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Dynamic Chiropractic – September 23, 1994, Vol. 12, Issue 20

Management of Instability of the Biceps Tendon in the Bicipital Groove

By R. Vincent Davis, DC, PT, DNBPM

The tendon of the long head of the biceps muscle arises from the tubercle on the superior aspect of the glenoid fossa. It passes in close proximity to the articular surface of the humeral head and then toward the bicipital groove.

It enters the groove and is covered by the transverse humeral ligament which extends between the corresponding tuberosities and is then enveloped by the regional extension of the synovium with which the tendon enters the groove. When movement occurs in the process of abduction, or adduction, of the upper extremity, the tendon undergoes a gliding movement within the bicipital groove.

Pressure against the fibrous roof of the supratubercular ridge of Meyer by the tendon results in inflammatory changes in the substance of the bicipital tendon. Also, shallowness of the bicipital, or intertubercular, sulcus, may result in vulnerability of the tendon to compressive irritative phenomenon and/or displacement from its characteristic anatomical location in the bicipital groove when influenced by forces capable of producing these results. Advancing age may result in degenerative softening of the bicipital tendon and excrescences with roughening of the margins of the bicipital groove. These changes may result in fraying of the tendon resulting in its reduced ability to resist the forces exerted upon it by the muscle. Attrition of the tendon and changes in the transverse humeral ligament render it prone to displacement from the bicipital groove.

Commonly, a rotatory injury of the shoulder in which forceful rotation of the arm externally is followed by symptoms of painful "clicking" or "thumping" in the shoulder is present in the history. Usually, external rotation of the arm results in the arm being locked temporarily in external rotation.

As a rule, the forceful rotation of the arm internally results in the repositioning of the tendon back into the bicipital groove. The shoulder motion is returned by repositioning of the bicipital tendon. As the repositioning occurs, a "click" or "thump" is often audible as the tendon dramatically returns to its groove.

The Abbott-Saunders test may be used to demonstrate and differentiate this clinical entity from peritendonitis. Following complete abduction at the shoulder, with the arm held in complete lateral rotation, it is slowly lowered to the side relative to the plane of the scapula. A palpable, or audible, and sometimes painful click may be noted as the biceps tendon is dislocated from its groove.

A conservative approach to this treatment is to reposition the bicipital tendon in its groove when tested and found displaced. Following this repositioning, moist cryotherapy is recommended directly over the site of the lesion for about twenty minutes, after which this agent should be removed. If desired, the cryotherapeutic agent may be reapplied to the site of the lesion after an 8-10 minute withdrawal, and then reapplied if prudent clinical judgment dictates.

Following this treatment to reduce traumatic edema and pain, the arm should be placed in a loose sling to allow the tendon and joint to rest. This regimen of cryotherapy and sling rest should continue daily until the patient is able to engage in appropriate therapeutic exercise (without pain) to rehabilitate the arm/shoulder to conditions allowing for activities of daily living.

With the formation of adhesions in the area of the biciptal tendon and the boundaries of the bicipital groove, it may be possible to offer some stability to the position of the tendon in its groove as a result of repeated episodes of displacement of this tendon. The development of pain at the tendon/groove site without displacement and as a possible result of a cumulative trauma phenomenon may respond adequately to moist cryotherapy application, or to the Davis procedure in the application of interferential current therapy applied, b.i.d. or p.r.n. for pain, especially to obtain increased range of motion without pain. Recommended IFC parameters are 120 Hz beat frequency with cross sectional electrode pattern located at the point of exquisite pain along the course of the tendon.

Needless to say, this traumatic displacement phenomenon may recur and require repeated episodes of clinical care. Resistance of the tendon to remain within the confines of its bicipital groove is an indication for the need to secure an orthopedic referral.

References

  1. Davis RV. Therapeutic Modalities for the Clinical Health Sciences. 2nd ed. Library of Congress Card #TXU 389-661, 1989.
  2. Griffin JE and Karselis TC. Physical Agents for Physical Therapists, 2nd ed. Springfield: Charles C. Thomas, 1982.
  3. Hoppenfeld. Physical Examination of the Spine & Extremities. Appleton/Century/Crofts.
  4. Krusen, Kottke, Ellwood. Handbook of Physical Medicine & Rehabilitation, 2nd ed. Philadelphia: W.B. Saunders Publishers, 1971.
  5. Schriber WA. A Manual of Electrotherapy, 4 ed. Philadelphia: Lea & Febiger Publishers, 1975.
  6. Turek. Orthopedics -- Their Principles & Applications, 3rd ed. Lippincott Publishers.

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