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Year : 2015  |  Volume : 15  |  Issue : 1  |  Page : 100-102

Efficacy of resisted training in bicipital tendon instability: A clinical case report

Department of Physical Therapy, College of Applied Medical Science, Majmaah University, Al Majmaah, Saudi Arabia

Date of Web Publication19-Jan-2015

Correspondence Address:
Mahamed Ateef
Department of Physical Therapy, College of Applied Medical Science, Majmaah University, Al Majmaah
Saudi Arabia
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DOI: 10.4103/1319-6308.149548

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The purpose of this study was to evaluate the efficacy of resisted exercise in a patient with pain and instability of bicipital tendon. A 45-year-old male patient was referred by an orthopedist, with a complaint of anterior shoulder pain and apprehension of mechanical symptoms such as a "clunk" when rotating the arm inward or outward since three-and-half months. He experienced pain severity of 7 on a visual analog scale (VAS). Many provocative tests such as Yergason, Neer and Speed were positive. The patient was given resisted exercise to biceps muscle twice a day for six weeks along with initial ultrasound therapy for pain relief. At the end of the sixth week, pain was normal on the numeric scale, and all provocative tests were also normal without apprehension of instability in forward shoulder movement during daily activities. Hence, an attempt was made to explore the efficacy of resisted exercise in a case of bicipital tendon instability.

  Abstract in Arabic 

تهدفهذهالدراسةلتقييمفعاليةتمارينالمقاومةلمرضى الالم الناجم عن عدم ثبات وتر العضلة ذات الرأسين لمفصل الكتف. المريض المحول من اخصائى العظام يبلغخمسة واربعينعاما يعانى منألم أمامى في مفصلالكتفوبعضالأعراضالميكانيكيةمثل صوت "طقة" عنددوران الذراعإلىالداخلأوالخارجمنذثلاثةأشهرونصف. ويعانى ايضا من الم شديد يصل الى المستوى السابع طبقا للمقياس التناظرى البصرى. وكانت العديدمننتائج الاختباراتالخاصة للوترمثليرغاسون،نيروالسرعةايجابية. تم اجراءتمارينمقاومة للعضلة ذاتالرأسين للكتفمرتينفياليوملمدةستةأسابيعبالاضافة الى تطبيقالموجاتفوقالصوتيةلتخفيفالألم لمدة اسبوع. فينهايةالأسبوعالسادس وصل الالم الى ادى مستوى لقياس الالم،وكانتجميعالاختباراتالخاصةسلبيةأيضادونالتخوفمنعدمثبات الوتر اثناء حركة الكتف خلال الانشطة اليومية. ،جرتمحاولةلاستكشافمدىفعاليةتمارين المقاومة فى فيحالةعدمثباتوترالغضلة ذاتالرأسين لمفصل الكتف.

الكلماتالدالة: عدم ثبات وتر العضلة ذات الرأسين لمفصل الكتف،الالم , تمارين المقاومة.

How to cite this article:
Ateef M. Efficacy of resisted training in bicipital tendon instability: A clinical case report. Saudi J Sports Med 2015;15:100-2

How to cite this URL:
Ateef M. Efficacy of resisted training in bicipital tendon instability: A clinical case report. Saudi J Sports Med [serial online] 2015 [cited 2020 May 30];15:100-2. Available from: http://www.sjosm.org/text.asp?2015/15/1/100/149548

  Introduction Top

Most sportspersons do come across shoulder problem in their lifetime, and bicipital tendinitis or instability is one among the many shoulder injuries that afflict sportspersons. The muscle-tendon complex/unit of long head of biceps muscle acts as a pulley and sling mechanism to move the upper part of the humerus bone to forward flexion. It is commonly either associated with sportspersons involving overhead activities where bicipital tendinitis or instability would be secondary to impingement syndrome or associated directly with trauma to shoulder joint. [1] Due to tendinitis pain, biceps muscle's mechanical strength declines leading to muscle atrophy and weakening of tendon resilience, which in turn causes loss of tendon stability within the bicipital groove (intertubercular sulcus) causing improper action of biceps pulley mechanism and hence instability. If not intervened on time, this would lead to instability/subluxation of the bicipital tendon. Most of the cases with tendon instability/subluxation have been surgically managed. Hence an attempt has been made by this study with resisted training (in a case of tendon instability) to build up biceps muscle, which in turn reduces the laxity of the tendon in and out of the groove mechanically.

  Case report Top

Patient history

The patient, a 45-year-old former tennis player complained of shoulder pain since three and half months that had started gradually. There was no history of trauma, postsurgical correction of shoulder injuries, congenital or acquired deformities, or any other surgical intervention leading to secondary development of instability. The cardinal symptoms were difficulty and painful to do forward flexion, "clunk" when rotating the arm lateral or medial, and apprehension of instability of the tendon leading to functional impairment involving forward overhead activities. He rated his pain threshold as 7 on a 0-10 numeric visual analog scale (VAS). He had a previous history of bicipital tendinitis.

