Case Study

The patient is a 74 year old female diagnosed with L bicipital tendinitis accompanied with shoulder and scapular instability. This occurs when the long head of the biceps is inflamed or impinged due to its position and function, causing pain and weakness. The long head of the biceps tendon is at risk of inflammation (tendonitis) or degeneration with inflammation (tendinosis) due to its anatomical relationship. It originates from the superior glenoid labrum and runs under the coracoacromial arch as it crosses the top of the humeral head and descends through the intertubercular groove. The tendon lies directly in contact with the superior aspect of the humeral head and between the greater and lesser tubercles. This is also why it is often caused by overuse of the muscle and with repetitive overhead activities. It is often accompanied with rotator cuff disease, subacromial impingement, osteoarthritis, shoulder instability, or labral tears. Specifically in her case, shoulder instability contributes to overuse of the long head of the biceps as a shoulder stabilizer.

At the initial eval she complained of pain in the anterior shoulder and along the bicipital groove that is increased with lifting, pushing, and overhead activities. She states this started about a week ago. She plays the banjo year-round and plays in a band all summer long as her main activity/participation within her community. She also does knitting/crocheting. She is now unable to do these things due to pain and weakness. Her banjo weighs about 50 pounds and she is unable to lift it. She is unable to lift her arm up and out to the side to get into the proper position without increased pain levels and severity. She is having significant difficulty with housework, chores, cooking/cleaning, bathing, and styling her hair. Lifting and reaching activities are the worst for her. She cannot even lift a cup of coffee or sit at her computer desk without pain and discomfort. She presents with rounded shoulders and a forward head posture which contributes to her scapular instability and weakness. This is another contributing factor as her scapula is not in the proper position to keep her shoulder and surrounding tissues in the proper positioning, leading to excess pressure and inflammation. Her main goal is to be able to return to playing the banjo and restore her prior level of function for self care and chores at home.

The following special tests were completed to help determine a diagnosis. Tests were completed bilaterally. All tests were negative on the R. Here are the results for the L side:

Empty Can (+)
Full Can (+)
Hawkins-Kennedy (-)
Neer (-)
Apprehension (-)
Jerk (-)
Speed (+)
Crank (-)
AC Shear (-)
Spurling (-)
Median/Radial/Ulnar Nerve (-)

These tests reveal pain and weakness in the supraspinatus & biceps tendinitis. No rotator cuff tear/impingement involvement. No neurological involvement. ROM for the neck, shoulder, elbow, and wrist were assessed. She has full AROM in the neck, elbows, and wrists bilaterally. AROM on the L shoulder was limited due to pain and weakness, but full AROM on the R. She has full shoulder PROM in all directions bilaterally. MMT reveals good strength in all shoulder motions on the R but limited for flexion, abduction, and IR/ER on the L indicating weakness. Scapular MMT showed weakness bilaterally. She therefore demonstrates significant weakness on the L and shoulder/scapular instability and weakness.

The POC included: to decrease inflammation/promote healing (phonophoresis with dexamethasone for 8 min, 3 MHz at 1.2 W/cm2 & 100% duty cycle over the biceps tendon); kinesiotape over biceps tendon long head and supraspinatus for pain relief and to promote scapular stability; scapular strengthening, scapular stability, postural re-education, proprioception/neuromuscular re-education, general UE strengthening to return to overhead reaching and lifting activities and restore prior level of function.

