1. The long head of the biceps tendon originates in the shoulder joint and travels down the arm, where its function is controversial. 2. Differential diagnoses for long head of the biceps tendon pain include inflammation, instability, and injuries to the superior labrum. 3. Treatment options depend on the diagnosis and can include conservative care or surgical procedures like tenotomy, transfer, or tenodesis.

1. [ CLINICAL COMMENTARY ]
RYAN J. KRUPP, MD¹ PT, DPT, SCS² MD³
PA-C4 MD, FACS5
Long Head of the Biceps Tendon Pain:
Differential Diagnosis and Treatment
he long head of the biceps tendon (LHBT) originates As the LHBT then exits the joint and
approximately 50% from the superior glenoid tubercle and the passes through the rotator interval to the
intertubercular groove (often referred
remainder from the superior labrum, with 4 different variations
to as the bicipital groove), between the
identified.73 The proximal tendon is richly innervated, with greater and lesser tuberosities, it is sur-
sensory nerve fibers containing substance P and calcitonin gene- rounded by a tendoligamentous sling.
related peptide. These substances are responsible for vasodilatation The coracohumeral ligament (CHL), su-
and plasma extravasation, as well as transmitting pain. As the neural perior glenohumeral ligament (SGHL),
network progresses distally, it becomes more sparse.2 The tendon fibers from the supraspinatus, and fibers
from the subscapularis are the major con-
receives its blood supply from the ascend- of the suprascapular artery.3 Moving away tributors to this sling.34 The CHL arises
ing branch of the anterior circumflex hu- from the origin, the tendon is encased in from its broad, thin origin on the lateral
meral artery, which travels along with a synovial sheath and is, therefore, intra- coracoid base and then divides into 2
the tendon in its groove in the proximal articular yet extrasynovial, as it courses major bands. One band inserts into the
humerus. The proximal tendon receives obliquely through the joint and arches anterior border of the supraspinatus and
some arterial supply from labral branches over the humeral head. greater tuberosity, and the other inserts
into the upper border of the subscapu-
Though the role of the long head of is based upon a variety of factors, including the laris and lesser tuberosity.15,36 The SGHL
the biceps tendon (LHBT) in shoulder pathology patient’s overall medical condition, severity, and arises from the labrum adjacent to the
has been extensively investigated, it remains duration of symptoms, expectations, associated superior glenoid tubercle, travels as the
controversial. Historically, there have been large shoulder pathology, and surgeon preference. The floor of the rotator interval, and crosses
shifts in opinions on LHBT function, ranging from purpose of this manuscript is to review current under the LHBT forming a U-shaped
being a vestigial structure to playing a critical role
anatomic, functional, and clinical information sling before inserting into the lesser tu-
in shoulder stability. Today, despite incomplete
understanding of its clinical or biomechanical
regarding the LHBT, including conservative berosity. The SGHL seems to stabilize the
involvement, most investigators would agree that treatment, surgical treatment, and postsurgical LHBT against anterior shearing forces
LHBT pathology can be a significant cause of rehabilitation regimens. proximal to its entry to the groove. The
anterior shoulder pain. When the biceps tendon Level 5. J Orthop subscapularis contributes fibers to the
is determined to be a significant contributor to a Sports Phys Ther 2009;39(2):55-70. doi:10.2519/ anterior/floor aspect of the sling while fi-
patient’s symptoms, the treatment options include bers of the supraspinatus insert into the
jospt.2009.2802
various conservative interventions and possible
impingement, rotator cuff, shoul-
posterior aspect of the roof.81
surgical procedures, such as tenotomy, transfer,
or tenodesis. The ultimate treatment decision der, tendinitis, tendinosis Once in the bicipital groove, the ten-
don passes under the transverse humeral
1
Orthopaedic Sports Medicine Fellow, Steadman Hawkins Clinic of the Carolinas, Greenville, SC. 2 Director of Qualifications, Proaxis Therapy, Greenville, SC. 3 Orthopaedic Sports
Medicine Fellow, Steadman Hawkins Clinic of the Carolinas, Greenville, SC. 4 Orthopaedic Sports Medicine Physician Assistant, Steadman Hawkins Clinic of the Carolinas,
Greenville, SC. 5 Orthopaedic Sports Medicine Physician, Steadman Hawkins Clinic of the Carolinas, Greenville, SC. Address correspondence to Dr Steven B. Singleton, 1650
Skylyn Drive, Suite 200, Spartanburg, SC 29307. E-mail: steven.singleton@shcc.info
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 55

2. [ CLINICAL COMMENTARY ]
ligament, which bridges the groove. This tact or torn rotator cuffs.46,83 Given vector a “peel-back” mechanism during the late
ligament is no longer believed to play a analysis of the pull of the long head of the cocking phase of throwing. As the arm
primary role in securing the biceps ten- biceps, a humeral head depression role shifts from resting position to an ab-
don, given that most of the stability is would be unlikely in most shoulder posi- ducted, externally rotated position, the
provided by the SGHL and CHL.6,65 The tions except in full external rotation.65 accompanying change in the force vector
groove itself has a mean depth of 4.3 Several biomechanical studies per- of the biceps causes a torsional force at
mm, with an average medial wall angle of formed on cadavers have also examined the LHBT insertion. This torsional force
56°.16 After coursing through the groove, glenohumeral joint stability in relation may “peel back” the biceps anchor away
the LHBT joins the short head of the bi- to the biceps tendon. Paganini et al59 from its insertion, causing progressive
ceps to form the biceps muscle belly at found contraction of the biceps to limit failure over time.12
the level of the deltoid insertion. glenohumeral translation. Rodosky et al63
showed that simulated contraction of the
biceps increases the stability of the gle- Pathologic disorders of the LHBT can be
The function of the LHBT at the shoul- nohumeral joint by increasing the shoul- divided into 3 categories: inflammatory/
der is controversial and incompletely un- der’s resistance to torsional forces in the degenerative conditions, instability of the
derstood. Stretching from the scapula to combined abducted and externally rotat- biceps tendon, and SLAP lesions/biceps
the forearm gives it the potential to have ed position. Additionally, injury to the bi- tendon anchor abnormalities. The 3 cat-
function at both the shoulder and elbow. ceps anchor results in increased strain on egories of disorders may all present with
Its contribution to elbow flexion and the inferior glenohumeral ligament and shoulder pain, though they differ widely
forearm supination is well established; increases anteroinferior glenohumeral in patient populations and pathogeneses.
