Biceps strain at MTJunction

Background:
I am a neurologic PT with a minimal amount of orthopedic experience. I just wanted to share my story b/c I want get feedback on what my Ortho doc told me today as my treatment moves forward. I am 35 y/o with no hx of arm injury.

While working with a significantly debilitated MS patient about 7 weeks ago, I strained my biceps, triceps, and a portion of the rotator cuff (subscapularis from what my and my PT can best tell). Well, no diagnostic testing was done, I was referred to OP PT with official diagnosis (from the occupational medicine doctor at my hospital) of "biceps/triceps strain". In case you're wondering how I strained opposing muscles, it was simply a case of maximum isometric cocontraction while I tried to keep this poor woman from pushing herself (and me!) on to the floor.

Anyway, I had formal therapy for about 5 weeks with mixed results. The triceps seems pretty resolved, I still have very mild subscapularis pain at insertion. What is most troubling to me and my therapist is the lack of progress with the biceps. This was always my worst pain. I have regained full ROM with little to no pain but can't lift more than about a pound or tolerate yellow t-band exercises without pain. I've had iontophoresis, kinesiotaping, daily ice, and BID naproxen for to help control inflammation. I returned to the MD and reported my persistent biceps pain. I implored her to order an MRI, almost positive that I had to have a minor tear that just couldn't heal. An MRI was done 3 days ago and was looked at by 2 different radiologists who both agreed that the tendon was intact, including at the musculotendinous junction where my worst pain is. There is little to no local edema and no major scarring.
The Orthopedic specialist (very prominent and works with major league baseball players frequently, so I trust his opinion) told me today that its just a bad strain and that when these occur at the MTJ they tend to take a long, long time to heal. He encouraged me to plug away, confident that my tendon is intact. He told me to let the pain be my guide and continue use of ionto and/or naproxen if I think its helping me to tolerate treatment. He also encouraged me to have Active Release Techniques done if my therapist was skilled in it. (I don't know much about this)

So, I ask you: Does this sound like a plan going forward? What ever happened to exercise in a pain free range or exercise progression once pain free tolerance is established? Again, I'm not an orthopedic therapist but I just don't want to push too hard...or not enough. Any other interventions you can think of?

Did I mention that I'm still working full time? I'm limited to patients that require min assist or less as a precaution. But its kind of a pain in the #$% for me and my staff to work around.

Thanks in advance for your feedback!
I'm fairly new to the board and look forward to giving some of my own in areas I think I can contribute.

Jeremy

Just get your physio to mobilise your cervical spine and there is a very good chance you will normalise the whole scenario. These kinds of problems commonly arise with exertion , where protective behaviour at your spine will cause ongoing referred pain. Sounds like your triceps got better by themselves , despite treatment.

Hi all!
Jeremy, I’m a bit confused about your signs and symptoms. You say that you have pain at the MT joint but the MRI doesn’t show anything there. At least that’s what I get from what you said. Moreover, the MD says that you have a bad strain. A bad strain would definitely be shown at an MRI, unless the strained area was not scanned at all. Please define the scanned area.
Secondly, you didn’t mention which MT joint is involved. Is it the distal one (at the elbow) or the proximal one (at the shoulder)? Remember that biceps has two tendons both at the shoulder and the elbow. And which motion is limited? Is it shoulder flexion/abduction/internal rotation/scapular elevation with shoulder externally rotated? Or is it elbow flexion/supination? And how about other motions at the shoulder or elbow? How about coupled motions as well? Furthermore, you said subscapularis was also involved. How’s its function now?
As for cervical assessment and/or treatment, I would suggest an assessment first, since the problem hasn’t resolved yet.
If you could give us more info about the initial assessment, MRI findings and current clinical situation, we could help more.
ilias

OK, I'll try to clarify some things.
- As for the C-spine: I think this was ruled out for a few reasons. No radicular symptoms, no numbness or tingling, no myotomal weakness, no cervical pain or restrictions. I wasn't given any specific provocation tests though.
- MRI: The area scanned was the proximal biceps region to the mid forearm. Coronal and sagittal views were taken. The radiologist and MD both focused their attention in on the distal biceps musculotendinous junction. This was always the location of the worst pain. No tear was visualized and there was little edema. But, I was told to keep in mind that the inflammation was probably worse at the time of the injury 7 weeks ago. I just had this scan done last week. Again, there was no obvious signs of scar tissue either.
- More detailed objective findings: Initially, I was so flared up that alot of ROM was limited: Shoulder abd, IR, ER, Flexion, Elbow Extension. Now I have nearly all shoulder AROM back and without pain, though I can get mild pain at max ER that is at about the area or subscapularis insertion (and originally had pain with resisted ER). So that is how Subscap was implicated. Combined motion of shoulder flexion, ERot, and supination now gives mild pain at anterior shoulder are (bicipital groove)tendon. I will also get the pain at the mtjunction if elbow fully extends at the top. I will say that that the biceps pain is less than before.

