay present with significant range-of-motion and strength deficits and need tobe progressed more slowly. The therapistplays an instrumental role in developinga treatment plan in which the patient isprogressed efficiently through the phasesof rehabilitation with minimal irritationto the healing tissue.

It is imperative to remember that anycomprehensive rehabilitation programfollowing biceps injury should focus onrestoring dynamic stability to the shoul-der. Rotator cuff strengthening has beenrecommended to improve shoulder func-

tion following biceps surgery.3 In additionto a rotator cuff strengthening program,rhythmic stabilization exercises can beused to retrain dynamic stability of theshoulder. Rhythmic stabilization exercis-es should be performed at varying shoul-der and elbow positions, because elbowposition is thought to affect the functionof the biceps at the shoulder. At our clinic,incorporation of these neuromuscular re-education exercises has helped us achievefavorable outcomes.

Injections are an additional inter-vention that can be very useful in thetreatment of this disease process, boththerapeutically and diagnostically. Sub-acromial steroid injections can providepain relief when treating biceps tendi-nopathy.13 These injections are typicallyutilized for patients with severe nightpain or symptoms that fail to resolve after6 to 8 weeks of conservative measures.65

Individuals with significant biceps tendi-nopathy may be more resistant to treat-ment and may not respond as well to thistype of injection.13,54 In these cases, injec-tions directly into the tendon sheath ofthe biceps can be beneficial, with stud-ies reporting as high as 74% good to ex-cellent results.39 These blind injectionsshould be done carefully, as detrimentaleffects on healing and atrophic changesof the tendon have been reported with di-rect tendon injections,70 including tendonrupture.25 An alternative option is injec-tion directly into the glenohumeral joint,which avoids the potential complicationsof direct tendon injection and delivers theanti-inflammatory medication directly tothe intra-articular portion of the biceps,which is often irritated.6

The nonoperative treatment of LHBTinstability is less well studied and manytimes less successful in practice. Thiscondition usually follows the develop-ment of significant rotator cuff diseaseand, therefore, the treatment should fo-cus on management of the rotator cufftear. Intra-articular injections can oftenbe helpful especially in the older, sed-entary patient; but prolonged activityrestrictions are often necessary to mini-

mize the symptoms. In younger, activepatients, this more often requires surgicalintervention to address the pathology.6,65

When the symptoms are secondary toimpingement, subacromial injectionscan often be helpful, and the rehabilita-tion once again focuses on the rotatorcuff. In all these situations, failure tomake significant improvement after 3 to4 months may indicate the need for surgi-cal intervention.

When biceps-related pain is secondaryto a SLAP lesion, especially type II and IVlesions, the initial treatment once againincludes rest, anti-inflammatory medi-cation, stretching, and strengthening,especially focusing on scapula stabiliza-tion, shoulder conditioning, and shoulderrange of motion. Care should be takento prevent the patient from placing theshoulder in positions that apply adversestresses to the biceps anchor. For example,patients who suffer SLAP lesions from acompressive injury mechanism should re-frain from upper extremity weight bear-ing to minimize sheer and compressionon the superior labrum.82 Likewise, exces-sive external rotation should be avoidedin overhead athletes who most commonlysuffer peel-back mechanisms of injury.12

A third subgroup of patients include trac-tion-related injuries, which require theavoidance of heavy eccentric or resistedbiceps contractions.82 It should be notedthat conservative management for type IIand IV SLAP lesions is often unsuccessfulsecondary to labral instability and oftenrequires surgical intervention.6,82

Agreat deal has been written

about LHBT disease and thevarious surgical treatments avail-

able,1,3,6,8,44,51,56,64,65,74 with little consen-sus among the experts.5 Much of thedisagreement can be traced to the com-plexity of the glenohumeral joint andthe lack of clear understanding of theactual function of the biceps tendonwithin that system. Clearly, the bicepstendon has some role, but to what extent


[ CLINICAL COMMENTARY ]is up for debate.4,45,46,58,59,63,78,83 The mostimportant factors in selecting a surgicaltreatment are the primary cause of thecondition, the integrity of the tendon, theextent of tendon involvement, and anyrelated pathology, such as impingementand rotator cuff disease, that also needsto be addressed.1,3,6

Decompressing the biceps tendon by re-leasing the transverse humeral ligamentand releasing the bicipital tendon sheathwithin the groove with either open or ar-throscopic surgery has been described.52

