Resisted Elbow Flexion Research Articles

Pronator Teres Tear at the Myotendinous Junction In the Recreational Golfer: A Case Report

Pronator teres muscle tear is a rare athletic injury that reportedly occurs in swinging sports such as golf and cricket. The main mechanism of injury appears to be caused by a forceful golf or racket swing striking the ground during resisted elbow flexion and supination. We report the case of a 50 year old right hand dominant male who presented with right elbow pain and volar sided ecchymosis of the right bicep, elbow, and forearm for two weeks following his injury while golfing. Initially after one episode of golfing, the patient reported experiencing right elbow pain with no ecchymosis. The following week while golfing, the patient developed pain over the anterior forearm and was forced to stop golfing. The next day he noted extensive ecchymosis of the right distal arm region that extended to the distal wrist. MRI confirmed an acute right pronator teres tear at the myotendinous junction. The patient was expected to make a complete return to pre-injury level athletic activity with conservative management. With this article, we consider biceps rupture on the differential diagnoses associated with pronator teres musculotendinous injuries, emphasize the significance of club type in relation to golfing injuries, and propose a potential pronator teres rupture non-operative rehabilitation protocol.

Elbow Pain - CrossFit

HISTORY: A 29-year-old male CrossFit and surfing instructor with a history of left ulnar shaft fracture treated nonoperatively presented with a 9 month duration of chronic, intermittent, left, sharp and burning elbow pain since injuring himself weight lifting. Bicep flexion and thumb rotation caused pain radiating to the elbow. He endorsed numbness of the left hand that led to an ER visit 9 months ago. His tingling resolved prior to our visit and he denied shoulder or neck pain. He has been seen previously by a Hand Specialist, was offered a steroid injection, and presented to us for further evaluation. PHYSICAL EXAMINATION: The patient exhibited no obvious atrophy of the forearm, but trace atrophy at the left medial triceps. He had full flexion and extension equal bilaterally, with slightly decreased supination on the left as compared to the right side. He was tender to palpation over the distal biceps, but nontender in the antecubital fossa. There was mild crepitus with resisted supination and pronation on the lateral epicondylar region. Radial head was minimally tender to palpation. He had elbow pain with resisted elbow flexion in neutral and supination more so than pronation. No skin changes were appreciated and no obvious elbow effusion. Distal neurovascular exam was grossly intact. DIFFERENTIAL DIAGNOSIS: 1. Distal biceps tear 2. Bicipitoradial bursitis 3. Ulnar shaft fracture 4. Radial head fracture 5. Osteochondritis dissecans of the capitulum TEST AND RESULTS: Elbow MR arthrogram (obtained 3 weeks ago) demonstrated a very small partial thickness tear of the ulnar collateral ligament, minimal radial cartilage loss, and a partial thickness tear of the distal biceps with prominent bicipitoradial bursitis. FINAL/WORKING DIAGNOSIS: Left partial thickness distal biceps tear AND associated bicipitoradial bursitis TREATMENT AND OUTCOMES: 1. Patient elected to avoid steroid injections and pursue conservative management involving physical therapy and topical NSAIDs 2. Pain continued intermittently. Further work up 1 year later included CT elbow showing mild left ulnohumeral joint osteoarthritis with small ossific joint loose bodies and healed proximal left ulna shaft and coronoid process fractures 3. Elbow pain may be subsequent to malalignment from an old Monteggia fracture

Shoulder Pain In A High School Football Player

HISTORY: 15 year old presents to clinic accompanied by father with right anterior shoulder pain for 6 days. He injured it during football practice doing contact drills. He lowered his head and got hit in the anterior aspect of his right shoulder by an opponent’s helmet. Initially he couldn’t even raise his arm up. He states that his motion has mildly improved but continues to have pain and points anterior and lateral when describing his pain. Denies significant swelling, bruising, paralysis, or paresthesias, or previous injuries to his shoulder. Pain is 4/10. Describes it as a shooting type pain worse with movement and better with ice and holding his arm still. No feelings of instability. PHYSICAL EXAMINATION: On examination of his right shoulder there is slight fullness appreciated over the proximal arm. He has mild tenderness over the coracoid anteriorly as well as over his lateral deltoid. Actively he will flex to 130 degrees, external rotation 0 degrees, shoulder adduction 30 degrees and internal rotation just past his iliac crest all of which give him some pain. He does have some mild pain with resisted elbow flexion anteriorly. 5-/5 strength on external rotation, internal rotation and Jobe’s. DIFFERENTIAL DIAGNOSIS: - Subacromial Impingement - Rotator Cuff Tear - Scapular Fracture TEST AND RESULTS: AP External Rotation and Axillary views were obtained which showed lucency over the base of the coracoid process consistent with fracture. FINAL WORKING DIAGNOSIS: Fracture of the base of the right coracoid process TREATMENT AND OUTCOMES: 1. Placed in a shoulder sling and was instructed to not do any lifting with that arm. 2. Seen 2 weeks later with significant improvement in pain and was able to move arm with still some mild discomfort over the anterior shoulder. 3. Followed up 6 weeks post injury and had no pain with range of motion and had symmetrical strength. 4. Blue Theraband with Jobe’s exercises started and was allowed back to play in a graded RTP fashion with follow up as needed.

