Hooper's Beta Ep. 27

Intro:

In this blog we will be talking about proximal proximal biceps tendinopathy. This is a shoulder dysfunction, compared to distal biceps tendinopathy which involves pain in closer proximity to the elbow. This is an irritation of the long head of the biceps near the origin of the muscle (at the shoulder). This can be a mild issue, or quite serious. 

• It may be a simple tendinopathy

• This may be a biomechanical issue, BUT

• It can be the precursor to a biceps rupture. 

• Or, it can also be a sign of a labral tear as the tendon for this inserts into the labrum of the shoulder. 

• Basically, this is a complex issue and if you don't get the answers you need from this video, seek professional help. 

 Signs & Symptoms:

The pain from LHBT tendinopathy is often focused in the anterior shoulder; the pain may radiate distally over the biceps muscle. If you have this issue, you may have a painful arc of motion associated with a click, and pain that worsens at night. Symptoms are gradual in onset, if your symptoms are sudden and acute, you may have a separate issue. 

Mechanism of Injury:

Symptoms are often aggravated by lifting, pulling, or repetitive overhead activities. Acute LHBT rupture usually occurs during a specific traumatic event that causes sudden pain, a "pop" in the shoulder, ecchymosis, swelling, and abnormal tendon appearance.  This abnormal appearance is called the Popeye sign and if you have it, you'll know. 

Testing:

The best way to test for this is with a multimodal approach. It will involve range of motion, strength, special tests, and palpation.   

• Range of motion: First, just be safe and test your range. If you can't fully flex your elbow without pain, or you cannot lift your shoulder overhead without pain, you may want to hold off on testing your strength as this may further irritate the issue. Once you've assured you have full elbow and shoulder range of motion, we can move on to strength.

• Strength: First, test your elbow flexion strength with your forearm in the thumb up position, this places less stress on the LHB so it is safer. If this causes pain, stop there, otherwise continue to the palm up position. If you have no pain in the palm up position as well, move onto our special tests. 

Special tests:

• Speeds: With the elbow straight and the palm up, lightly resist shoulder flexion, stopping if there are reproductive symptoms or pain, or at 90 degrees (shoulder height). Maintain briefly, then slowly lower while continuing to push against the resistance. This test is easier with someone to help. 

• Yergasons: This is essentially the opposite of the arm wrestling position. So instead of pulling down and in (pronation and internal rotation) you want to push into external rotation and supination. Imagine you are trying to lose the arm wrestling match but the other person won’t let you. Again, this is easier with another person. 

If either of those tests reproduce pain in the front of the shoulder, you may have an irritation to the LHB or to the ligament that is holding the bicep tendon in place. 

• Finally, palpation: Create pressure directly over the LHB in the front of the shoulder. Keep in mind, this is a sensitive area do make sure to compare to your unaffected arm. It is only positive if it is significantly different from your unaffected side.

Treatment:

This is most often a biomechanical issue but when it comes to climbing we need to look at our training and climbing styles. If you are doing a lot of hangs in full shoulder extension you could be causing impingement. If you’re climbing with your elbows always bent this could be an issue or if Monday, Wednesday, and Friday are all Biceps days, you may be doing too much. 

But, this IS MOST LIKELY a biomechanical issue. The long head of the bicep is prone to irritation from the humerus being too anteriorly translated or if the scapula does not have proper upward rotation during overhead activities. If the humerus is too anterior, the LHB in a sense acts as a restraining device to keep the shoulder in place, definitely not what it is designed to do. Whereas if you have poor muscle fire, coordination, or weakness in some of the upward rotators of the shoulder, the LHB may be getting compressed during overhead activities, such as climbing. 

So how do you know what you have? Well, if you have noticed you have terrible posture and your shoulders are always forward and you are slouched often, your shoulders / the humerus is likely sitting too far anterior. A professional can easily assess this and help with your treatment. What about the mechanics? 

If you notice your pain is worse when you are reaching overhead, it may be a mechanical issue of poor upward rotation. In order to treat that, you likely will need to strengthen the rotator cuff and certain scapular muscles. A professional would be best for this, but you can always check out our shoulder strengthening series. Look at your weakness and go from there. 

Additional note: My greatest recommendation would be looking at your ability to perform scapular retraction with your arms overhead. This means you need to strengthen your middle trapezius and lower trapezius. It may also be really important to strengthen your serratus anterior. 

Other forms of treatment if the above advice is not working: 

Other things to treat this will be rest from aggravating activities. Or in issues that are not resolving, local or systemic nonsteroidal antiinflammatory drugs (NSAIDs), or subacromial or biceps tendon sheath injections form the core of conservative care for LHBT tendinopathy.

Differential Diagnosis:

Finally, maybe you do have pain in the shoulder, BUT you didn’t have a lot of positive signs from the testing section, what else could it be?

• Shoulder impingement: Having this pain may be secondary to shoulder impingement. If you have a painful arc, or pain with the Hawkins Kennedy test, check out our video on shoulder impingement as this can help give you some answers. 

• Labral tear: The more serious differential diagnosis is a labral tear. The LHB tendon inserts into the labrum, so if you have a labral tear there's a chance that activating the long head of the biceps will pull on this year, causing pain. Fortunately, there is a good test for this called Bicep load I and II. I show these in the video but basically it involves placing your hand on your head and pulling down. Again, it is easier to have someone help with this to try and pull your hand off. You may test this with the palm down on the head or by making a fist and placing the thumb side down. It is possible to have pain with this and NOT have a labral tear, but it is not likely that you will be painfree and have a tear. So basically, if this is painfree, you probably don’t have a SLAP tear (superior labral anterior to posterior tear) and if you do have pain, you may have a tear but you will need more testing to confirm. 

Thanks for watching, supporting, and reading. As always feel free to leave a comment but please subscribe and give a thumbs up if you appreciated this video. 

And remember: Train. Climb. Send. Repeat.

Disclaimer:

As always, exercises are to be performed assuming your own risk and should not be done if you feel you are at risk for injury. See a medical professional if you have concerns before starting new exercises.

Written and Presented by Jason Hooper, PT, DPT, OCS, CAFS

IG: @hoopersbetaofficial

Filming and Editing by Emile Modesitt

www.emilemodesitt.com

IG: @emile166

Special thanks to The Wall for letting us film!

IG: @thewallclimbinggym