A Short Study from the Table
For several months I’ve been seeing a client for- specifically- pain and weakness proximally and anteriorly in the left shoulder. The pain started during a workout- specifically during the bench press, after recently increasing the weight. The client reported sharp pain during the ascending phase and weakness and pain on the descending phase of the exercise. The client reported a drastically shortened the duration of the exercise, eventually leading to a cessation of the exercise altogether.
Pain continued well after the workout, and disrupted the client’s sleep and activities of daily living. The pain subsided, though not leaving entirely, by not doing the exercises or actions which reproduced the pain, i.e.- flexing the shoulder and extending the elbow against an opposing force or dead weight.
Client also reported taking naproxen sodium for pain when necessary, but disliked taking pills if it could be avoided.
Muscle testing showed strong deltoids, rotators of the shoulders, triceps and pectorals. Muscle testing of the bicep, specifically of the long head of the bicep, reproduced the pain the client was describing.
Breakdown of Bicipital Tendonitis
Tendonitis is the inflammation or irritation of the tendon or osteotendinous junctions. Tendonitis is commonly caused by over use of the muscle or muscle group, specific stressors placed on the tendon through muscle contraction, eccentric contraction, or trauma (i.e.- forcible contraction or elongation, or sudden kinetic force) during isometric contraction.
Typically, bicipital tendonitis is found in athletes and is a common injury in athletes over the age of 35 participating in activities heavy in elbow flexion (especially with the humorous externally rotated to 45 degrees) or shoulder abduction (in the act of reaching over one’s head). Swimming, tennis, sports that involve throwing like baseball or football, rock climbing, as well as certain career paths in construction, warehouse, etc are susceptible to bicep tendonitis, though any sport or occupation which relies heavily on the use of the shoulder is more at risk.
In this case, it appears the combination of age, general inflexibility of the affected structures and the wide grip the client was using on the Olympic bar on the bench press, seem to have aggravated, if not triggered, the inflammation at the proximal end of the long head of the bicep.
The main focus of any case of inflammation is to get the affected area to calm first. No lasting work can be done while the affected area is inflamed, as any stress placed on the inflamed area can prolong the cycle of inflammation.
Initially, I used Swedish and gentle range of motion for the actual work, after the assessment and also focused on the immediate area- scapula, rotator cuff, superior Trapezius, Pectoralis Major and Minor, Deltoids, Serratus Anterior, and Triceps.
I also sent the client home with stretches specifically for the long head of the biceps and pectoralis major.
In following sessions the client indicated a lessening of pain and a return of some strength. The client had, at that point, returned to a limited extent, the workout regime- which indicated to me that the inflammation seemed to be calming.
From that point, the work become more intense and focused on the flexibility of the bicep through passive and active stretching and range of motiom, active stretching with directional tension releasing towards the long head tendon, as well as various Swedish modalities- effleurage, petrissage, friction- and some PNF.
The client continues to report gains as the sessions progressed. Muscle hypertrophy was present in the chest and arms, which indicated the client was back lifting heavy weight. Client has also reported doing the stretches on a regular basis both prior to and following the work out.
Though this particular assessment seemed to be accurate and the protocols enacted were helpful in restoring ADL’s for the client, any number of factors which could have been present or absent from the assessment could have indicated a different problem altogether.
Tendonosis – a syndrome of overuse and degeneration caused by use over time. Different from tendonitis in that there is tendon damage, wearing and or fraying, but no inflammation present. This is often a function of extended use and is typical of injuries found in older populations (65+)
In this case, it could very well have been tendonosis instead of tendonitis. The protocols would have been pretty much the same.
Impingement Syndrome: a syndrome caused when the tendons of the rotator cuff, which pass under the subacromial space (the space between the acromion process and the head of the humorous), become irritated. Symptoms usually include pain in shoulder movements related directly to the rotator cuff.
In this case, all the rotator cuff muscle tests reproduced no pain, which indicates it was a different muscle or group altogether that was affected.
Subacromial Bursitis- Much in the same manner as the impingement syndrome above, Subacromial Bursitis involves the supraspinatus tendon, but as an accessory or irritant to the inflammation. The bursa, which lies between the supraspinatus tendon and the coraco-acromial ligament, acromion, coracoid (the acromial arch) and from the deep surface of the deltoid muscle, is what actually is inflamed.
It is often lumped into the diagnosis of “Impingement Syndrome” and presents many of the same symptoms.
Frozen Shoulder- Frozen shoulder is a term used to describe painful abduction of the glenohumeral joint resulting in a limited range of motion. Typically, Frozen Shoulder is when tightness in the subscapularis muscle restricts movement causing pain in both the anteriosuperior aspects of the glenohumeral joint, as well as in the proximal deltoid muscles.
Labrum tears- The head of the Humerus articulates with the Scapula in a depression in the bone called the Glenoid fossa. The Glenoid labrum is a ring of cartilage which acts as a gasket deepening the depression and holds the head of the Humerus securely in place. A major tears can happen though traumatic injury- falls, etc, while minor tears can happen through repetitive use and age.
Typically, pain is felt in the joint, with the location relevant to the tear, accompanied with a “clicking” feel as the shoulder articulates.
This is a small list of possible issues that share commonalties with bicipital tendonitis. Obviously a more comprehensive list would require an expertise in multiple fields of medicine, and therefore, should the work we do prove ineffective for any reason, it’s best to refer the client to their doctor.
Remember: When in doubt, refer out.
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