Physical examination

On observation, it was found that the patient had decreased biceps muscle mass (atrophy) on right biceps muscle compared with left; measured about 8 inches on right, 9 inches on left, the muscle power due to atrophy was 4 + on 5. On examination, palpation revealed that there was tenderness over the bicipital groove along with clunk feeling during forward flexion, internal and external rotation of the shoulder. Using the universal goniometer, forward flexion range of motion of the shoulder was measured, which was normal, and there was pain and clunk during internal and external rotation without affecting the range. Shoulder joint was thoroughly evaluated with differential diagnosis, and proactive special tests such as Yergason, Neer, Hawkins and Speed were done to rule out bicipital tendon pain, which were positive. [2]

Treatment methods

The patient was informed about the study, and his consent was taken. Prior to the physiotherapy treatment approach, his outcomes measured in terms of quantity of pain were taken on a VAS. Ferraz and Aquino [ 3 ] have studied the use of pain rating scales previously, especially VAS in various conditions.


Initially, in the first two weeks, the patient was treated with pulsed ultrasound for 15 minutes in sitting position with the shoulder in forward flexion and neutral rotation, forearm resting on the bed for relief of pain.

Exercise therapeutics


After gaining control over the pain with ultrasound therapy, strengthening exercises involving resisted regimen with gradual increase in load was started with dumbbells and springs, rubber exercise tubing in the direction of the muscle action such as supination to elbow flexion for biceps [4] were administered to bring the muscle mass and strength to normal for smooth mechanical action of the tendon as a pulley in the groove. Rest from overhead activities was also advised to prevent any impingement, thereby further increasing pain pathology.

Clinical outcomes

After four weeks of intervention, the patient was reassessed; his pain had decreased from 7/10 to 4.5/10 on the VAS, biceps muscle compared with left measured about 8 1/2 inches on right, 9 inches on left. On examination, tenderness was quite less and "clunk" was much less during shoulder lateral and medial rotation and apprehension of instability of the tendon was also minimized. On reassessment after six weeks of intervention, his pain had become normal from 4.5/10 to 0/10 on the VAS, right biceps muscle had become 9 inches, which was normal as on left, and the muscle power was also assessed and found to be normal, 5 on 5. There was no tenderness found over the groove and Yergason, Neer and Speed tests [2] were also negative.

  Discussion Top

Biomechanically, joint congruency basically comes through intra- and extra-articular structures such as articular surfaces, capsule, ligaments and muscle tendon unit/complex. If any muscle loses its mass following painful pathology, it would also lose its strength, affecting its muscle-tendon complex mechanism of action thereby losing tendon resilience. Long head of biceps tendon acts as a pulley mechanism at shoulder joint. Due to chronic tendinitis pain, biceps muscle had lost its tone and had become atrophic leading to decline in mechanical strength, which in turn caused the loss of tendon stability within the bicipital groove (intertubercular sulcus) causing improper action of biceps pulley mechanism and hence instability. [5] A study with 229 patients recently conducted by Braun et al. found that one-third of the study group had a biceps pulley lesion. Disruption of the biceps pulley mechanism allows the biceps tendon to subluxation/instability (partially move out of the bicipital groove). The outcome can be anterior shoulder pain (chain of events) and later tendon instability. [6],[7] Kubo et al. had proved that resistance training could help to increase the elasticity of the tendon and hence proper action of the biceps tendon muscle-tendon complex pulley system. [8] The obvious limitations of this study include difficulty in generalizing the results for other patients, and hence, future research may be done with case series.

  Conclusion Top

In today's mechanical life, it is obvious that lack of proper muscle strength maintenance could lead to development of mechanical means of musculotendinous and ligament joint laxity/instability. Resisted regimens can be used as an adjunct to regular physiotherapeutic interventions for the relief of pain and integrity/stability of musculoskeletal system.

Clinical Implications

Physiotherapists should acknowledge that with proper assessment and evaluation without neglecting bilateral comparison of muscle strength in case of shoulder injuries, it is possible to prescribe impairment-based therapeutic interventions to prevent residual laxity and instability leading to disability.

  References Top

Eakin CL, Faber KJ, Hawkins RJ, Hovis WD. Biceps tendon disorders in athletes. J Am Acad Orthop Surg 1999;7:300-10.  Back to cited text no. 1
Magee DJ. Hip: Orthopedic physical assessment. 4 th ed. Philadelphia: Saunders Elsevier; 2000. p. 292, 308-9.  Back to cited text no. 2
Ferraz MB, Quaresma MR, Aquino LR, Atra E, Tugwell P, Goldsmith CH. Reliability of pain scales in the assessment of literate and illiterate patients with rheumatoid arthiritis. J Rheumatol 1990;17:1022-4.  Back to cited text no. 3
Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br 2007;89:1001-9.  Back to cited text no. 4
Nakata W, Katou S, Fujita A, Nakata M, Lefor AT, Sugimoto H. Biceps pulley: Normal anatomy and associated lesions at MR arthrography. Radiographics 2011;31:791-810.  Back to cited text no. 5
Braun S, Horan MP, Elser F, Millett PJ. Lesions of the biceps pulley. Am J Sports Med 2011;39:790-5.  Back to cited text no. 6
Kumar VP, Satku K, Balasubramaniam P. The role of the long head of biceps brachii in the stabilization of the head of the humerus. Clin Orthop Relat Res 1989;172-5.  Back to cited text no. 7
Kubo K, Kanehisa H, Miyatani M, Tachi M, Fukunaga T. Effect of low-load resistance training on the tendon properties in middle-aged and elderly women. Acta Physiol Scand 2003;178:25-32.  Back to cited text no. 8


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