however, contradictory experimental joint translation.58 Though it may be helpful for treatment
proof about its function at the shoulder Though considerable evidence sug- purposes to classify a patient’s particu-
has left its role unclear. gests that the biceps is not an active sta- lar disorder, there is significant overlap
Neer53 proposed that the tendon served bilizer of isolated shoulder motion, the among the pathologies.
as a humeral head depressor and empha- LHBT may still contribute passively to LHBT Degeneration As the synovial lin-
sized the importance of maintaining the glenohumeral stability. It is possible that ing of the biceps tendon sheath is con-
tendon for shoulder stability. Andrews et the biceps serves more as a physical block tinuous with the glenohumeral joint and
al4 noted that electrical stimulation of the to superior and anterior glenohumeral intimately related to the rotator cuff,
biceps during arthroscopy led to humeral translation than as an active contractor inflammatory conditions affecting any
head compression within the glenoid. Us- against translation. Furthermore, activi- of these structures can affect the others.
ing a freely hanging arm cadaveric shoul- ties that require coordinated shoulder Biceps tendonitis, or inflammation of the
der model, superior humeral migration was and elbow motions may still receive active biceps tendon, is a misnomer, as is lateral
noted following LHBT tenotomy,45 though stabilization from the biceps. Finally, the epicondylitis, in that histological inflam-
these data have been difficult to interpret proprioceptive influence of the LHBT on matory changes in the tendon are rarely
due to difficulties in reproducing physi- shoulder stability has yet to be studied. seen. Instead, tenosynovitis (inflamma-
ologic tension in the remaining cadaveric Understanding the muscle activation tion of the tendon sheath) may occur,
shoulder girdle. Similarly, superior humer- patterns of the biceps during throwing while changes in the tendon are more
al migration during active abduction has motions can help treat the overhead ath- appropriately called tendinosis, as degen-
been noted radiographically in patients lete. Most overhead sports activities, such erative changes occur histologically with-
with isolated LHBT tears when compared as pitching a baseball or serving in ten- out evidence of inflammation.14 It should
to their intact contralateral shoulders.78 nis, are broken down into phases: cock- be noted that the term tendinopathy is
However, some evidence exists that ing, acceleration, and follow-through. also used throughout the literature as a
refutes any major role of the biceps at Significant biceps activity is seen after general term for tendon disorders that
the shoulder. In most patients with mas- ball release during follow-through as the are characterized by pain, swelling, and
sive rotator cuff tears and absent LHBTs, forearm is decelerated to prevent hyper- impaired performance.77 The tendon may
either from rupture or surgery, superior extension of the elbow. This eccentric initially swell, appearing dull and discol-
migration of the humeral head is uncom- contraction, transferring large forces to ored, but remains mobile. As the stages
mon.3 Furthermore, based on electro- the biceps anchor, has been postulated of degeneration progress, the tendon
myographic studies that have controlled to cause superior labrum anterior-to- becomes thickened, irregular, and may
for elbow motion, no long head of biceps posterior (SLAP) tears.4 Others hypoth- become scarred to its bed through hem-
muscle activity was measured during ac- esize that SLAP lesions occur not during orrhagic adhesions. When this biceps
tive shoulder motion in patients with in- eccentric contraction but, rather, through degeneration accompanies subacromial
56 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

3. impingement and rotator cuff disease, nal shear forces that overcome the biceps an eccentric firing of the long head of the
this may be termed secondary biceps and its anchor, leading to tendon fiber biceps muscle causes injury to the supe-
tendinopathy. In contrast, primary bi- degeneration or frank anchor failure. rior labrum complex and its attachment
ceps tendinopathy may occur exclusive LHBT Instability Biceps tendon instabil- during the deceleration phase of overhead
of these conditions. In addition, it is our ity can vary from subluxation to disloca- throwing.4 Finally, the peel-back explana-
belief that degeneration of the tendon fi- tion, and from intermittent to fixed. The tion has also been described.12 When the
bers leads to painful symptoms and may tendon angles 30° to 40° laterally from its arm is abducted and maximally externally
occur without any demonstrable change origin to the bicipital groove; therefore, a rotated, the twisting of the biceps tendon
in the gross appearance of the tendon. medially directed force may displace the may result in the peel-back of the an-
“Biceps tenosynovitis” was described tendon into the subscapularis insertion on chor and its subsequent gradual or acute
by Neer53 as being caused by subacromial the lesser tuberosity.61 These forces are in- detachment from the superior glenoid.
impingement. The pathology was initially creased during repetitive throwing, when Further, we speculate that injury to the
thought to be limited to the older, rota- the arm is in the abducted and externally tendon intra-articular or intertubercular
tor cuff population, as Murthi et al52 de- rotated position. The soft tissue sling fibers may also occur in association with
scribed it correlating highly with rotator that secures the biceps within the groove the development of a SLAP lesion.
cuff disease, and Peterssons’60 dissection receives contributions from the CHL,
of 151 shoulders showed no biceps degen- SGHL, and the subscapularis, and must
eration in cadavers from people under be disrupted for the biceps to become
the age of 60. unstable. Because the tendon most fre-
Relatively recent interests have fo- quently subluxes medially, the subscapu- he usual presenting symptom
cused on repetitive motion in overhead laris tendon insertion and its contribution is pain localized to the anterior
athletes contributing to biceps patholo- to the sling are most frequently involved. shoulder over the bicipital groove.
gy. Crossbody motion, internal rotation, Although isolated biceps instability has Often, the pain may be diffuse or vague,
and forward flexion have been shown to been reported in some young throwers,56 especially when another condition, such
translate the humeral head anteriorly most agree that it is extremely uncommon as rotator cuff disease, subacromial im-
and superiorly. Thus, while the arm is in to find biceps tendon instability without pingement, or shoulder instability, is
this position during the follow-through some injury to the rotator cuff.23 Finally, present. An accurate history includes the
motion of throwing and hitting, ante- a shallow groove may also predispose the description of the onset of symptoms, du-
rior structures, like the biceps, are at patient’s biceps tendon to instability. ration and progression of pain, history of
increased risk of impingement on the SLAP Lesions/LHBT Anchor Abnormali- a traumatic event, activities that worsen
coracoacromial arch. A tight posterior ties Snyder et al69 introduced the term the pain, and previous treatments and
capsule, which is found in many over- “SLAP lesion” to describe a spectrum of outcomes. Sensations of instability, pop-
head athletes, may further exacerbate injuries to the superior labrum and LHBT ping, and grinding should be noted and
the anterior translation during these origin, and classified the injuries into 4 qualified to location and arm position.