The use of tendon release within thegroove is limited to intact tendons withmild inflammation that lack additionalpathologies. In addition, severe recal-citrant tendinopathy and tendinopathyoutside the groove will not respond. Fail-ure to comply with these tight indicationssignificantly decreases the effectivenessof the procedure, thus it is performedinfrequently.1

Subacromial decompression with bothopen and arthroscopic techniques hasbeen described in the past to addresstendinopathy of the biceps secondary to“impingement syndrome.”53 As mentionedabove, when utilized in conjunction withdebridement of the biceps tendon formild disease this option can be very ef-fective. In fact, Neer53 demonstrated thatonly 30% of the 50 patients in his studywho had a diagnosis of tendinopathypreoperatively actually had significantbiceps disease that could be verified, andgood results were obtained with address-ing the impingement component usingacromioplasty alone. In a series of 307cases, Walch et al75 found that acromio-plasty, in association with biceps tenod-esis or tenotomy, was only beneficial inthose patients with an acromiohumeraldistance of greater than 7 mm and anisolated supraspinatus tear. In addition,patients with proximal migration of thehumeral head may actually have a pooreroutcome by performing the procedure.

However, the utilization of acromioplastyalone for isolated biceps pathology hasnot been studied. We postulate that faileddecompressions or acromioplasties occurbecause of unrecognized biceps diseasethat is not effectively treated by acromio-plasty alone.

Debridement of the intra-articularportion of the biceps tendon has beensuggested for partial tears, includingdelamination and fraying that involvesless then 25% of the tendon in young,active patients5,6,65 or less than 50% ofthe tendon in older, sedentary patients.6

Often, this is accompanied by a decom-pression of subacromial soft tissue alonein younger patients, or bursectomy andacromioplasty in older patients. Manyauthors believe that debridement alone isnot effective in eliminating symptoms orpreventing eventual biceps rupture, thusbiceps tenotomy or tenodesis should beundertaken in these situations.1,11,30,38,76

Throughout the literature there is a cleardebate between tenotomy and tenod-esis for the treatment of biceps pathol-ogy.1,5,6,9,10,65 Tenotomy consists of cuttingthe LHBT prior to its intra-articular su-perior labral insertion ( ). In con-trast, tenodesis also requires a tenotomyof the LHBT, but with the additional stepof anchoring the tendon along its origi-nal course more distally. Traditionally, avariety of tenodesis techniques have beendescribed as the surgical treatment ofchoice,7,9,11,22,28,43,44,47,51,64 providing main-tenance of the form and possibly func-tion of the biceps, while at the same timeproviding pain relief.5 Numerous authorshave questioned the long-term results ofthis procedure.7,9,22,30,38,76

Biceps tenotomy was initially pro-posed by Walch76 in an attempt to pro-vide pain relief in the setting of massiverotator cuff tears, which were not rep-arable using an open technique. Gillet al30 then reported the results of 30patients treated with intra-articulartenotomy as the primary procedure forbiceps degeneration, instability, and re-calcitrant tendinopathy ( ). Anassociated subacromial decompressionwas performed in 2 cases. Seventeen ofthe patients in the study group partici-pated in athletics less than 3 days perweek, 12 were recreational athletes with

Arthroscopic views of degenerative bicepstendons within the glenohumeral joint. Note thehyperemia (A) and the frayed degenerative conditionof the tissue (B). The use of an arthroscopic biter toperform a tenotomy (C) with the final result (D).


participation 4 to 7 days per week, and 1participated at a professional level. Post-operatively, only 2 patients complainedof activity-related pain that was moder-ate in nature, 90% returned to their pre-vious level of sports, and 97% returnedto their previous occupation at an aver-age follow-up of 19 months. There wasan overall complication rate of 13.3%with 2 cases of impingement-relatedoverhead-activity pain, 1 instance ofpainless “Popeye” deformity ( )that resolved with tenodesis, and 1 con-tinued complaint of biceps pain. Themean American Shoulder and ElbowSurgeons (ASES) score was 81.8.

