Ah, the diagnosis of biceps tendonitis. We’ve all seen it so many times on script from doctors.
Is all anterior shoulder pain coming from the biceps? How can you tell? How does this change your rehab?
We’ll answer all this and more in this episode.
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#AskMikeReinold Episode 355: Evaluation and Treatment of Biceps Pain
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Show Notes
• Eval and Treatment of the Shoulder Masterclass
Transcript
Gavin Harden:
This week, Nathan from Ireland asks, “I’ve been a practicing physio for a few years. I have one doctor that tends to diagnose anterior shoulder pain as biceps pain in the majority of her patients. How do you evaluate biceps pain and how does your treatment change if you feel it is more biceps than rotator cuff?”
Mike Reinold:
Awesome. All right. Really good question. I think this happens to a lot of people, right? I think we see this a lot. Biceps pain, tendonitis, tendinosis, common diagnosis when you have anterior pain. I think just selectively with my caseload and who I work with right now, I feel like I’ve seen that a little bit less lately. But I do remember at one point in time, anytime it was anterior shoulder pain, the doctors would send a script that says biceps pain. So let’s talk about that a little bit. Let’s talk about maybe the evaluation in figuring this out, but how do we determine this is biceps pain? And before we talk about what we do with it, but is all anterior shoulder pain biceps pain? Who wants to start with that? And I got to ask, Kevin, have you and Dan Pope done your deep dive on this topic yet? I feel like you’ve hit most topics by now, but do you want to start this one off?
Kevin Coughlin:
Sure. Yeah. We did look at this and Dan had a really good interview with Rob Mansk talking about biceps tendinopathy and kind of…
Mike Reinold:
Oh cool.
Kevin Coughlin:
…Asking Rob that question, “Is this all biceps tendon pain?” And kind of what we found when we were looking at things is that they kind of categorize it as there’s primary biceps tendon pain where maybe somebody has a bone spur or a thickening of one of the ligaments in the front of the shoulder that can irritate the biceps tendon, but more often it seems to be secondary. And within that, almost never is the biceps tendon the only pain source in isolation. It seems like there’s usually some other pathology in the shoulder, whether it’s the rotator cuff or the labrum or something else that’s leading to biceps tendon pain. So I guess from an evaluation standpoint, you’re just trying to get a lens into when it started and maybe why it started. And at Champion, we obviously see a lot of overhead athletes and in that population, it doesn’t seem like you get a lot of that primary biceps tendon pain.
There usually is other things going on, whether it’s a very hypermobile joint or a weak rotator cuff or lack of overhead mobility contributing to biceps pain. So I guess from an evaluation standpoint, you’re trying to figure out why is the biceps taking a little bit more load? What else is going on in the shoulder that’s changing the biomechanics to irritate the biceps tendon? And then some of our special tests, I guess, can aggravate it a little bit, but I don’t think there are any great ones for the bicep tendon specifically. Palpation obviously is one. You could palpate it. And I think with that, it’s just important to look at the other side because I don’t have any biceps tendon pain, but if I get in there and dig it feels really uncomfortable. So you want to make sure that it’s not just the incidental finding there. But that’s kind of what we came across, is it doesn’t seem to be something that occurs in a high frequency just by itself. There’s often other things going on in the shoulder and we want to find that primary cause.
Mike Reinold:
I like that. And I think one of the biggest things I got from Kevin there was that there’s probably more things going on. So don’t take that diagnosis and say, “Oh, biceps tendonitis. I’m going to do this program.” No, it’s like you have to figure out what else is going on. Before we go too deep, here’s a question to the group. Okay. Kevin kind of said there’s often other times stuff going on, stuff like that. When is it just an isolated biceps? Because there’s always examples. There’s always times and it’s like, what would be an example of you definitely just have isolated biceps pain and it’s nothing else? What do you guys think? Dave?
Dave Tilley:
I recently treated like a mid-50-year-old guy who just went hard in the paint on a biceps workout at the gym. He did hammer curls, supinated curls, preacher curls. And he came in two weeks later. He was like, “Yeah, I think I hurt my labrum.” I’m like, “What’d you do?” He’s like, “Nine sets of biceps.” And I was like, “Think it’s your biceps, my guy.”
Mike Reinold:
Really?
Dave Tilley:
Yeah.
Mike Reinold:
So long head biceps pain he just had…
Dave Tilley:
Yeah. Just straight-up bicep strain.
Mike Reinold:
Wow. I like that.