motions.35 Jobe and Bradley37 described types. Type I lesions involve a degenera-
repetitive overload to anterior structures tive fraying of the superior labrum, with
from pitching leading to stretching and the biceps anchor intact. Type II injuries The following tests are only a small sam-
injury. Once the anterior structures are are detachments of the biceps anchor ple of those cited throughout the litera-
lax, subtle glenohumeral instability may from the superior glenoid, and are the ture, with no one test offering acceptable
cause increased anterior humeral transla- most common type. Type III is a bucket- sensitivity and specificity. Based on this
tion and increased anterior impingement. handle tear of the superior labrum, with fact, the clinician must utilize multiple
Alternatively, the anterior humeral trans- an intact biceps anchor. Type IV lesions exam findings in combination with the
lation can cause “internal impingement” are similar to type III, except that the tear patient history, differential injections,
of the posterior rotator cuff on the pos- extends into the biceps. and imaging to determine the appropri-
terosuperior glenoid labrum during the The SLAP lesion has several proposed ate treatment course.
late cocking and early acceleration phases causes. First, such injury may be the re- The shoulder should be inspected for
of throwing, when the shoulder is maxi- sult of a shearing mechanism caused symmetry with the unaffected side. A
mally externally rotated and abducted.31 by compression of the superior glenoid common finding for biceps tendon pain
This impingement may result in patho- rim, which occurs during a fall onto an is point tenderness over the bicipital
logical fraying of the posterior rotator outstretched arm abducted and flexed groove.65 LHBT pain rotates laterally and
cuff and superior labral biceps anchor. In slightly forward.23 Second, a traction medially, with external and internal rota-
addition, this rotation may lead to inter- mechanism has been suggested, in which tion of the shoulder, respectively; thus it
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4. [ CLINICAL COMMENTARY ]
can be differentiated from painful super- mial hooks, and acromioclavicular joint
ficial structures, like the anterior deltoid, lesions can be identified with these views.
which do not move with arm rotation. A special “groove view” may permit mea-
Assessment of shoulder range of motion surement of the width, depth, and medial
should be performed and compared to wall angle of the biceps groove, and allow
the contralateral side. Overhead throw- evaluation for degenerative changes.16
ers may have a loss of internal rotation Ultrasound imaging has the advantage
in their throwing arm, which can be a of being inexpensive and noninvasive.
normal finding in this population. If a Diagnoses of bicipital tendinopathy and
normal total arc of motion is maintained ruptures can be accurate; however, SLAP
by an associated increase in external rota- lesions can be more difficult to diagnose
tion, then the internal rotation deficit is with ultrasound.62 The radiologic study
less likely to be a contributing problem. Magnetic resonance imaging
of choice for biceps tendon pathology is
LHBT pathology itself can lead to loss demonstrating rupture of the subscapularis tendon magnetic resonance imaging (MRI). Bi-
of shoulder range of motion, similar to with instability of the biceps tendon. ceps tendon subluxation with subscapu-
what is seen with rotator cuff tendinopa- laris and rotator interval lesions can be
thy. Neer and Hawkins signs will often be ing the patient’s arm in the apprehension readily identified with this modality ( -
positive. The rotator cuff should be tested position of 90° abduction while palpat- ). Associated tears of the rotator cuff
for strength, which may be normal in the ing the bicipital groove. Then, upon ap- are also best defined by MRI. MRI also
face of isolated biceps disease. proaching 90° external rotation, a clunk has a reported 98% sensitivity, 89.5%
Glenohumeral joint stability testing may be appreciated near the anterior specificity, and 95.7% accuracy for detec-
is particularly important to perform in edge of the acromion, as the biceps ten- tion of SLAP lesions.17
the athlete. The crank test and the load- don subluxes out of its groove.8
and-shift test may be used. Subtle gle- Once these tests have been performed,
nohumeral joint instability in the athlete differential diagnostic injections can be
may not produce a feeling of pending helpful when considering biceps tendon reatment of suspected LHBT
subluxation during apprehension testing, pathology. A subacromial lidocaine injec- tendinopathy begins with first at-
but may reproduce the pain that occurs tion should not typically provide signifi- tempting to make an accurate di-
during athletic activities.31 Yergason’s test cant pain relief when the primary origin agnosis of the primary pathology. As
of resisted supination causing anterior of pain is from the biceps, unless a rota- previously discussed, this can be difficult
shoulder pain may be specific for biceps tor cuff tear is present. It is important to to determine, given the multiple condi-
pathology but tends to lack sensitivity.18 remember, however, that there is often tions, including rotator cuff disease, in-
Speed’s test is considered positive if pain associated pathology in these conditions, stability, impingement, and SLAP lesions,
localized to the proximal biceps area is including subacromial bursitis, which which often accompany disorders of the
caused by resisted shoulder forward flex- is addressed with this type of injection. biceps tendon.1,3,6,72 Initial treatment of
ion with the forearm supinated. O’Brien’s An intra-articular injection should help both primary and secondary bicipital
active compression test can be used to biceps anchor pain, but groove pain may tendinopathy is nonoperative and be-
help detect superior labral pathology. sometimes persist if marked inflamma- gins with a period of rest and withdrawal
For this test, the patient elevates the arm tion or scarring of the surrounding tissues from aggravating activities, ice, a course
to 90° and adducts the arm 10° to 15°, prevents infiltration of the anesthetic into of anti-inflammatory medication, and
with the elbow in full extension and the the groove. In such cases, if significant formal physical rehabilitation. There are
arm internally rotated so that the thumb concern for biceps pathology persists, a limited studies detailing the conservative
is pointing to the floor. The patient then biceps tendon sheath injection may be at- management of biceps lesions alone, as
resists downward pressure applied by tempted with or without the assistance of they usually occur in combination with
the examiner. The palm is then fully su- ultrasound guidance. other pathologies. A Cochrane review33
pinated and the patient resists downward looked at 26 different studies involving
pressure again. A positive test for labral physical therapy for shoulder conditions
pathology is “deep” shoulder pain in the Imaging of patients suspected to have and concluded that there is some role for
thumb-down position, relieved in the su- LHBT pathology begins with standard mobilization and exercise in the manage-
pinated position.55 plain radiographs consisting of a true an- ment of rotator cuff disease; but none of
LHBT instability can be difficult to di- terior posterior (AP), axillary, and outlet these studies specifically evaluated the
agnose. One common test involves plac- view. Concomitant osteoarthritis, acro- management of biceps pathology in isola-
58 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

5. tion. This review also evaluated the use of tion following biceps surgery.3 In addition mize the symptoms. In younger, active
therapeutic ultrasound and laser therapy to a rotator cuff strengthening program, patients, this more often requires surgical
in the treatment of these conditions and rhythmic stabilization exercises can be intervention to address the pathology.6,65
could not find any evidence to support used to retrain dynamic stability of the When the symptoms are secondary to
their utilization.33 shoulder. Rhythmic stabilization exercis- impingement, subacromial injections
The first consideration for nonopera- es should be performed at varying shoul- can often be helpful, and the rehabilita-
tive biceps rehabilitation is to establish der and elbow positions, because elbow tion once again focuses on the rotator
a causal relationship between physical position is thought to affect the function cuff. In all these situations, failure to
impairments and biceps pathology. It is of the biceps at the shoulder. At our clinic, make significant improvement after 3 to
then necessary to develop a treatment incorporation of these neuromuscular re- 4 months may indicate the need for surgi-
plan specifically designed to address the education exercises has helped us achieve cal intervention.