These results were reconfirmed ina separate, 2-year-minimum follow-up study of 40 patients with refractorybiceps tendinopathy who underwentarthroscopic release alone or in combina-tion with other shoulder procedures. Inthis series, the mean ASES was 77.6; butin those patients with an isolated LHBTrelease, this increased to 87.8, with only 1patient having a poor result, secondary tosevere arthritis of the glenohumeral joint.This same study reported no loss of bicepscurl strength in individuals over 60, andminimal strength loss overall. Even moreimportantly, 100% of patients reported apain-free biceps at rest, 95% experienceda significant decrease in overall bicepstendon pain, and 95% had relief of theiranterior shoulder pain upon palpation.There was a 70% incidence of Popeyedeformity,38 which is higher than that re-ported in the literature.30,57,76 Osbahr et al57

reported no significant difference in thelevels of anterior shoulder pain, cosmeticdeformity, or muscle spasm between pa-tients treated with tenotomy versus teno-desis for chronic bicipital pain, and Gillet al30 had only 1 tenotomy patient out of30 who required a tenodesis to address anunacceptable Popeye deformity.

Shank et al66 further compared the2 procedures by using Cybex isokineticstrength testing. Their results demonstrat-ed no statistical difference in either fore-arm supination or elbow flexion strengthwhen comparing 31 control subjects, 17patients posttenotomy, and 19 patientsposttenodesis. In comparison, papersspecifically looking at ruptures report lossof forearm supination strength of 10% to20% and up to 8% loss of elbow flexionstrength in the acute setting.50,79 However,Warren79 demonstrated no change in theflexion strength in a series of patients withchronic ruptures. Pronation, grip, and el-bow extension strength were all normalthroughout the various studies.

As stated previously, the traditional in-dications for tenodesis have been par-tial tears of the biceps involving greaterthan 25% of the tendon, subluxation,disruption of the soft tissue stabilizersof the groove, recalcitrant tendinopathy,chronic tendon atrophy, and significantbiceps disease following failed rotatorcuff or impingement treatment.21,51,56,65

This procedure can be performed eitherin an open fashion9,24,26,51,56 or arthroscop-ically.11,28,43,44,47,64 Gilcreest29 in 1926 firstdescribed tenodesis to the coracoid forrupture of the LHBT. This was followedby methods that secured the tendon with-in the groove, but left a proximal stump.Later Froimson and Oh26 described anopen keyhole interosseous tunnel tech-nique that relocated the tendon withinthe groove after amputating the proximalstump. Although rather tedious, Froim-son and Oh’s technique was a superiorclinical advancement and led others todevelop simpler techniques. Mazzoccaet al51 and Edwards and Walch24 have de-

scribed open techniques utilizing inter-ference screws with good success.

Building upon these advances, nu-merous other authors have developedall arthroscopic techniques.11,28,43,44,47,64

Gartsman and Hammerman28 in 2000presented a technique using suture an-chors for tenodesis. Several others havedeveloped procedures using interfer-ence screw technology, with variationson passing the tendon, including Boileauet al,11 using a transhumeral guide pin,Klepps et al,44 employing a bone anchorat the bottom of the tunnel to act as a pul-ley, and both Romeo et al64 and Lo andBurkhart,47 using the Arthrex (Arthrex,Inc, Naples, FL) biotenodesis system.Boileau et al11 reported the early resultsof 43 patients who underwent their pro-cedure, with a minimum 1-year follow-up. In this study, the absolute Constantscore increased from 43 to 79 points, withno loss of elbow motion, and the overallbiceps strength was 90% of the contralat-eral side. There were 2 cases of rupture ofthe tenodesis, which was attributed to us-ing screws of insufficient diameter earlyin the study, and no cases of neurologic orvascular compromise. It should be notedthat the prolonged ache and spasm oftendiscussed in relation to tenotomy is actu-ally an uncommon long-term complica-tion and has been described in relationto tenodesis as well.

Boileau et al10 in 2007 reported theirretrospective data on 68 consecutive pa-tients, in whom existed a total of 72 ir-reparable rotator cuff tears with bicepspathology, and who were treated with ar-throscopic biceps tenotomy (39 cases) ortenodesis (33 cases). Seventy-eight per-cent of the patients were satisfied withtheir result, and the average Constantscore increased from 46.3 to 66.5. Therewas no difference in the results betweenthe procedures when utilized in this pa-tient population. The authors noted thatatrophy of the teres minor significantlydecreased shoulder function, and pseu-doparalysis of the shoulder and severerotator cuff arthropathy are contraindi-cations to this procedure.

“Popeye” deformity secondary to rupturedlong head of the biceps.



At our clinic, the decision to utilizetenotomy or tenodesis is based upon alengthy discussion with the patient re-garding the risks and benefits of eachprocedure, the time required for reha-bilitation following surgery, and the in-dividual patient expectations. In olderpatients who desire pain relief with aquick return to their activities, teno-tomy is often the treatment of choice. Incontrast, the young laborer, who is mostconcerned with cosmesis and supinationstrength, will often prefer tenodesis. It isimportant to remember that both of theseprocedures offer excellent treatment op-tions, and the ultimate selection should

be made in partnership with the indi-vidual patient.

