Bicipital tendonitis is inflammation
or degenerative changes
at the tendon of the
long head of the bicep.
The long head of
bicep runs between
the greater and lesser
tubercles of the humerus.
Sometimes due to overuse
or repetitive trauma,
you could have injury,
inflammation in that area.
There's also a slight slip of a ligament,
the transverse humeral ligament,
that helps to keep the
bicep tendon in place.
If that ligament is ruptured,
that could also cause pain.
A special test to screen for this
is called the Yergason's test.
includes rest, ice.
Sometimes you could have injections
in the area for the inflammation.
You could use nonsteroidals
for pain control, or if needed
you could use steroid injections to try
to decrease some of the inflammation.
Osteopathic management includes
trying to free up the restrictions
in the glenohumeral
You want to try to perform myofascial
to soften up the area.
This is a good place that you could
perform counterstrain technique
to try to decrease any sort of
tenderness in the region.
Yergason's test is a test to evaluate for
bicipital tendon instability or tendonitis.
So remember that the long head
of the bicep runs between
the greater and lesser tubercles
on the humerus
with a ligament that covers
over the tendon.
Any sort of repetitive motion,
any sort of inflammation,
or if that ligament is disrupted, patients
complain about anterior shoulder pain.
So, to perform the test, we start off
by having the patient
bring their arm to their sides with
their elbow flexed to 90 degrees.
The physician is going to monitor the
tendon at the bicipital groove.
Then we're going to ask the patient
to actively externally rotate
or supinate their forearm
Remember that the bicep is an elbow
flexor and also supinates the arm.
So, when you ask the patient to supinate
the arm, you're activating the muscle.
If there's any sort of pain in the
anterior portion of the shoulder
or if the physician actually feels the
tendons slipping out of the groove,
that is a
We could utilize counterstrain for treatment
of our patients with bicipital tendonitis.
There is a point right over the tendon
that treats really well with positioning.
So remember that counterstrain
is a passive indirect technique.
With this technique, what we
do is we adjust the joint
by putting the patient into
a position of comfort.
So first, we have to identify
the point of tenderness.
Then we will move the joint so that
the point is no longer tender.
That point is also called
the mobile point.
Once we find that mobile point, we hold that
position of comfort for 90 seconds
at the same time monitoring gently
at the region of tenderness.
After 90 seconds, we should gently bring
the joint back to its neutral position
and then that point should
have decreased pain.
What we're doing here is we're resetting
the muscle spindle of the muscles
in the region in order to decrease
any sort of spasm and tenderness.
Thoracic outlet syndrome is a condition
where the brachial plexus is being compressed
as it exits the cervical spine and
travels down the upper extremity.
Patients will typically complain about a
shooting pain going down their arm.
They may have some numbness
and tingling in their hand.
A special test that we could
perform is the Adson's test.
Usually, what happens is the
nerves in the brachial plexus
could be compressed
in three major spots.
The first one is between
the scalene muscles,
the anterior and middle scalenes as
the brachial plexus traverses.
Then comes underneath the clavicle
but above the first rib,
the costoclavicular space
is the second place
where the brachial plexus
could be compressed.
Then it could also be compressed
behind the pectoral minor
near the coracoid
So, there are three major areas
where this brachial plexus
Patients will have neck pain,
pain that radiates down the arm.
Sometimes they'll have diminished
pulses in the upper extremities.
This is because the vasculature
runs with the nerves.
So, if there's compression
of the nerves,
sometimes there will also be compression
of the blood vessels.
When we treat patients with
osteopathic manipulative medicine
that may have thoracic
it's important to remember the anatomy
and the course of the brachial plexus
and the key areas where
they could be compressed.
So treatment of the scalene
muscles is important,
treatment of the first rib because the
scalene muscles attach to that region.
If we could relax some of the muscle
spasm in the scalene muscles,
that could potentially decrease
any sort of compression there.
It's really important to treat
the clavicle and the first rib.
Any restrictions where the
clavicle might be depressed
or the first rib is elevated, that could
also compress the brachial plexus.
Also looking at the shoulder joint and
the regions around the shoulder,
any other muscles like
the pectoralis minor
could also compress
on the brachial plexus.
We also want to treat the cervicothoracic
junction and the cervical spine.
This is because the scalenes attach
to the cervical spine.
You’ll also want to look at different sort of
areas that innervate the upper extremities.
So from C2-T1, there
are different nerves
that innervate the shoulder
and upper extremities,
any sort of compression on those nerves
can potentially cause those symptoms.
We also want to free any fascial restrictions
located in the thoracic outlet region.
So, the Adson’s test helps to evaluate
for thoracic outlet compression.
This test is performed by monitoring
the radial pulse.
The neurovascular bundle
So, if you have compression
of the nerves,
at times that might also
compress the blood vessels.
So, what we're doing here
is we're checking to see
if the vasculature is
and then assuming that that is also occurring
for the nerves running with it.
So, we're monitoring
the radial pulse.
We're going to extend the arm and externally
rotate it slightly abducting the arm.
We're going to ask
the patient to rotate
and extend their head towards
the ipsilateral arm.
This is going to cause a decrease
or absence of the pulse
if there's a thoracic outlet compression
because you're adding compression
to the region in the thoracic outlet
with this motion and movement.
Cervical radiculopathy is impingement
of the cervical nerve roots.
There are many different
could be caused
from a bulging or herniated
disc in the cervical spine.
You could also have
narrowing of the region
where the nerve roots exit
at the foramina.
Certain degenerative changes could occur
that impinges on the nerve roots.
You could perform a special test to try to
recreate the signs and symptoms.
This test is the
Usually treatment, you start
to see if you could
decrease the pain.
However, sometimes surgical management
might be required.
could be utilized
to try to decrease any sort of
cervical spine dysfunction.
Sometimes you could treat the muscle
spasms in the cervical region
that might be contributing
to compression and pain.
Overall, you could try to improve
circulation and lymph flow
to help clear the inflammation
that's occurring in the region.
Spurling's test is a special
test that could be used
to evaluate for cervical
nerve root disorder.
What we're doing is we're
narrowing that space
where the cervical
nerve roots exit.
So, what we're going to do is
we’re going to have the patient
gently extend and rotate the patient's
head at the cervical spine
to the ipsilateral side
of the affected shoulder.
So, if someone is
complaining of pain,
numbness and tingling, and chilling
down their right arm,
what you’re going to do is
you're going to gently extend,
rotate the patient's head
towards the right.
If needed, you could
add axial compression.
If the patient already has pain
with just the passive movement,
then you should not add
the axial compression.
What you're doing here is
you are narrowing that space
where the nerve
So if there is pain,
that is a positive test.
Here is a list of the special tests
that we just reviewed.
It also has a diagnosis that could be
confirmed with the special test.
Remember that these special tests have
different sensitivities and specificities.
So, just because you
have a negative test
doesn't always mean
that it's not present.
Just because you have a positive test
doesn't mean that they always have that.
So, you definitely have to take a thorough
history, physical examination,
and other imaging studies to try to confirm
what your patient is presenting with.
So, in reviewing all these different
common shoulder presentations,
now hopefully, you have a better understanding
of different shoulder diseases,
how they present, what tests you
could do to try to identify them,
and how osteopathic manipulation
could be integrated
into the identification and treatment
of these syndromes.