impairments. The patient is advanced favorable outcomes. When biceps-related pain is secondary
through the phases of rehabilitation, Injections are an additional inter- to a SLAP lesion, especially type II and IV
with particular attention paid to pa- vention that can be very useful in the lesions, the initial treatment once again
tient response to treatment in terms of treatment of this disease process, both includes rest, anti-inflammatory medi-
changes in pain, swelling, or motion. The therapeutically and diagnostically. Sub- cation, stretching, and strengthening,
patient progresses through phases simi- acromial steroid injections can provide especially focusing on scapula stabiliza-
lar to postoperative biceps rehabilitation pain relief when treating biceps tendi- tion, shoulder conditioning, and shoulder
( ). Phase 1 consists of pain nopathy.13 These injections are typically range of motion. Care should be taken
management, restoration of full passive utilized for patients with severe night to prevent the patient from placing the
range of motion, and restoration of nor- pain or symptoms that fail to resolve after shoulder in positions that apply adverse
mal accessory motion. Phase 2 consists 6 to 8 weeks of conservative measures.65 stresses to the biceps anchor. For example,
of active range-of-motion exercises, and Individuals with significant biceps tendi- patients who suffer SLAP lesions from a
early strengthening. Phase 3 entails rota- nopathy may be more resistant to treat- compressive injury mechanism should re-
tor cuff and periscapular strength train- ment and may not respond as well to this frain from upper extremity weight bear-
ing, with a strong emphasis on enhancing type of injection.13,54 In these cases, injec- ing to minimize sheer and compression
dynamic stability. Finally, the return-to- tions directly into the tendon sheath of on the superior labrum.82 Likewise, exces-
sport phase focuses on power and higher- the biceps can be beneficial, with stud- sive external rotation should be avoided
speed exercises similar to sport-specific ies reporting as high as 74% good to ex- in overhead athletes who most commonly
demands. Conservative management of cellent results.39 These blind injections suffer peel-back mechanisms of injury.12
biceps pathology is highly variable among should be done carefully, as detrimental A third subgroup of patients include trac-
patients, depending on their clinical pre- effects on healing and atrophic changes tion-related injuries, which require the
sentation. Some patients will present of the tendon have been reported with di- avoidance of heavy eccentric or resisted
with near full passive and active shoulder rect tendon injections,70 including tendon biceps contractions.82 It should be noted
range of motion and be ready to begin re- rupture.25 An alternative option is injec- that conservative management for type II
sistance training on their first visit. Con- tion directly into the glenohumeral joint, and IV SLAP lesions is often unsuccessful
versely, individuals with acute injuries which avoids the potential complications secondary to labral instability and often
or acute irritation of the biceps tendon of direct tendon injection and delivers the requires surgical intervention.6,82
may present with significant range-of- anti-inflammatory medication directly to
motion and strength deficits and need to the intra-articular portion of the biceps,
be progressed more slowly. The therapist which is often irritated.6
A
plays an instrumental role in developing The nonoperative treatment of LHBT great deal has been written
a treatment plan in which the patient is instability is less well studied and many about LHBT disease and the
progressed efficiently through the phases times less successful in practice. This various surgical treatments avail-
of rehabilitation with minimal irritation condition usually follows the develop- able,1,3,6,8,44,51,56,64,65,74 with little consen-
to the healing tissue. ment of significant rotator cuff disease sus among the experts.5 Much of the
It is imperative to remember that any and, therefore, the treatment should fo- disagreement can be traced to the com-
comprehensive rehabilitation program cus on management of the rotator cuff plexity of the glenohumeral joint and
following biceps injury should focus on tear. Intra-articular injections can often the lack of clear understanding of the
restoring dynamic stability to the shoul- be helpful especially in the older, sed- actual function of the biceps tendon
der. Rotator cuff strengthening has been entary patient; but prolonged activity within that system. Clearly, the biceps
recommended to improve shoulder func- restrictions are often necessary to mini- tendon has some role, but to what extent
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 59

6. [ CLINICAL COMMENTARY ]
is up for debate.4,45,46,58,59,63,78,83 The most
important factors in selecting a surgical Debridement of the intra-articular
treatment are the primary cause of the portion of the biceps tendon has been
condition, the integrity of the tendon, the suggested for partial tears, including
extent of tendon involvement, and any delamination and fraying that involves
related pathology, such as impingement less then 25% of the tendon in young,
and rotator cuff disease, that also needs active patients5,6,65 or less than 50% of
to be addressed.1,3,6 the tendon in older, sedentary patients.6
Often, this is accompanied by a decom-
pression of subacromial soft tissue alone
Decompressing the biceps tendon by re- in younger patients, or bursectomy and
leasing the transverse humeral ligament acromioplasty in older patients. Many
and releasing the bicipital tendon sheath authors believe that debridement alone is
within the groove with either open or ar- not effective in eliminating symptoms or
throscopic surgery has been described.52 preventing eventual biceps rupture, thus
The use of tendon release within the biceps tenotomy or tenodesis should be
groove is limited to intact tendons with undertaken in these situations.1,11,30,38,76
mild inflammation that lack additional
pathologies. In addition, severe recal-
citrant tendinopathy and tendinopathy Throughout the literature there is a clear
outside the groove will not respond. Fail- debate between tenotomy and tenod-