In response to the potential cosmeticdeformity and occasional painful cramp-ing that can accompany biceps tenoto-my, and the persistent local pain oftenseen after tenodesis, the technique ofall arthroscopic transfer of the LHBTto the conjoint tendon was developed( ). First described by O’Brien,74

this procedure is a soft tissue variationof the earlier described techniques oftransferring the tendon to the coracoidprocess using anchors. This transfer isfelt to more closely approximate the nor-mal anatomical axis of the biceps muscleand should have improved results overconventional tenodesis. In addition, theauthors feel the technique offers a sim-pler option by working in an avascularplane without implants. Other authorspoint out that this changes the course ofthe tendon nonetheless and may resultin pain secondary to traction or adhe-sions under the insertion of the pecto-ralis major.1 In addition, some authorsfeel the increased force on the scapulamay lead to anterior scapular tilting andultimately contribute to subacromial im-pingement. As previously stated, this isa relatively new variation of an old tech-nique and no long-term studies compar-ing the 2 methods have been reported inthe literature.

A chronically subluxating or dislocat-ing LHBT will often show signs of ad-vanced inflammation or degeneration.There is usually pathology traceableto the rotator interval as well as rota-tor cuff tearing, primarily involvingthe subscapularis. The indications fortenotomy or tenodesis parallel thosediscussed previously for significant bi-ceps tendinopathy and these are themost common procedures performed inthis setting. If the patient is young andactive, one might consider a tenodesis;along with a subscapularis repair via an

open deltopectoral approach, or, if onlya partial tear of the deep superior por-tion of the tendon exists, an arthroscopicapproach can be used.3 If the patient isless active, a tenotomy with or without asubscapularis repair may be a better op-tion.6 O’Donoghue56 reported on a seriesof 53 throwers (56 cases) with isolatedbiceps tendon subluxation treated withtenodesis. In this study, 71% of patientsreported excellent progress, with 77%able to throw satisfactorily and 77%able to return to their sport of choice. Ofthose patients unable to return to play, 4had unrelated problems, 6 had pain andrestricted range of motion, and 1 injuredhis shoulder in a fall.

An attempt at relocation of a sublux-ated or dislocated tendon may be pos-sible if the tendon is still mobile andsignificant degeneration has not oc-curred. It is extremely important to re-pair and tighten the rotator cuff intervalin this situation to maintain the positionof the tendon in the groove. In addition,following the repair, it is imperative to

Arthroscopic view in the subacromialspace, demonstrating the steps of a biceps tendontransfer. The biceps tendon being released from thegroove (A), during passing of the sutures (B), and thefinal attachment of the long head of the biceps to theconjoint tendon (C).

Arthroscopic view of a superior labral(SLAP) lesion, demonstrating detachment of thebiceps tendon anchor from the glenoid (A). A similarSLAP lesion has been repaired using a suture anchor,once again providing fixation between the bicepsanchor and glenoid rim (B).


verify the location of the tendon withinthe center of the groove and adequatestability throughout the shoulder rangeof motion.3 Recurrent instability, with aresulting stenosed, painful tendon, is acommon long-term complication follow-ing any procedure that attempts to repairthe sling and stabilize the tendon in thegroove.

An entire contribution within this spe-cial issue is devoted to the recognitionand treatment of SLAP tears, thus wewill only make a few brief comments asit relates to type II and IV tears involvingthe proximal biceps tendon. Type II tearshave, by definition, a detached bicepsanchor and therefore require stabiliza-tion usually with suture anchor fixationor bioabsorbable tacks ( ). A typeIV SLAP tear includes a bucket-handleportion of the labrum that extends intothe biceps tendon. In these cases, if thetendon is not too degenerative and thetear involves less than 30% to 40% ofthe tendon anchor, the tendon can sim-ply be debrided and the superior labrumeither debrided or reattached, providedthe flap is large enough.82 If more than40% of the tendon is involved, usu-ally a side-to-side repair is performed,where possible, along with treatment ofthe labrum, as above. However, in caseswhere the biceps origin is more signifi-cantly damaged or if there is a great dealof degeneration of the tendon, bicepstenodesis or tenotomy offers a betteroption to direct repair.3

All caregivers working togeth-

er as a cohesive team improvepatient management and help to

ensure optimal patient outcomes. Dueto the variety of surgical techniques usedto manage biceps pathology, it is impera-

tive that the therapist communicates fre-quently with the physician to ascertain thetype of surgery performed, the type of fix-ation, the patient’s tissue quality, the qual-ity of the repair, concomitant proceduresperformed, and any special instructionsspecific to the patient’s rehabilitation. Tofacilitate this communication, doctors atour clinic typically visit with the patientsduring the first therapy session with thephysical therapist. Patient understand-ing and compliance are improved whenthere is consistent communication fromall members of the team regarding pre-cautions, sling use, activity restrictions,and a timeline for return to activities.