Each treatment session began with phonophoresis to decrease inflammation and pain. Kinesiotape was reapplied each visit to promote further pain relief in the biceps tendon and the supraspinatus, and also to promote scapular stability. Education was provided on her posture and why this contributes to her shoulder pain. Her rounded shoulders and forward head posture put extra pressure on the tissues and create more inflammation. Without the scapula in the proper position, the shoulder joint is not in the proper position. When you add movement, specifically repetitive and overhead activities, the tissues have more stress placed on them and they have to work harder to compensate. She lacked a lot of postural awareness when I first started seeing her. She had no idea her head and shoulders were so far forward. She especially doesn't notice her posture when she is playing music and holding her banjo up. This is why postural correction exercises are important for her - to promote/normalize scapular positioning and stability. She was instructed in chin tucks for home, and cane AAROM for the L shoulder. She was instructed to only go to pain-free ranges within her tolerance. Education on allowing her shoulder to rest was also provided. I explained to her even if it starts to feel better later, or tomorrow, that doesn't mean the tissues are fully healed yet. Just because there is no pain, that doesn't mean she should fully return to her regular activities again, because that will increase her risk of reinjury and she will have to go through therapy longer and risk not being able to play in her band this summer. Her warm-up was on the upper body ergometer for 8 minutes to increase circulation and warm up the surrounding tissues in her shoulder. The first few visits we worked on supine scapular/shoulder strengthening and stability exercises. This included shoulder flexion, sidelying shoulder abduction, and shoulder external rotation. Stability exercises included serratus punches and UE movements up/down/sideways/cw/ccw while maintaining scapular retraction and avoiding shoulder hiking. This was a difficult concept for her to understand. She would naturally compensate for scapular motion with shoulder motion. She was unable to retract her scapula, or complete any scapular motion, without rotating her upper body or hiking her shoulder. We worked on scapular PNF exercises for neuromuscular re-education, and eccentric bicep curls (as studies have shown eccentric bicep strengthening is more beneficial than concentric bicep strengthening with bicipital tendinopathy). As she progressed throughout the course of treatment, we progressed these exercises by increasing the sets/reps, eventually added weights or therabands, and progressed the exercises from supine to standing once she was able. She was eventually doing standing theraband rowing, shoulder extension, ER/IR, flexion, and abduction. Standing scapular stability eventually consisted of using the body blade, punching balloon, shoulder movements with a ball on the wall while maintaining scapular stability, and sky reaches. We also added the wall roller and eventually were able to add a theraband to this exercise as well. The ultimate goal was to get her back to her prior level of function to be able to do chores around her house, overhead reaching and lifting, self-care, and return to playing the banjo without increased pain symptoms.

She stated the kinesiotape seemed to really help with her pain. After only a couple treatments she noticed her range of motion was already improving and she was being careful not to overdo it. After a few weeks she noticed she didn't need to remind herself as often to correct her posture and maintain a chin tuck and scapular retraction, although she did say she is still not perfect at it. I reminded her she doesn't have to be perfect at it and reminded her how great of a job she was doing because of the work she was putting in to her home exercises and therapy sessions. Criteria used to progress included her pain-free ROM, strength, and scapular/postural stability. If she was unable to maintain scapular stability for a certain exercise, we would not move on until this was achieved. This is probably what took the longest during treatment. She slowly showed improvements, though, with verbal and tactile cueing required much less frequently than when she first started therapy.

Overall, treatment went as expected. She was very compliant with her home exercises and postural education, along with giving her shoulder time to rest without overdoing it. There were no major changes to the POC. We did have a few minor setbacks during the 2nd week - this was when we did not reapply kinesiotape to avoid skin irritation, and she said she tried playing her banjo a little bit. She held off on trying again for a while. We just worked on getting her to be able to get into the position, then worked on strengthening and stability in order to get her there. After several more weeks, she was finally able to hold her banjo without any increased pain symptoms during or afterwards. She was not able to play it yet (when she started playing she had minor discomfort), but she was at least able to get it up where she needed it to be in order to hold it properly. Chores around her house were becoming much easier, including reaching into cabinets, doing laundry, vacuuming, etc. She was also able to style her hair without increased symptoms.

This case was a really good educational experience. She showed the typical progress throughout treatment for a condition like this, without any major setbacks besides the one in the second week. However, we knew exactly what caused the setback: the one thing I would have suspected to cause any setbacks - returning to activity too quickly because she feels better. This gave me an opportunity to really provide further education on pain/symptom/activity management. I was able to see all the special tests, ROM, and MMT performed on this patient and see how a diagnosis was determined. This case also demonstrated clearly how important and difficult restoring/promoting scapular stability can be and its relation to shoulder pathology. I was able to incorporate many different aspects of patient care, including strengthening, posture, neuro re-ed, and stabilization. It was also nice we had specific functional goals to reach for, and it was something that really motivated the patient and increased her compliance with therapy. A big lesson I learned in this case is to always be prepared to progress or regress treatment at any time; always have a backup plan because things will not always go as expected. You should always have an idea on exercises you can add to treatment, or ways to progress current interventions and how you can make them functional. What was most difficult for the patient was scapular stability and learning how to move the scapula without compensating. It made me realize how difficult this can be for someone. It also challenged me to find different ways to provide verbal and tactile cues as what works great for one patient will sometimes not work at all for another. This also challenged the patient and myself on being patient with treatment and healing, and patient with relearning proper posture. It is a tough habit to change and be aware of, but it pays off day by day.