ure to comply with these tight indications esis for the treatment of biceps pathol-
significantly decreases the effectiveness ogy.1,5,6,9,10,65 Tenotomy consists of cutting
of the procedure, thus it is performed the LHBT prior to its intra-articular su-
infrequently.1 perior labral insertion ( ). In con-
trast, tenodesis also requires a tenotomy
of the LHBT, but with the additional step
Subacromial decompression with both of anchoring the tendon along its origi-
open and arthroscopic techniques has nal course more distally. Traditionally, a
been described in the past to address variety of tenodesis techniques have been
tendinopathy of the biceps secondary to described as the surgical treatment of
“impingement syndrome.”53 As mentioned choice,7,9,11,22,28,43,44,47,51,64 providing main-
above, when utilized in conjunction with tenance of the form and possibly func-
debridement of the biceps tendon for tion of the biceps, while at the same time
mild disease this option can be very ef- providing pain relief.5 Numerous authors
fective. In fact, Neer53 demonstrated that have questioned the long-term results of
only 30% of the 50 patients in his study this procedure.7,9,22,30,38,76
who had a diagnosis of tendinopathy Biceps tenotomy was initially pro-
preoperatively actually had significant posed by Walch76 in an attempt to pro-
biceps disease that could be verified, and vide pain relief in the setting of massive
good results were obtained with address- Arthroscopic views of degenerative biceps rotator cuff tears, which were not rep-
tendons within the glenohumeral joint. Note the
ing the impingement component using hyperemia (A) and the frayed degenerative condition
arable using an open technique. Gill
acromioplasty alone. In a series of 307 of the tissue (B). The use of an arthroscopic biter to et al30 then reported the results of 30
cases, Walch et al75 found that acromio- perform a tenotomy (C) with the final result (D). patients treated with intra-articular
plasty, in association with biceps tenod- tenotomy as the primary procedure for
esis or tenotomy, was only beneficial in However, the utilization of acromioplasty biceps degeneration, instability, and re-
those patients with an acromiohumeral alone for isolated biceps pathology has calcitrant tendinopathy ( ). An
distance of greater than 7 mm and an not been studied. We postulate that failed associated subacromial decompression
isolated supraspinatus tear. In addition, decompressions or acromioplasties occur was performed in 2 cases. Seventeen of
patients with proximal migration of the because of unrecognized biceps disease the patients in the study group partici-
humeral head may actually have a poorer that is not effectively treated by acromio- pated in athletics less than 3 days per
outcome by performing the procedure. plasty alone. week, 12 were recreational athletes with
60 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

7. reported no significant difference in the scribed open techniques utilizing inter-
levels of anterior shoulder pain, cosmetic ference screws with good success.
deformity, or muscle spasm between pa- Building upon these advances, nu-
tients treated with tenotomy versus teno- merous other authors have developed
desis for chronic bicipital pain, and Gill all arthroscopic techniques.11,28,43,44,47,64
et al30 had only 1 tenotomy patient out of Gartsman and Hammerman28 in 2000
30 who required a tenodesis to address an presented a technique using suture an-
unacceptable Popeye deformity. chors for tenodesis. Several others have
Shank et al66 further compared the developed procedures using interfer-
2 procedures by using Cybex isokinetic ence screw technology, with variations
strength testing. Their results demonstrat- on passing the tendon, including Boileau
“Popeye” deformity secondary to ruptured ed no statistical difference in either fore- et al,11 using a transhumeral guide pin,
long head of the biceps.
arm supination or elbow flexion strength Klepps et al,44 employing a bone anchor
when comparing 31 control subjects, 17 at the bottom of the tunnel to act as a pul-
participation 4 to 7 days per week, and 1 patients posttenotomy, and 19 patients ley, and both Romeo et al64 and Lo and
participated at a professional level. Post- posttenodesis. In comparison, papers Burkhart,47 using the Arthrex (Arthrex,
operatively, only 2 patients complained specifically looking at ruptures report loss Inc, Naples, FL) biotenodesis system.
of activity-related pain that was moder- of forearm supination strength of 10% to Boileau et al11 reported the early results
ate in nature, 90% returned to their pre- 20% and up to 8% loss of elbow flexion of 43 patients who underwent their pro-
vious level of sports, and 97% returned strength in the acute setting.50,79 However, cedure, with a minimum 1-year follow-
to their previous occupation at an aver- Warren79 demonstrated no change in the up. In this study, the absolute Constant
age follow-up of 19 months. There was flexion strength in a series of patients with score increased from 43 to 79 points, with
an overall complication rate of 13.3% chronic ruptures. Pronation, grip, and el- no loss of elbow motion, and the overall
with 2 cases of impingement-related bow extension strength were all normal biceps strength was 90% of the contralat-
overhead-activity pain, 1 instance of throughout the various studies. eral side. There were 2 cases of rupture of
painless “Popeye” deformity ( ) the tenodesis, which was attributed to us-
that resolved with tenodesis, and 1 con- ing screws of insufficient diameter early
tinued complaint of biceps pain. The As stated previously, the traditional in- in the study, and no cases of neurologic or
mean American Shoulder and Elbow dications for tenodesis have been par- vascular compromise. It should be noted
Surgeons (ASES) score was 81.8. tial tears of the biceps involving greater that the prolonged ache and spasm often
These results were reconfirmed in than 25% of the tendon, subluxation, discussed in relation to tenotomy is actu-
a separate, 2-year-minimum follow- disruption of the soft tissue stabilizers ally an uncommon long-term complica-
up study of 40 patients with refractory of the groove, recalcitrant tendinopathy, tion and has been described in relation
biceps tendinopathy who underwent chronic tendon atrophy, and significant to tenodesis as well.