There are differences in the managementof biceps tenotomy compared to tenode-sis. Tenotomy rehabilitation will be moreaggressive and advance more quickly, be-cause the necessary protection for heal-ing tissue is minimal. The primary riskof an aggressive approach is a Popeyedeformity ( ). The Popeye defor-mity has been reported to be present in62% to 70% of patients following teno-tomy.10,38 However, the resultant negativeconsequences of a Popeye deformity arerelatively benign.10,38 Conversely, reha-bilitation following tenodesis will prog-ress more slowly over the first 6 weeksto protect the healing biceps tendon.The patient is instructed on several be-havior modification strategies to protectthe repair. They are taught that activitiescausing contraction of the biceps muscleshould be avoided, such as resisted elbowflexion and forearm supination.67 Thepractical implication is that the patientneeds to refrain from activities such aslifting, opening door knobs, or using ascrew driver with the involved extremity.Clear instruction to the patient regard-ing activity and behavior modificationsfrom all members of the “clinical team”will help protect the repair and ensureoptimal outcome.

In general, in our clinic, each patientreceives instruction on a comprehensive,individualized, written home exercise

program. The program is routinely re-viewed with the patient and updated withmore challenging exercises as the patientprogresses.

Successful biceps rehabilitation requiresthe therapist to create a healing environ-ment based on soft tissue healing prop-erties. Creating a healing environmentinvolves controlling pain, swelling, irrita-tion, and the loads placed on the healingtissue. Tendons have 7.5 times lower oxy-gen uptake than skeletal muscles, whichmay explain why tendons can be slow toheal after an injury.67 Progressively load-ing a healing tissue can promote soft tis-sue healing, as long as the applied loadis appropriate to the patient’s stage ofhealing.

Sharma and Maffuli67 state that tendonhealing occurs in 3 broadly overlappingstages. Patients will progress throughthe stages at different rates. Treatmentmust be individualized, based on soft tis-sue healing as well as the patient’s clini-cal presentation. Therefore, decisions toadvance patients through the phases ofrehabilitation should be based on soft tis-sue healing times, as well as clinical pre-sentation and response to treatment.

The proposed functions of the biceps atthe shoulder include joint compression,anterior stabilization, and superior stabi-lization.4,41,42,45,53,78 It is difficult to deter-mine the extent to which biceps surgerywill affect shoulder function, becausethe role of the biceps at the shoulder isnot fully understood. Maintaining thebiceps muscle length-tension relation-ship and the axis of the biceps muscle isthought to be important for preservingbiceps function at the shoulder.74 Bicepstenodesis provides the opportunity tomaintain tension in the tendon along itsoriginal alignment, but the attachmentsite is distal to the shoulder. Techniquessuch as the biceps transfer will attachthe LHBT proximal to the shoulder butin a different alignment along the con-


[ CLINICAL COMMENTARY ]joint tendon. Regardless of the surgicalprocedure, there will likely be alterationsin shoulder proprioception and functionthat will have to be addressed duringrehabilitation.

here is minimal research spec-ifically relating to the rehabilita-tion of the long head of the biceps.

In the latest Cochrane review33 of physi-cal therapy for shoulder pain there wereno studies specific to long head of bicepslesions. Currently, the best evidence forpostoperative rehabilitation is surgeonand physical therapist experience. Ourclinic has developed protocols that areused as an outline to guide the rehabili-tation process ( ). Theprotocols are divided into 3 phases. Ad-justments are made depending on thepresentation of the individual patient.It is important to take into accountpertinent patient history, mechanismof injury, and patient goals when plan-ning the course of treatment for thepatient. Decisions to advance throughthe phases of rehabilitation are basedon protecting the healing tissue, apply-ing controlled loads to the healing tis-sue, and monitoring patient response totreatment in terms of changes in painand swelling.

