A thorough examination was performed of the patient in order to determine the specific tissues involved in causing the patient's symptoms:
Posture: In sitting, the patient presented with a forward head and protracted scapulae posture. In standing there was a noticeable improvement of posture as a visual and palpatory inspection revealed no significant findings or asymmetries in scapular boney landmarks (acromion and inferior angle position). Scapulohumeral rhythm during bilateral shoulder elevation was normal. Patient was 6’0” tall, 242 pounds with a mesomorphic musculoskeletal appearance.
Cardiopulmonary Screen: Blood pressure: 118/70 mmHg; resting heart rate: 58 bpm, 2+ (normal) pulse noted at both brachial and radial pulse sites; respiratory rate: 12 bpm; all within normal limits
Cervical Screen: Negative for reproduction of symptoms or discomfort
Range of Motion (ROM): Upper extremity active ROM was within functional limits and pain free throughout. Active and passive ROM at the elbow was pain free.
Sensation: Intact to light touch throughout bilateral neck/upper extremities in all dermatomal distri-butions.
Palpation: Localized tenderness was noted at the right distal biceps tendon insertion at the radial tuberosity and running proximally for 2 cm over the biceps tendon in the antecubital fossa. Palpation of the medial and lateral epicondyles, the common wrist flexor and extensor tendons, brachioradialis, brachialis, supinator, median, ulnar and radial nerves did not reproduce pain. No retraction or defect consistent with a complete rupture was noted. No warmth or swelling was present when compared bilaterally. The biceps muscle belly and proximal biceps tendon were not tender to palpation.
Myotomes: Grossly 5/5 bilaterally in the neck/upper extremities except the right elbow flexors which were 4/5 and demonstrated pain upon resistance testing.
Manual muscle testing (MMT): Right elbow flexion with forearm supinated (to bias biceps brachii): 4/5 with reproduction of pain at the distal biceps tendon; elbow flexion with the forearm in neutral (‘hammer curl’ position to bias brachioradialis): 4/5 with reproduction of pain at the distal biceps tendon; elbow flexion with the forearm pronated (to bias brachialis): 5/5 with report of slight pain at the distal biceps; supination: 4/5 and pain free
: Yergason's, Speed's, Hook, and Bicep Squeeze tests all yielded negative results. The procedures, indications and available statistical information of these tests can be seen in Appendix 1
Reflexes: Biceps, brachioradialis and triceps were normal (2+) and symmetrical bilaterally
Neural Tension: Upper limb tension test (ULTT) median nerve bias was negative bilaterally
Diagnostic Ultrasound: Hypoechoic signal was noted throughout the length of the distal tendon and location of pain. Substantial enlargement of the right distal biceps tendon was not noted when compared to the left.
Pain Score (verbal analog scale: 0–10, 0 being no pain, 10 being worst pain ever experienced): Current: 5/10; Least since onset: 5/10; With activity: 10/10; Worst since onset: 10/10.
QuickDASH (Three sections each scored 0–100, 0 is no disability): Main module: 27.3; work module: 0; sports/performing arts module: 87.5
Clinical Impression #2
Given the fact that the patient's symptoms were brought on by particular motions involving the biceps brachii coupled with the patient's report of a traumatic onset, non-mechanical sources of pain causing symptoms were ruled less likely. The patient's cardiovascular screen was normal and no complaints of ischemic type pain were reported, indicating vascular compromise of the area was also unlikely. A cervical screen was negative as was a neural screen (ULTT, reflexes and light touch sensation) ruling out a radicular or nerve entrapment source of symptoms. Given the anatomy and function of the biceps brachii, injury to the distal aspect is generally accompanied by pain and/or weakness with resisted elbow flexion and/or supination both of which were noted with this patient. Proximal biceps brachii involvement was ruled out by the absence of symptoms, and negative Speed's and Yergason's tests. Given the point tenderness along the distal biceps tendon, mechanism of injury, and ruling out of proximal bicep involvement it appeared that the right distal biceps brachii tendon was the tissue involved.
With a tendinitis, physical markers of inflammation such as edema, redness or warmth may be expected. These signs were not present with this patient. Also, this patient had been experiencing symptoms for two months prior to coming to therapy, long after a tendinitis would be expected to last. Additionally, the patient was able to continue all daily and vocational activities using the right biceps brachii (duties required of an electrician, carrying his children, etc) without being limited by pain, and participate in wrestling and weight lifting with pain. If a tendinitis was the pathology, symptoms would likely limit all activities stressing the involved tissues, not necessarily just activities with heavy weights or large resistance. Diagnostic ultrasound imaging can also be an effective method of determining the appropriate pathology. A tendinosis typically appears as hypoechoic swelling of the tendon on diagnostic ultrasound, as compared to hypoechoic tendon fiber disruption seen frequently with a tendon tear.38
Partial tears are usually characterized by enlargement and abnormal contour of the tendon, with peritendinous fluid (edema, bursitis, hemorrhage) occasionally seen.39
Although substantial enlargement was not noted at the right distal biceps tendon, hypoechoic swelling consistent with tendinosis was visualized.
Plain radiographs sometimes show hypertrophic bone formation at the radial tuberosity with partial tears27
however, radiographs of the elbow of this patient did not show significant abnormalities. With a complete rupture, the proximal position of the biceps muscle belly is often visually readily apparent.31
This was not the case with this patient, making a complete rupture less likely. Based on the results of the examination, the initial hypothesis of distal biceps tendinosis was made more likely.
Informal re-evaluation was performed at each follow up visit. Formal reassessment of tests and measures performed during the initial evaluation was performed four weeks after initial evaluation (one month prior to the competition). Objective measures comparing initial evaluation and the patient's status at discharge can be seen in . Outcome measures were pain, strength, tenderness to palpation and QuickDASH scores. The QuickDASH is an abbreviated version of the validated Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, investigating a patient's reported level of disability in upper extremity function. With this outcome measure, lower scores are indicative of less disability while higher scores indicate greater reported disability. The minimum clinically important difference (MCID) has been determined to be 8 points.40
Outcome measurements at initial evaluation and discharge.