arthroscopic release alone or in combina- biceps disease following failed rotator Boileau et al10 in 2007 reported their
tion with other shoulder procedures. In cuff or impingement treatment.21,51,56,65 retrospective data on 68 consecutive pa-
this series, the mean ASES was 77.6; but This procedure can be performed either tients, in whom existed a total of 72 ir-
in those patients with an isolated LHBT in an open fashion9,24,26,51,56 or arthroscop- reparable rotator cuff tears with biceps
release, this increased to 87.8, with only 1 ically.11,28,43,44,47,64 Gilcreest29 in 1926 first pathology, and who were treated with ar-
patient having a poor result, secondary to described tenodesis to the coracoid for throscopic biceps tenotomy (39 cases) or
severe arthritis of the glenohumeral joint. rupture of the LHBT. This was followed tenodesis (33 cases). Seventy-eight per-
This same study reported no loss of biceps by methods that secured the tendon with- cent of the patients were satisfied with
curl strength in individuals over 60, and in the groove, but left a proximal stump. their result, and the average Constant
minimal strength loss overall. Even more Later Froimson and Oh26 described an score increased from 46.3 to 66.5. There
importantly, 100% of patients reported a open keyhole interosseous tunnel tech- was no difference in the results between
pain-free biceps at rest, 95% experienced nique that relocated the tendon within the procedures when utilized in this pa-
a significant decrease in overall biceps the groove after amputating the proximal tient population. The authors noted that
tendon pain, and 95% had relief of their stump. Although rather tedious, Froim- atrophy of the teres minor significantly
anterior shoulder pain upon palpation. son and Oh’s technique was a superior decreased shoulder function, and pseu-
There was a 70% incidence of Popeye clinical advancement and led others to doparalysis of the shoulder and severe
deformity,38 which is higher than that re- develop simpler techniques. Mazzocca rotator cuff arthropathy are contraindi-
ported in the literature.30,57,76 Osbahr et al57 et al51 and Edwards and Walch24 have de- cations to this procedure.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 61

8. [ CLINICAL COMMENTARY ]
be made in partnership with the indi-
vidual patient.
In response to the potential cosmetic
deformity and occasional painful cramp-
ing that can accompany biceps tenoto-
my, and the persistent local pain often
seen after tenodesis, the technique of
all arthroscopic transfer of the LHBT
to the conjoint tendon was developed
( ). First described by O’Brien,74
this procedure is a soft tissue variation
of the earlier described techniques of
transferring the tendon to the coracoid
process using anchors. This transfer is
felt to more closely approximate the nor-
mal anatomical axis of the biceps muscle
and should have improved results over
conventional tenodesis. In addition, the
authors feel the technique offers a sim- Arthroscopic view of a superior labral
(SLAP) lesion, demonstrating detachment of the
pler option by working in an avascular
biceps tendon anchor from the glenoid (A). A similar
plane without implants. Other authors SLAP lesion has been repaired using a suture anchor,
point out that this changes the course of once again providing fixation between the biceps
the tendon nonetheless and may result anchor and glenoid rim (B).
in pain secondary to traction or adhe-
sions under the insertion of the pecto- open deltopectoral approach, or, if only
ralis major.1 In addition, some authors a partial tear of the deep superior por-
feel the increased force on the scapula tion of the tendon exists, an arthroscopic
may lead to anterior scapular tilting and approach can be used. 3 If the patient is
Arthroscopic view in the subacromial ultimately contribute to subacromial im- less active, a tenotomy with or without a
space, demonstrating the steps of a biceps tendon
pingement. As previously stated, this is subscapularis repair may be a better op-
transfer. The biceps tendon being released from the
groove (A), during passing of the sutures (B), and the
a relatively new variation of an old tech- tion.6 O’Donoghue56 reported on a series
final attachment of the long head of the biceps to the nique and no long-term studies compar- of 53 throwers (56 cases) with isolated
conjoint tendon (C). ing the 2 methods have been reported in biceps tendon subluxation treated with
the literature. tenodesis. In this study, 71% of patients
At our clinic, the decision to utilize reported excellent progress, with 77%
tenotomy or tenodesis is based upon a able to throw satisfactorily and 77%
lengthy discussion with the patient re- A chronically subluxating or dislocat- able to return to their sport of choice. Of
garding the risks and benefits of each ing LHBT will often show signs of ad- those patients unable to return to play, 4
procedure, the time required for reha- vanced inflammation or degeneration. had unrelated problems, 6 had pain and
bilitation following surgery, and the in- There is usually pathology traceable restricted range of motion, and 1 injured
dividual patient expectations. In older to the rotator interval as well as rota- his shoulder in a fall.
patients who desire pain relief with a tor cuff tearing, primarily involving An attempt at relocation of a sublux-
quick return to their activities, teno- the subscapularis. The indications for ated or dislocated tendon may be pos-
tomy is often the treatment of choice. In tenotomy or tenodesis parallel those sible if the tendon is still mobile and
contrast, the young laborer, who is most discussed previously for significant bi- significant degeneration has not oc-
concerned with cosmesis and supination ceps tendinopathy and these are the curred. It is extremely important to re-
strength, will often prefer tenodesis. It is most common procedures performed in pair and tighten the rotator cuff interval
important to remember that both of these this setting. If the patient is young and in this situation to maintain the position
procedures offer excellent treatment op- active, one might consider a tenodesis; of the tendon in the groove. In addition,
tions, and the ultimate selection should along with a subscapularis repair via an following the repair, it is imperative to
62 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

9. verify the location of the tendon within tive that the therapist communicates fre- program. The program is routinely re-
the center of the groove and adequate quently with the physician to ascertain the viewed with the patient and updated with
stability throughout the shoulder range type of surgery performed, the type of fix- more challenging exercises as the patient
of motion.3 Recurrent instability, with a ation, the patient’s tissue quality, the qual- progresses.
resulting stenosed, painful tendon, is a ity of the repair, concomitant procedures
common long-term complication follow- performed, and any special instructions
ing any procedure that attempts to repair specific to the patient’s rehabilitation. To Successful biceps rehabilitation requires
the sling and stabilize the tendon in the facilitate this communication, doctors at the therapist to create a healing environ-
groove. our clinic typically visit with the patients ment based on soft tissue healing prop-
during the first therapy session with the erties. Creating a healing environment
physical therapist. Patient understand- involves controlling pain, swelling, irrita-
ing and compliance are improved when tion, and the loads placed on the healing
An entire contribution within this spe- there is consistent communication from tissue. Tendons have 7.5 times lower oxy-
cial issue is devoted to the recognition all members of the team regarding pre- gen uptake than skeletal muscles, which
and treatment of SLAP tears, thus we cautions, sling use, activity restrictions, may explain why tendons can be slow to
will only make a few brief comments as and a timeline for return to activities. heal after an injury.67 Progressively load-
it relates to type II and IV tears involving ing a healing tissue can promote soft tis-
the proximal biceps tendon. Type II tears sue healing, as long as the applied load
have, by definition, a detached biceps There are differences in the management is appropriate to the patient’s stage of
anchor and therefore require stabiliza- of biceps tenotomy compared to tenode- healing.
tion usually with suture anchor fixation sis. Tenotomy rehabilitation will be more Sharma and Maffuli67 state that tendon
or bioabsorbable tacks ( ). A type aggressive and advance more quickly, be- healing occurs in 3 broadly overlapping
IV SLAP tear includes a bucket-handle cause the necessary protection for heal- stages. Patients will progress through
portion of the labrum that extends into ing tissue is minimal. The primary risk the stages at different rates. Treatment
the biceps tendon. In these cases, if the of an aggressive approach is a Popeye must be individualized, based on soft tis-
tendon is not too degenerative and the deformity ( ). The Popeye defor- sue healing as well as the patient’s clini-
tear involves less than 30% to 40% of mity has been reported to be present in cal presentation. Therefore, decisions to
the tendon anchor, the tendon can sim- 62% to 70% of patients following teno- advance patients through the phases of
ply be debrided and the superior labrum tomy.10,38 However, the resultant negative rehabilitation should be based on soft tis-
either debrided or reattached, provided consequences of a Popeye deformity are sue healing times, as well as clinical pre-
the flap is large enough.82 If more than relatively benign.10,38 Conversely, reha- sentation and response to treatment.