Manual therapy treatments, such asrange-of-motion exercises and gle-nohumeral joint mobilizations, are mostappropriate during phases 1 and 2 (AP-

). Particular attentionis focused on the posterior and inferiorcapsule. Tightness of these structures islinked to impingement.27,37,48 Soft tissuemobilizations are utilized to decreasepain and spasms of the biceps or othershoulder muscles. As patient range ofmotion increases, manual interven-tions are decreased in favor of activeexercises.

Rehabilitation begins 1 day postopera-tively. A standard sling is used as neededfor comfort. An elastic wrap is placedover the upper arm to provide supportto the healing biceps. A transcutane-ous electrical nerve stimulation unit isapplied in the recovery room and senthome with the patient for pain manage-ment. The goals for phase 1 are to de-crease pain and swelling, initiate gentlerhythmic stabilization exercises, initiatescapular stabilization exercises, and re-store full passive shoulder range of mo-tion. Passive shoulder external rotationis often painful, and placing half of afoam roll under the patient’s arm duringsupine exercises helps to relieve some ofthe discomfort. Full passive motion is ex-pected 1 to 2 weeks postoperatively, withpatients posttenotomy typically achievingfull motion slightly ahead of those post-tenodesis. Manual therapy treatmentsand modalities are utilized as needed todecrease pain and improve range of mo-

tion. During this phase, nothing super-sedes the importance of protecting thehealing tissue.

Particular attention is placed onrhythmic stabilization and scapular sta-bilization exercises during phase 1. Iso-lated scapular retraction, with the armimmobilized, has been shown to producelow levels of biceps activity.68 Therefore,scapular retraction exercises are initiatedearly in phase 1 to improve neuromus-cular control. This sets the stage for thescapular stabilization and rhythmic sta-bilization exercises performed in phases2 and 3. Gentle rhythmic stabilizationexercises are initiated with the patientsupine, the arm at 0° of shoulder flexion,and half of a foam roll supporting the el-bow, then progressed to 90° of forwardelevation.

At our clinic, to advance the patientfrom phase 1 to phase 2, patients shouldbe able to perform passive range of mo-tion to 80% or greater of the uninvolvedshoulder, 1 minute of rhythmic stabiliza-

Lawn chair active range-of-motion progression from supine to sitting. The patient is progressed throughincreasingly upright positions to gradually increase the effect of gravity on the shoulder.


tion in the supine position with arm at90° forward elevation, and no increase inpain or swelling after treatments. Typi-cally, both biceps tenodesis and tenotomypatients are able to advance beyond phase1 after the first week.

At this point, patients are typically out ofthe sling and experiencing minimal pain.Some patients will attempt to resumeactivities too early, which can result inirritation to the biceps. Patient educa-tion about proper behavior modificationbecomes important for maintaining ahealing environment for the biceps. Thegoal for phase 2 is to increase active rangeof motion, activity tolerance, and muscleendurance.

A key rehabilitation regimen used dur-ing this phase is the lawn chair progression( ), which involves transitioningfrom supine active range of motion tomore functional active range-of-motionexercises sitting upright. Flexion above90° in the supine position will be gravityassisted. As the patient becomes increas-ingly upright, the external torque on theshoulder is increased due to the orienta-tion of the upper extremity in relation togravity and the related increased lengthof the upper extremity moment arm. Theultimate result of this higher load is anincreased muscle demand, which is nec-essary to maintain proper shoulder kine-matics. Any upper trapezius substitutionnoted at this point should be addressedimmediately. Side-lying shoulder flex-ion is a good alternative exercise if thepatient struggles with proper techniqueduring the lawn chair progression. If thissubstitution is necessary, the lawn chairprogression should be reinstituted oncethe patient demonstrates mastery of theside-lying flexion maneuver. In addition,rhythmic stabilization exercises are ad-vanced in accordance with the lawn chairprogression, so that the effect of gravityon the arm is gradually increased withthis regimen as well.

At our clinic, to advance from phase2 to phase 3, patients should be able to

perform 30 repetitions of active shoulderelevation in standing to 80% or greater ofthe uninvolved shoulder, without uppertrapezius substitution, and 30 repetitionsof side-lying external rotation to 80% orgreater of the uninvolved side, with noincrease in pain or swelling after treat-ments. Patients posttenotomy typicallyadvance more quickly than those post-tenodesis. Phase 2 lasts approximately 2weeks for tenotomy compared to 6 weeksfor tenodesis.

