Biceps Tendonits- A clear view

Technology is fantastic (when it works) I recently invested in some to allow me to talk to clients in a clearer way. Since I have it at my finger tips, quite literally, I thought that I would take the time to explain Biceps Tendinitis from an Orthopedic point of view. We will go over both the anatomy of the injury and a basic treatment principles.

Biceps tendinitis is an equal opportunity injury. By that I mean that you will find it in mothers lifting heavy babies, factory workers, athletes such as tennis players, massage therapists, and even office workers reaching for heavy books on their desks. Across the board what connects all these things is the repeated over loading of the biceps tendon,  irritation of the synovial membrane encasing it, and irritation of the transverse humeral ligament.  Clients with biceps tendinitis will report pain at the bicipital groove, point tenerness at the same location, pains or aches into the arm and shoulder, and often have hard rope-y muscles around the area. The speeds test should be used to confirm your assessment. 

In treating biceps tendinitis its essential to understand the anatomy fully, because although the suffix "itis" tells you that it is an inflammatory condition, the anatomy of the shoulder lends special complications to the treatment. By fully understanding the anatomy, you can quite effectively treat.

Let's take a look at what is so special about the shoulder anatomy for the biceps. Here are images that will help you understand what makes this different than your normal "itis" treatment. The first view is a highlighted isolation shot of the biceps tendon and attached muscle. As the muscle turns to tendon you can see it travel up into the bicipital groove, passing below the transverse humeral ligament and into the shoulder where it attaches at the supra-glenoid tubrical. The second image is what is really interesting. That same anatomy shot from above gives you a clear idea that this is not just about swelling from overloading, but also about space and angles. If that tendon becomes so inflamed that it cannot in fact pass easily through the "tunnel" formed by the anatomy, it will friction along it, which in turn creates more inflammation. There are 3 factors at play here which can be directly effected by massage, the width of the tendon passing through (is it irritated?), the health of the ligament (is it swollen from repeated impact and abuse) and the angle at which the tendon passes through the "tunnel" (which can effect both the tendons inflammation and the ligaments) Your intake should help you decide what the aggravating factors are, and there by the main problem, which might be 1 or all of the contributing factors.  

You will want to determine if the client is in acute, sub-acute or chronic before the treatment. Treatments in the early stages can be used to help speed healing, and re-educate clients about alignment, but it is the later stages that can be used to correct problems. For this the injury must be in chronic. Someone who has had the injury for a length of time but has reoccurring flairs is considered chronic as well. 

During treatment you will want to pillow the shoulders into the correct anatomical position, relive any trigger points, use active release to strip out the muscle and activate the muscle pump to restore circulation. When you begin to work the biceps tendon, I recommend ending the process with a biceps stretch. I usually do this by hanging the arm off the table and using gentle pnf techniques which will lower the pain response to the tender tissue at the anterior of the shoulder. The goal here is a nice long lean biceps tendon, that fits well through the anatomical structures. For this particular type of "itis" treatment sometimes I recommend the use of ice, not because there is inflammation present, but because as a side effect ice causes contraction. Imagine trying to thread a needle with a fuzzy thread? almost impossible, but if we get that thread wet, it is  a lot easier. Be careful however to ice only at the point where the transverse ligament is, as ice can contract the entire length of the muscle the long way, causing other complications and frictions against the bone. Over aggressive use of ice or inappropriate use of ice can cause just as many problems as what you are treating. 

In many other "itis" treatments you will want to use heat rather than ice in the chronic stages (which sounds counter intuitive), but again knowing the anatomy is essential. If a structure is shortened in chronic, and rubbing across a bone, contracting the structure would be in no way beneficial, and would in fact cause more damage. 

After the treatment take the time to explain to your client how to align their shoulder during their aggravating tasks for the least possible irritation. Many relapses can be avoided by simple client education. 

The biceps tendinitis is VERY treatable through massage and has a high success rate because for most people, letting the arm rest is less of a problem than say, resting the achilles.  Provided you understand what is really going on to create the problem in the first place, this should be a staple go to 'success' in your massage practice. 

For more information please see NYC sports massage
by Beret Kirkeby