40% of the tendon is involved, usu- bilitation following tenodesis will prog-
ally a side-to-side repair is performed, ress more slowly over the first 6 weeks
where possible, along with treatment of to protect the healing biceps tendon. The proposed functions of the biceps at
the labrum, as above. However, in cases The patient is instructed on several be- the shoulder include joint compression,
where the biceps origin is more signifi- havior modification strategies to protect anterior stabilization, and superior stabi-
cantly damaged or if there is a great deal the repair. They are taught that activities lization.4,41,42,45,53,78 It is difficult to deter-
of degeneration of the tendon, biceps causing contraction of the biceps muscle mine the extent to which biceps surgery
tenodesis or tenotomy offers a better should be avoided, such as resisted elbow will affect shoulder function, because
option to direct repair. 3 flexion and forearm supination.67 The the role of the biceps at the shoulder is
practical implication is that the patient not fully understood. Maintaining the
needs to refrain from activities such as biceps muscle length-tension relation-
lifting, opening door knobs, or using a ship and the axis of the biceps muscle is
screw driver with the involved extremity. thought to be important for preserving
Clear instruction to the patient regard- biceps function at the shoulder.74 Biceps
ing activity and behavior modifications tenodesis provides the opportunity to
A
ll caregivers working togeth- from all members of the “clinical team” maintain tension in the tendon along its
er as a cohesive team improve will help protect the repair and ensure original alignment, but the attachment
patient management and help to optimal outcome. site is distal to the shoulder. Techniques
ensure optimal patient outcomes. Due In general, in our clinic, each patient such as the biceps transfer will attach
to the variety of surgical techniques used receives instruction on a comprehensive, the LHBT proximal to the shoulder but
to manage biceps pathology, it is impera- individualized, written home exercise in a different alignment along the con-
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 63

10. [ CLINICAL COMMENTARY ]
joint tendon. Regardless of the surgical
procedure, there will likely be alterations
in shoulder proprioception and function
that will have to be addressed during
rehabilitation.
here is minimal research spec-
ifically relating to the rehabilita-
tion of the long head of the biceps.
In the latest Cochrane review33 of physi-
cal therapy for shoulder pain there were
no studies specific to long head of biceps
lesions. Currently, the best evidence for
postoperative rehabilitation is surgeon
and physical therapist experience. Our
clinic has developed protocols that are
used as an outline to guide the rehabili-
tation process ( ). The
protocols are divided into 3 phases. Ad-
justments are made depending on the
presentation of the individual patient. Lawn chair active range-of-motion progression from supine to sitting. The patient is progressed through
It is important to take into account increasingly upright positions to gradually increase the effect of gravity on the shoulder.
pertinent patient history, mechanism
of injury, and patient goals when plan- tion. During this phase, nothing super-
ning the course of treatment for the Rehabilitation begins 1 day postopera- sedes the importance of protecting the
patient. Decisions to advance through tively. A standard sling is used as needed healing tissue.
the phases of rehabilitation are based for comfort. An elastic wrap is placed Particular attention is placed on
on protecting the healing tissue, apply- over the upper arm to provide support rhythmic stabilization and scapular sta-
ing controlled loads to the healing tis- to the healing biceps. A transcutane- bilization exercises during phase 1. Iso-
sue, and monitoring patient response to ous electrical nerve stimulation unit is lated scapular retraction, with the arm
treatment in terms of changes in pain applied in the recovery room and sent immobilized, has been shown to produce
and swelling. home with the patient for pain manage- low levels of biceps activity.68 Therefore,
ment. The goals for phase 1 are to de- scapular retraction exercises are initiated
crease pain and swelling, initiate gentle early in phase 1 to improve neuromus-
Manual therapy treatments, such as rhythmic stabilization exercises, initiate cular control. This sets the stage for the
range-of-motion exercises and gle- scapular stabilization exercises, and re- scapular stabilization and rhythmic sta-
nohumeral joint mobilizations, are most store full passive shoulder range of mo- bilization exercises performed in phases
appropriate during phases 1 and 2 (AP- tion. Passive shoulder external rotation 2 and 3. Gentle rhythmic stabilization
). Particular attention is often painful, and placing half of a exercises are initiated with the patient
is focused on the posterior and inferior foam roll under the patient’s arm during supine, the arm at 0° of shoulder flexion,
capsule. Tightness of these structures is supine exercises helps to relieve some of and half of a foam roll supporting the el-
linked to impingement.27,37,48 Soft tissue the discomfort. Full passive motion is ex- bow, then progressed to 90° of forward
mobilizations are utilized to decrease pected 1 to 2 weeks postoperatively, with elevation.
pain and spasms of the biceps or other patients posttenotomy typically achieving At our clinic, to advance the patient
shoulder muscles. As patient range of full motion slightly ahead of those post- from phase 1 to phase 2, patients should
motion increases, manual interven- tenodesis. Manual therapy treatments be able to perform passive range of mo-
tions are decreased in favor of active and modalities are utilized as needed to tion to 80% or greater of the uninvolved
exercises. decrease pain and improve range of mo- shoulder, 1 minute of rhythmic stabiliza-
64 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

11. tion in the supine position with arm at
90° forward elevation, and no increase in
pain or swelling after treatments. Typi-
cally, both biceps tenodesis and tenotomy
patients are able to advance beyond phase
1 after the first week.
At this point, patients are typically out of
the sling and experiencing minimal pain.
Some patients will attempt to resume
activities too early, which can result in
irritation to the biceps. Patient educa-
tion about proper behavior modification
becomes important for maintaining a
healing environment for the biceps. The
goal for phase 2 is to increase active range
of motion, activity tolerance, and muscle
endurance.