Dave Tilley:
Or our friend who’s a gymnastics coach who lifted a grill into his truck and tore his bicep pretty clearly at bicep…
Mike Reinold:
That’s a good point. Yeah. Yeah, I like that. That seems aggressive, though. Everybody knows a Popeye sign. I like that. What else? What else? I guess you can have a subluxing long head. So you can tear the ligament that goes across the groove. You can have a subluxing biceps tendon. So it is possible. It’s funny, I just got back from a big conference with a lot of surgeons and when we get to the case studies, they love showing crazy case studies. There’s never the normal people we see, it’s all these disasters. And I will say you see somewhere you’re scoping the shoulder because they think it’s a SLAP tear and it looks pretty good, and then they just go up around the corner and they look at the biceps and it’s like, “Ooh, that thing looks awful. What happened?” So you never know.
And there was one example, it was really interesting, when they brought the person into external rotation, the undersurface of the biceps was actually rubbing on the humeral head and kind of chafing it. So I mean, I would say earlier in my career, I would probably be somebody that would say like, “Ah, it’s never the biceps.” And I never meant it, like it’s never the biceps. It was kind of just like a rhetorical statement, I guess. Meaning it’s rarely the biceps. But I think a lot of people think like, “Oh, Mike said it’s never the bicep.” No, it can definitely be the biceps. It’s probably just rare. But all right, sorry, I’m rambling here. So let’s get back to it. So we have biases, we have that. I would say, before we talk about treatment, one thing with special tests, Kevin said there aren’t a lot of good special tests, which I would agree. Like speeds test, stuff like that.
There’s not a lot good biceps tests out there. What I actually do in my exam when I’m looking at biceps pain is I try to rule out everything else in my exam. So I’ll try to rule out rotator cuff symptoms. Because that’s the first thing I tend to jump at is rotator cuff when it’s anterior shoulder pain. And if I can rule that out, there’s no near, there’s no Hawkins, there’s no full can, empty can discomfort. There’s no discomfort with rotator cuff, like manual muscle testing. It’s almost like you can rule the muscles out that are around that area. So I would just say that as a tidbit. Okay, we have biceps pain, what do we do? Anybody want to hit what do we do for folks? I think they asked how does your treatment change if it’s more biceps than rotator cuff was the exact question. So who wants to hit this one? I mean, I don’t know. It’s probably not a ton different, but what do you guys think?
Dave Tilley:
Sure. Yeah, I can jump back in. I think the biggest thing is to figure out whether someone’s getting a coracoacromial impingement or they’re getting direct biceps overload. So I think a lot of times people will have overhead pressing or they’re throwing a lot or something like that and the biceps tendon is getting rubbed and/or chafed or irritated along with maybe the bursa on the front of the shoulder. And so if it’s something else that is causing the biceps to get cranky from an overload point of view, that’s very different than someone who is the guy who was just going hard in the paint on bicep stuff. I often find, almost always, it’s like the coracoacromial issue more so than the direct loading. So yeah, you look at all the basic stuff of soft tissue mobility and strength and workload management, all that kind of stuff.
You have to dig in the weeds a bit to figure out what is causing this one area of the shoulder to get blown up a bit. And I think it comes down to a little, “Can we back off on some of these loading exercises? Do you have to overhead barbell press? Can you landmine press?” A lot of those times, it’s just someone doesn’t realize that 80% of the things they’re doing are causing pain. And so little soft tissue work, little modification of stuff, and then a little posterior cuff work and these people tend to do okay.
Mike Reinold:
Yeah. And taking a step back, going back to what Kevin said, if this is something that is usually not in isolation, you just take a step back and you start your checklist of things that you find. And most often, these are people that I don’t want to say beat up, I don’t know if that’s the right phrase for this particular population, but they tend to have some motion restrictions. Older individuals, maybe they have tight thoracic mobility concerns, they have loss of glenohumeral mobility, for example, or their rotator cuff strength stinks, that sort of thing. You’re not necessarily doing much to the biceps. I guess you could throw some modalities at it like laser and stuff, but I wouldn’t shockwave a long head of the bicep unless you just really hate your patient or something. That seems terrible. But I mean, maybe it’ll work if they’re just going to go home and not use their shoulder for a couple of days, but to me, that seems like a lot of work.
So yeah, so I’d say big take-homes from this episode then. So evaluation treatment or biceps pain. It’s not an isolation oftentimes, so take a deeper dig into what’s going on with the person. Try to figure out if you have any other sources, anything else that may be occurring. And then just take a step back. And this is just a prime example to me where we shouldn’t always just be treating a diagnosis. You should be treating what’s functionally wrong with the person in front of you. So dig through that and then I think your treatment plan will write itself when you start looking at all the things that are probably wrong with the person. Okay. All right. Good question, Nathan. Thanks so much. Appreciate that. If you have a question like that, head to mikereinold.com, click on that podcast link. And please subscribe, Apple Podcasts, Spotify, so you can keep getting notifications and we’ll keep doing these episodes. Thank you so much.