The goals for the third phase are in-creased endurance and strength. Bicepsstrengthening should begin week 3 forpatients posttenotomy and week 7 forthose posttenodesis. Isotonic exercisesshould begin with eccentric biceps con-traction only, then progress to a full iso-tonic exercise range, including concentricand eccentric biceps contraction, as tol-erated by the patient. Biceps strengthen-ing should include both supination andelbow flexion exercises. Exercise selec-tion is based on patient goals and activitydemands. For example, baseball playersrequire eccentric control of elbow flex-ion during throwing, whereas a manual

laborer may require supination strengthfor screwdriver use.

Proprioception and neuromuscularre-education exercises are important tocounteract the inhibitory effects painand inflammation have on the rotatorcuff and scapular stabilizers.40,49 Resistedshoulder extension is a good exercise toemphasize lower trapezius muscle activ-ity, while minimizing upper trapeziussubstitution ( ). Proper scapularstabilization will provide a stable basefor glenohumeral joint movement, aswell as maintain optimal length-tensionrelationships for the rotator cuff mus-cles.20,80 With our scapular and rotatorcuff-strengthening programs, muscleendurance is emphasized, because mus-cle response times at the shoulder havebeen shown to decrease after fatiguingexercise.19 Therefore, neuromuscular re-education should include multijoint andmultiplanar endurance exercises. Flexbar and Bodyblade rhythmic stabiliza-tion exercises are performed at varyingshoulder and elbow positions. Strength-ening exercises focus on incorporation ofthe entire kinetic chain, including coordi-nated lower extremity, trunk, and shoul-der movements in multiple planes.

Resisted shoulder extension performed with red sport cord resistance. The focus is on scapularretraction with minimal upper trapezius activity.



Rotator cuff strengthening beginswith basic sport cord external and in-ternal rotation exercises performed withthe arm supported at 30° of abduction( ). The position of 30° abduc-tion with an isometric adduction forcewill increase the subacromial space,which is advantageous in minimizingrisk for impingement during rotator cuffstrengthening.32 At our clinic, exerciseswith shorter lever arms and exercisesbelow 90° of arm elevation are utilizedfor strengthening the shoulder. In thisposition, strength and endurance can beincreased with minimal risk of impinge-ment. Once the patient has developed anadequate strength base, the focus shiftsto improving neuromuscular control infunctional positions. We do not performheavy resistance strengthening exercises

in positions above 90° of elevation orwith long lever arms. In our opinion,the increased risk for impingement out-weighs the potential benefits. Exerciseswith longer lever arms and exercisesabove 90° arm elevation are utilized formuscle endurance and neuromuscularre-education only.

For patients to advance to the return-to-sport phase, they must be able to per-form 1 minute of red sport cord externalrotation at 30° of abduction, 1 minute ofrhythmic stabilization standing with armat 90° forward elevation, and no increasein pain or swelling after treatments. Pa-tients with tenotomy usually make thetransition 4 to 6 weeks postoperatively,whereas those posttenodesis will not ad-vance until weeks 8 to 12.

The goals for this phase are to increasemuscle strength, increase muscle power,successfully complete an interval throw-ing program, and return to the previouslevel of sport participation. Plyometricexercises are appropriate at this phaseto enhance dynamic stability, enhance

proprioception, and gradually increasethe sport-specific loads applied to theshoulder. For example, Swanik et al71

demonstrated that a 6-week internal ro-tation plyometric training program per-formed by female swimmers enhancedproprioception, kinesthesia, and muscleperformance characteristics. Plyometricexercises should be chosen individuallyfor each athlete based on sport-specificdemands. Plyometric exercises are ad-vanced from 2-arm, short-lever-armactivities below 90° of arm elevation,to single-arm long-lever-arm activitiesabove 90° of arm elevation. A sampleplyometric progression could begin witha chest pass exercise and progress to aproprioceptive neuromuscular facilita-tion (PNF) D2 pattern exercise.

Our athletes are able to return tosport if they have minimal pain, full mo-tion, and full strength. The athlete shouldbe able to tolerate 1 minute of rhythmicstabilization at 90° of abduction and 90°of external rotation with red sport cordresistance ( ), 1 minute of forwardPNF D2 plyometrics, and 1 minute ofbackward PNF D2 plyometrics (

Rhythmic stabilization performed at 90°of abduction and 90° external rotation with red sportcord resistance.

Shoulder external rotation performed at30° of abduction with red sport cord resistance.