A key rehabilitation regimen used dur- Resisted shoulder extension performed with red sport cord resistance. The focus is on scapular
ing this phase is the lawn chair progression retraction with minimal upper trapezius activity.
( ), which involves transitioning
from supine active range of motion to perform 30 repetitions of active shoulder laborer may require supination strength
more functional active range-of-motion elevation in standing to 80% or greater of for screwdriver use.
exercises sitting upright. Flexion above the uninvolved shoulder, without upper Proprioception and neuromuscular
90° in the supine position will be gravity trapezius substitution, and 30 repetitions re-education exercises are important to
assisted. As the patient becomes increas- of side-lying external rotation to 80% or counteract the inhibitory effects pain
ingly upright, the external torque on the greater of the uninvolved side, with no and inflammation have on the rotator
shoulder is increased due to the orienta- increase in pain or swelling after treat- cuff and scapular stabilizers.40,49 Resisted
tion of the upper extremity in relation to ments. Patients posttenotomy typically shoulder extension is a good exercise to
gravity and the related increased length advance more quickly than those post- emphasize lower trapezius muscle activ-
of the upper extremity moment arm. The tenodesis. Phase 2 lasts approximately 2 ity, while minimizing upper trapezius
ultimate result of this higher load is an weeks for tenotomy compared to 6 weeks substitution ( ). Proper scapular
increased muscle demand, which is nec- for tenodesis. stabilization will provide a stable base
essary to maintain proper shoulder kine- for glenohumeral joint movement, as
matics. Any upper trapezius substitution well as maintain optimal length-tension
noted at this point should be addressed The goals for the third phase are in- relationships for the rotator cuff mus-
immediately. Side-lying shoulder flex- creased endurance and strength. Biceps cles.20,80 With our scapular and rotator
ion is a good alternative exercise if the strengthening should begin week 3 for cuff-strengthening programs, muscle
patient struggles with proper technique patients posttenotomy and week 7 for endurance is emphasized, because mus-
during the lawn chair progression. If this those posttenodesis. Isotonic exercises cle response times at the shoulder have
substitution is necessary, the lawn chair should begin with eccentric biceps con- been shown to decrease after fatiguing
progression should be reinstituted once traction only, then progress to a full iso- exercise.19 Therefore, neuromuscular re-
the patient demonstrates mastery of the tonic exercise range, including concentric education should include multijoint and
side-lying flexion maneuver. In addition, and eccentric biceps contraction, as tol- multiplanar endurance exercises. Flex
rhythmic stabilization exercises are ad- erated by the patient. Biceps strengthen- bar and Bodyblade rhythmic stabiliza-
vanced in accordance with the lawn chair ing should include both supination and tion exercises are performed at varying
progression, so that the effect of gravity elbow flexion exercises. Exercise selec- shoulder and elbow positions. Strength-
on the arm is gradually increased with tion is based on patient goals and activity ening exercises focus on incorporation of
this regimen as well. demands. For example, baseball players the entire kinetic chain, including coordi-
At our clinic, to advance from phase require eccentric control of elbow flex- nated lower extremity, trunk, and shoul-
2 to phase 3, patients should be able to ion during throwing, whereas a manual der movements in multiple planes.
journal of orthopaedic & sports physical therapy | volume 39 | number 2 | february 2009 | 65

12. [ CLINICAL COMMENTARY ]
A
Shoulder external rotation performed at
30° of abduction with red sport cord resistance.
This series of pictures demonstrates plyometric proprioceptive neuromuscular facilitation D2 reverse
throws with a small, green, 1-kg medicine ball. (A) To start, the therapist throws the ball over the patient’s shoulder.
(B) The patient catches the ball and decelerates it down to the front foot, (C) then accelerates the ball back over
the shoulder, (D) throwing it to the therapist.
in positions above 90° of elevation or proprioception, and gradually increase
with long lever arms. In our opinion, the sport-specific loads applied to the
the increased risk for impingement out- shoulder. For example, Swanik et al71
weighs the potential benefits. Exercises demonstrated that a 6-week internal ro-
Rhythmic stabilization performed at 90° with longer lever arms and exercises tation plyometric training program per-
of abduction and 90° external rotation with red sport above 90° arm elevation are utilized for formed by female swimmers enhanced
cord resistance. muscle endurance and neuromuscular proprioception, kinesthesia, and muscle
re-education only. performance characteristics. Plyometric
Rotator cuff strengthening begins For patients to advance to the return- exercises should be chosen individually
with basic sport cord external and in- to-sport phase, they must be able to per- for each athlete based on sport-specific
ternal rotation exercises performed with form 1 minute of red sport cord external demands. Plyometric exercises are ad-
the arm supported at 30° of abduction rotation at 30° of abduction, 1 minute of vanced from 2-arm, short-lever-arm
( ). The position of 30° abduc- rhythmic stabilization standing with arm activities below 90° of arm elevation,
tion with an isometric adduction force at 90° forward elevation, and no increase to single-arm long-lever-arm activities
will increase the subacromial space, in pain or swelling after treatments. Pa- above 90° of arm elevation. A sample
which is advantageous in minimizing tients with tenotomy usually make the plyometric progression could begin with
risk for impingement during rotator cuff transition 4 to 6 weeks postoperatively, a chest pass exercise and progress to a
strengthening.32 At our clinic, exercises whereas those posttenodesis will not ad- proprioceptive neuromuscular facilita-
with shorter lever arms and exercises vance until weeks 8 to 12. tion (PNF) D2 pattern exercise.
below 90° of arm elevation are utilized Our athletes are able to return to
for strengthening the shoulder. In this sport if they have minimal pain, full mo-
position, strength and endurance can be The goals for this phase are to increase tion, and full strength. The athlete should
increased with minimal risk of impinge- muscle strength, increase muscle power, be able to tolerate 1 minute of rhythmic
ment. Once the patient has developed an successfully complete an interval throw- stabilization at 90° of abduction and 90°
adequate strength base, the focus shifts ing program, and return to the previous of external rotation with red sport cord
to improving neuromuscular control in level of sport participation. Plyometric resistance ( ), 1 minute of forward
functional positions. We do not perform exercises are appropriate at this phase PNF D2 plyometrics, and 1 minute of
heavy resistance strengthening exercises to enhance dynamic stability, enhance backward PNF D2 plyometrics (
66 | february 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

13. ). The patient must also be free of pain and microscopic anatomy. J Bone Joint Surg
Am. 1992;74:713-725.
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