Alright, hope that helps some. Going to bed now............................................

Jerram,
I must admit I'm still a bit confused. Since the proximal arm was scanned, no conclusion can be made radiographically about the distal part. Secondly, having pain at max ER at about the area of subscapularis insertion could also be that other structures might be involved, like glenohumeral ligaments or the capsule (maximally stretched at maximum ER). Since at onset you had pain with resisted ER and subscapularis is an internal rotator, it couldn't be involved. Perform manual muscle test for subscapularis (arm at the back and resisted IR) to rule this out. Infraspinatus and teres minor, both external rotators, could be involved, but again these attach to the greater tuberosity, not the lesser. And they are not the only external rotators. Therefore, shoulder rotation is kind of confusing concerning symptoms and area of pain.
A comment about biceps brachialis... biceps is a strong forearm supinator, stronger than elbow flexor. So, its muscle test should be focused on supination first (from full pronation to full supination with elbow flexed at 70-90 degrees) and elbow flexion then. At the shoulder joint, it flexes and slightly internally rotates it. So, if during shoulder flexion, ER and forearm supination you get pain at the anterior shoulder, then it could be biceps. With IR and pronation, you should feel less pain since it's anterior band of deltoid that works harder. Check again these movements (supination with elbow flexion-classical manual muscle test for biceps-, shoulder flexion with ER shoulder and supinated forearm-for biceps- and with IR shoulder and pronated forearm-for anterior deltoid) and inform us of the symptoms and area of pain.
ilias

I'd say you do have at least one "radicular"symptom, pain. when you "cleared "the neck,did you attempt passive movements of spinal facet joints unilateraly ? or was this with just active movement?. Most referred pain events will be missed if only active movements are tested, the lack of other nerve related symptoms is not an indicator for the prospect I suggest here of somatic referred pain to your bicep. The only way to discover the presence of these common neurlagias is to treat them as if present, by unilateral mobs , in this case , to C56. This can also be done AP.
Are you familiar with a method known as traction rotations ?

OK further clarification:

I thought that in my original post I had stated that there was pain with resisted IR and ER, but in reviewing it I did not. Sorry. That is one reason I think subscap was suspected to be involved. To me, the residual tenderness is pretty isolated to the lesser tuberosity (vs. the greater) and of course at the distal MTJ of the biceps as noted before.

As for the MRI, I thought this was clear: "The area scanned was the proximal biceps region to the mid forearm." meaning every thing from about the proximal MTjunction of the long head of the biceps down to the first few inches of the forearm beyond the elbow. So, no shoulder structures were visualized b/c they were trying to rule out a problem at the distal MTjunction of the biceps or at the insertion (though I never really had any pain there).

Ginger -I am resuming therapy later this week and will ask about a few of the c-spine manuevers. I don't know Traction/rotations by name, is it just a unilateral mob performed with manual traction (i.e. in supine) or a gross passive rotation of the c-spine while manual traction is applied (or something else altogether?)

I can also have her try some of the shoulder motions that you describe Iliastolos. If the MTJ on the medial side is more affected than the lateral side (thus with more fibrous contribution from the long head) could this affect the amount of pain that does or does not occur during resisted supination?

Thanks for your thoughtful questions and patience with my explanations.

Jerram

Jerram,
My fault about scanned area, I read 'proximal biceps region to the mid arm', not forearm as is correct. About biceps, forearm supination is performed by the radial attachment and the muscle as a whole, not long or short head. Therefore, there won't be any difference in pain intensity at the elbow if the problem is at the shoulder. There will be a difference at the shoulder though. So, assuming that the long head is involved and not the short, testing of supination won't clarify which head is injured. Testing of shoulder will do. I hope this was what you asked...
ilias