Patient Profile:
Name: Mr. Rohan Mehta
Age: 32 years
Gender: Male
Occupation: Software Engineer
Hand Dominance: Right-handed
Activity Level: Regular gym-goer (weight training 4x/week)
Chief Complaint:
Pain in the front of the right shoulder, worsening over 3 weeks, especially during overhead activities and lifting.
History of Present Illness:
Patient reports a gradual onset of pain after starting an intense weightlifting program focusing on biceps curls and pull-ups.
Initially mild discomfort, now moderate pain that limits exercise performance and daily activities like reaching for objects overhead.
No history of trauma or direct injury.
Denies numbness, tingling, or instability in the shoulder.
Past Medical History:
No significant past medical history.
No previous shoulder injuries.
No history of diabetes, rheumatoid arthritis, or steroid use.
Observation:
Posture: Slight anterior shoulder rounding.
No visible swelling, redness, or muscle atrophy.
Patient holds arm slightly flexed to reduce discomfort.
Palpation:
Tenderness localized over the bicipital groove (anterior aspect of the shoulder).
No warmth or effusion noted.
Range of Motion (ROM) Testing:
Active ROM: Slightly painful in flexion and abduction beyond 90°.
Passive ROM: Full but discomfort at end range of flexion.
Resisted Testing: Pain and weakness with resisted elbow flexion and shoulder flexion.
Special Tests:
Speed’s Test: Positive (Pain reproduced in the bicipital groove area).
Yergason’s Test: Positive (Pain over bicipital groove with resisted supination).
Hawkins-Kennedy Test: Mild discomfort but negative (rules out impingement as primary cause).
Imaging:
Ultrasound: Thickened biceps tendon with mild effusion in the bicipital sheath, no tear seen.
MRI: (optional) Could be ordered if conservative management fails, but currently not required.
Clinical Diagnosis:
Biceps Tendinitis (Long Head of Biceps Tendon)
Management Plan:
Physiotherapy Goals:
Reduce pain and inflammation
Restore normal shoulder mechanics
Improve strength and flexibility
Prevent recurrence
Treatment:
Initial Phase (1–2 weeks):
Rest from aggravating activities (especially overhead movements and heavy lifting).
Cryotherapy (ice packs) 10–15 minutes, 2–3x/day.
Gentle ROM exercises (pendulum exercises).
Patient education on posture correction and activity modification.
Subacute Phase (2–4 weeks):
Gradual introduction of isometric exercises for shoulder and biceps.
Stretching of the pectoralis minor, anterior shoulder structures.
Scapular stabilization exercises (e.g., serratus punches, scapular retraction).
Strengthening Phase (4–6 weeks):
Progress to isotonic strengthening of the rotator cuff and biceps.
Eccentric exercises for the biceps.
Functional training focusing on overhead mechanics.
Return to Activity:
Sport-specific and gym-specific training with proper warm-up and load management.
Emphasis on eccentric control during lifting.
Prognosis:
Excellent with early intervention.
Full return to activities expected within 6–8 weeks if compliant with physiotherapy.
Key Clinical Teaching Points:
Always assess posture and biomechanics in overuse injuries.
Differentiate biceps tendinitis from rotator cuff tendinopathy and shoulder impingement.
Early load management and education are crucial.
Eccentric training has a strong evidence base for tendon healing.
Section 1: Clinical Reasoning Questions
Q1. List three differential diagnoses you should consider besides biceps tendinitis.
Answer: Rotator cuff tendinopathy, shoulder impingement syndrome, labral tear.
Q2. Why is it important to differentiate between rotator cuff pathology and biceps tendinitis?
Answer: Because treatment strategies and rehabilitation timelines may differ; misdiagnosis can delay recovery.
Q3. Explain why Speed’s Test and Yergason’s Test are useful in diagnosing biceps tendinitis. What structures are stressed during these tests?
Answer: These tests specifically stress the biceps tendon; pain elicited indicates inflammation or injury.
Q4. Which phase of rehabilitation should focus on eccentric strengthening of the biceps tendon? Why?
Answer: Mid to late phase; eccentric loading promotes tendon healing and remodeling.
Q5. If the patient reported clicking or snapping in the shoulder along with pain, what additional diagnosis would you suspect?
Answer: Subluxation of the biceps tendon or a SLAP (Superior Labrum Anterior and Posterior) lesion.
Section 2: Short Answers
Q6. Describe the role of posture correction in managing biceps tendinitis.
Answer: Correct posture reduces shoulder anterior strain and promotes optimal biomechanics.
Q7. Explain how you would educate Mr. Rohan on modifying his gym workouts to prevent aggravation.
Answer: Avoid overhead lifts and heavy biceps curls; focus on controlled, pain-free range of motion exercises.
Q8. List two scapular stabilization exercises you would prescribe and why.
Answer: Scapular retraction exercises and wall slides; they enhance shoulder stability and prevent anterior shoulder overload.
Q9. If conservative management fails after 8–12 weeks, what medical or surgical options could be considered?
Answer: Corticosteroid injections, tenotomy, or tenodesis.
Section 3: Clinical Skill Practice
Task 1: Demonstrate Speed’s Test and Yergason’s Test on a partner.
Task 2: Plan a 4-week rehabilitation program for Mr. Rohan:
Week 1-2:
Rest from aggravating activities
Ice therapy
Gentle passive ROM exercises
Isometric strengthening
Week 3:
Progress to active-assisted and active ROM exercises
Start light resistance band exercises
Scapular stabilization drills
Week 4:
Introduce eccentric strengthening of biceps
Functional movement training
Postural re-education exercises