Clinical Decision Making for the Management of Biceps-Related Shoulder Pain, Friend or Foe: A Case Report

The purpose of this case report is to describe a pragmatic approach in guiding optimal management of LHBT impairment.

A 41-year-old female presented with a one-year history of anterior shoulder pain. Shoulder Pain and Disability Index (SPADI) score was 110 and Quick Disabilities Arm, Shoulder & Hand (DASH) was 63.6. She presented with decreased shoulder range of motion (ROM) in scaption and internal rotation (IR), and manual muscle testing (MMT) of elbow flexion and IR. Positive findings: Biceps load test II, O’Briens, and pain with LHBT palpation. Ability of the biceps to assist in stabilizing the anterior shoulder was compromised based upon clinical examination: “foe”. Dynamic function of the LHBT as a stabilizer was assessed with response to biceps contraction in an unstable shoulder position (abduction and maximal external rotation). These findings, in conjunction with the Numerical Pain Rating Scale (NPRS), guided determination of tissue capacity/irritability and loading considerations. Baseline 9/10 pain with Biceps load test II was present, along with inability to anteriorly stabilize the shoulder with the LHBT, which prompted initial isometrics and patient education on avoidance of certain movements/activities. Eccentric strengthening was introduced in the third week as pain levels decreased. Eccentric exercises were progressed with the biceps in a lengthened position (forearm pronated), with ongoing assessment to anterior stabilization with the LHBT. Exercises were all performed pain-free in the scapular plane to minimize stress to the biceps-labral complex. Other interventions included joint mobility, peri-scapular/rotator cuff strengthening, and proprioceptive training.

Patient was managed once a week for 6 weeks. By her 6^th visit, she had improved ROM in scaption and IR, and MMT for elbow flexion and IR. Pain gradually decreased in Biceps load test II, from 9/10 to 2/10 and she regained ability to anteriorly stabilize the shoulder with the LHBT: “friend” function established. Repeat SPADI and quick DASH scores, 21 and 25, respectively, both exceeded the minimal clinical change for improvement.

This case report highlights successful implementation of a pragmatic approach in treating biceps-related pain addressing shoulder dynamic stabilization.

Clinical diagnosis of LHBT pathology can be difficult due to poor diagnostic utility of individual orthopedic special tests. There is a need to determine meaningful causal relationships between LHBT pathology and functional deficits. This may be beneficial to establish a program inclusive of specific biceps rehab. Special consideration should be given to biceps stabilization function in the management of biceps-related shoulder pain.