This series of pictures demonstrates plyometric proprioceptive neuromuscular facilitation D2 reversethrows with a small, green, 1-kg medicine ball. (A) To start, the therapist throws the ball over the patient’s shoulder.(B) The patient catches the ball and decelerates it down to the front foot, (C) then accelerates the ball back overthe shoulder, (D) throwing it to the therapist.

A


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32. Graichen H, Hinterwimmer S, von Eisenhart-

). The patient must also be free of painduring sport activities.

here has been an increasing

focus on the involvement of theLHBT in shoulder dysfunction and

pain generation, but there is little consen-sus on the overall function of the tendonat the glenohumeral joint. In addition,the diagnosis of biceps pathology is dif-ficult secondary to the high incidence ofconcurrent disease processes, that occurabout the shoulder when biceps problemsare encountered. We have obtained an in-creased understanding since the advent ofdiagnostic arthroscopy, but there are stillnumerous questions to be answered. Thelack of agreement is most evident whendiscussing treatment options that includetenotomy versus tenodesis. Despite thecontroversy, most authors would agreethat the primary treatment principle isthe removal of the proximal biceps fromthe shoulder joint. The LHBT clearly hassome role in the shoulder, but, based oncurrent information, the loss of this func-tion is much less detrimental than retain-ing a diseased tendon.

We have only begun to fully compre-hend the complex dynamics of the shoul-der, but it is clear that a comprehensivemultidisciplinary team approach will berequired to achieve good patient out-comes. The rehabilitation team will playan instrumental role in that process. Werecommend postoperative rehabilita-tion based on the specific pathology andprocedures performed with adjustmentsmade, depending on the presentation ofthe individual patient. Decisions to ad-vance through the phases of rehabilitationare based on protecting the healing tissue,applying controlled loads, and monitor-ing the patient response to treatment,with an ultimate goal of a safe return tofunctional activities. Given the paucity ofoutcome literature regarding the rehabili-tation protocols utilized in the treatmentof biceps lesions, all patients would ben-efit from further studies in this area.


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41. Kido T, Itoi E, Konno N, Sano A, Urayama M,Sato K. The depressor function of biceps onthe head of the humerus in shoulders withtears of the rotator cuff. J Bone Joint Surg Br.2000;82:416-419.

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swelling allow

Pendulums to warm-upPassive range of motionWeek 1Full passive elbow flexion/extensionFull passive forearm supination/pronationFull passive shoulder range of motionSeated scapular retractions

Pendulums to warm-up

Active range of motion, with terminal stretch toprescribed limits

Week 2Full active shoulder range of motion, lawn chair

progressionActive elbow flexion and extension, full range of motion

allowedActive forearm supination/pronation, full range of motion

allowed

Pendulums to warm-up and continue with phase 2Week 3Sport cord internal rotation at 30° abductionSport cord external rotation at 30° abductionProne I, T, Y, W

Sport cord standing forward punchSport cord low rowsSport cord bear hugsBicep curlsResisted supination/pronation

Week 4Keep hands within eyesight, keep elbows bentMinimize overhead activities(No military press, upright rows, or wide-grip bench)

Computer: 1-2 wkGolf: 4 wkTennis: 8 wk

*Produced with the help of Dr Richard Hawkins and Howard Head Sports Medicine at Vail, CO.

Clinical modalities as neededGlenohumeral range of motion

capsular tissues

- Cross-arm stretch- Sleeper stretch

Early scapular strengthening

trapezius facilitation

Continue with modalities and range of motion as outlinedin phase 1

Begin rotator cuff strengthening

- Prone I, T, Y, W- Scaption (not above 90°)- Ceiling punch- Biceps- Triceps

Continue with phase 2 strengthening, with the followingadditions:

re-education

exercises

- Keep hands within eyesight, keep elbows bent

- Minimize overhead activities

- No military press, upright rows, or wide grip bench

Continue with phase 3 program

Re-evaluation with physician and therapist

Advance to return-to-sport program, as motion and

strength allow

* Produced with the help of Dr Richard Hawkins and Howard Head Sports Medicine at Vail, CO. This protocol is intended to provide a general guideline to treating biceps tendinopathy.Progress should be modified on an individual basis.



APPENDIX C

Phase 1: Passive

Phase 2: Active

Phase 3: Resisted

Weight Training

Return to Activities

BICEPS TENODESIS POSTOPERATIVE REHABILITATION PROTOCOL

* Produced with the help of Dr Richard Hawkins and Howard Head Sports Medicine at Vail, CO.

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