Biceps Tendinopathy Rehabilitation Protocol

Pathophysiology

Biceps tendinopathy of the shoulder involves inflammation or degeneration of the long head of the biceps tendon (LHBT) as it courses through the bicipital groove in the humerus. It's often associated with other shoulder pathologies, such as rotator cuff tears, SLAP lesions, and shoulder impingement. The LHBT contributes to shoulder flexion, supination of the forearm, and humeral head stability. Repetitive overhead activities, direct trauma, and age-related changes can lead to microtrauma, inflammation, and eventual tendon degeneration. Chronic overuse can lead to tendinosis, characterized by disorganized collagen, increased vascularity, and altered matrix composition. Symptoms include anterior shoulder pain, particularly with overhead activity, resisted elbow flexion, and supination.

Evaluation and Special Tests

A thorough physical examination is crucial to diagnose biceps tendinopathy and rule out other shoulder pathologies. Common special tests include:

• Speed's Test: The patient flexes their shoulder against resistance with the elbow extended and forearm supinated. Pain in the bicipital groove suggests biceps tendinopathy.
• Yergason's Test: The patient attempts to supinate against resistance with the elbow flexed to 90 degrees and the shoulder in neutral. Pain or snapping in the bicipital groove indicates biceps instability or tendinopathy.
• Biceps Load Test I & II: Patient supine, shoulder abducted to 90 degrees, elbow flexed to 90 degrees. External rotation is applied. Test I: patient flexes elbow against resistance. Test II: patient resists elbow extension against resistance. Positive test is apprehension or pain during resistance.
• Resisted Elbow Flexion: The patient flexes their elbow against resistance with the shoulder at varying degrees of flexion. Pain provocation further confirms biceps involvement.

Phase I: Protection (Week 1-3)

Goals: Reduce pain and inflammation, protect the healing tendon, restore pain-free range of motion.

• Pain and Inflammation Management:
  • Rest and activity modification: Avoid activities that exacerbate pain.
  • Cryotherapy: Apply ice packs for 15-20 minutes, several times a day.
  • Modalities: Consider pulsed ultrasound, electrical stimulation (TENS) for pain control.
  • NSAIDs: May be prescribed by a physician to reduce inflammation.
• Range of Motion (ROM) Exercises:
  • Pendulum exercises: Gentle, pain-free circular motions of the arm.
  • Supine shoulder flexion with cane assistance: Gradually increase flexion within pain limits.
  • External and internal rotation at side with cane assistance: Progress within pain tolerance.
  • Scapular retractions and protractions: Improve scapular stability and mechanics.
• Isometric Exercises:
  • Isometric biceps contractions: Performed at multiple elbow flexion angles, holding for 5-10 seconds each, minimal resistance.
  • Isometric rotator cuff exercises (internal rotation, external rotation, abduction, scaption): Gentle contractions with minimal resistance, focusing on maintaining proper form.
• Precautions:
  • Avoid heavy lifting or forceful activities that stress the biceps tendon.
  • Monitor pain levels and avoid overexertion.

Phase II: Loading (Week 4-8)

Goals: Gradually increase tendon loading, improve strength and endurance, restore normal shoulder mechanics.

• Progressive Strengthening Exercises:
  • Biceps curls with light weights: Begin with low weight and high repetitions (15-20), gradually increasing weight and decreasing repetitions as tolerated.
  • Hammer curls: Focus on neutral wrist position to reduce stress on the biceps.
  • Concentric and eccentric exercises: Emphasize controlled movements during both the lifting and lowering phases.
  • Rotator cuff strengthening with resistance bands: Progress from light to medium resistance, focusing on proper form and scapular stabilization. Exercises include external rotation, internal rotation, abduction, scaption.
  • Scapular stabilization exercises: Rows, serratus punches, prone T's and Y's to improve scapular control.
• Neuromuscular Control Exercises:
  • Rhythmic stabilization exercises: Perturbations applied to the shoulder to improve dynamic stability.
  • Plyometric exercises (e.g., wall toss): Start with low-intensity, controlled movements to improve power and coordination.
• Range of Motion Progression:
  • Continue stretching exercises to improve shoulder ROM.
  • Cross-body adduction stretch.
  • Sleeper stretch.
• Activity Modification: Gradually return to light activities, avoiding aggravating movements.
• Criteria to Progress to Phase III:
  • Minimal pain with activities of daily living.
  • Good strength in biceps and rotator cuff muscles.
  • Full or near-full ROM.

Phase III: Return to Function (Week 9+)

Goals: Restore full function, return to sport or work activities, prevent recurrence.

• Advanced Strengthening Exercises:
  • Increase weight and resistance for biceps and rotator cuff exercises.
  • Incorporate functional exercises that mimic sport or work activities (e.g., throwing motion, lifting overhead).
  • Progress to more challenging plyometric exercises.
• Sport-Specific Training (if applicable):
  • Gradually increase the intensity and duration of sport-specific activities.
  • Focus on proper technique and biomechanics to prevent re-injury.
• Work-Specific Training (if applicable):
  • Simulate work tasks to prepare for return to work.
  • Address any ergonomic issues that may contribute to biceps tendinopathy.
• Maintenance Program:
  • Continue performing strengthening and stretching exercises to maintain strength, flexibility, and endurance.
  • Implement a proper warm-up and cool-down routine before and after activities.
  • Monitor for any signs of recurrence and address them promptly.
• Criteria for Return to Sport/Work:
  • Full pain-free ROM.
  • Sufficient strength and endurance to meet the demands of the activity.
  • Successful completion of functional testing.