The Role of the Muscle Brachioradialis in Elbow Flexion: An Electromyographic Study.

In the classical conception, the brachioradialis is a forearm supinator. The hypothesis of this study was that, at least in certain positions of elbow flexion and forearm rotation, the brachioradialis is, along with the biceps and brachialis, one of the main elbow flexors. Fifteen young healthy male volunteers participated in this research. The activities of the biceps, brachialis and brachioradialis muscles were studied using surface electromyography, while the subjects were performing elbow flexions/extensions with as much strength as possible, forearm in neutral position, then in full pronation, then in full supination. The elbow flexion torques were isokinetically measured at 60°/sec for an arc of 120°. The biceps, brachialis and brachioradialis muscles were electromyographically very active throughout resisted elbow flexion, in all three investigated positions of forearm rotation. At certain positions, the electromyographic activities were much higher than the maximal voluntary contraction signal. For what concerns specifically the brachioradialis, in all three forearm rotation investigated positions, the activity curve demonstrated a slow increase during the first part of elbow flexion, reaching in 73.3% of subjects its peak at the end of flexion; in the remaining 26.7%, the brachioradialis had a flat activity without significant peak. The activity was slightly higher in supination. This study indirectly supports the idea that the brachioradialis is one of the main elbow flexors, especially when the elbow flexion is done with the forearm in supination. This observation could be important in clinical elbow and wrist surgical practice.

Ulnar Head Reconstruction with Microvascular Second Metatarsal.

Background:The distal radioulnar joint along with the interosseous ligament of the forearm and the proximal radioulnar joint, form a functionally integrated system responsible for the pronation–supination of the hand. The distal ulna, the so-called ulnar head, is an integral part of this system. Apart from its well-known role in forearm rotation, the ulnar head is essential in transverse load transmission through the distal radioulnar joint upon resisted elbow flexion. Autologous reconstruction of ulnar head would theoretically be beneficial with respect to prostheses.Methods:Three cases of ulnar head reconstruction with microvascular second metatarsal are reported herein including trauma, oncological, and congenital ethiologies.Results:The clinical result was good without complaints of instability.Conclusions:The cases included in this series, although heterogeneous, indicate that this treatment may be feasible also in postoncological resections and in congenital cases.

Arthroscopic Transfer of the Long Head of the Biceps Tendon

Objectives:Evaluation of the mid-term clinical and functional outcome in a cohort of patients who underwent transfer of the long head of the biceps tendon (LHBT).Methods:Patients diagnosed with biceps instability or related pathology that underwent arthroscopic assisted or all arthroscopic transfer of the long head of the biceps tendon to the conjoint tendon were considered. The procedure was performed either as an isolated procedure on in conjunction with another procedure by the senior author. Outcome surveys were collected for 157 patients with a subset of 43 patients available for clinical examination at 2-10 years postop time point. Outcome measures were based on American Society of Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA), and L’Insalata questionnaires. Ipsilateral and contralateral metrics were also evaluated.Results:157 patients (25 female, 132 male; average age 50 years; average postop 4.9 years) were evaluated with L’Insalata, UCLA, and ASES questionnaires, scoring 84.78, 29.77, and 83.4, respectively. In the 33 patients who had an isolated LHBT transfer, the L’Insalata, UCLA, and ASES scores were 79.52, 27.6, and 83.95, respectively. 43 shoulders (7 female, 36 male; average age 50 years; average postop 5.1 years) were available for clinical examination by a physician other than the treating surgeon. There was no statistically significant side-to- side strength difference using a 10-pound weight. All of the patients reported no arm pain at rest with regard to the biceps. 81% of patients reported no biceps tenderness upon palpation of the bicipital groove and 85.8% had a negative throwing test. 95.2% of patients had a negative active compression test. Speed’s and Yergason’s tests were negative in 90.5% and 95.2% of patients respectively. One patient (3%) complained of fatigue discomfort (soreness) isolated to the biceps muscle following resisted elbow flexion. Five patients (12.0%) had a Popeye sign and one patient (3%) exhibited biceps subsidence. 86% of patients were self-rated as good to excellent, with the remaining 14% reporting fair or poor results.Conclusion:Arthroscopic subdeltoid transfer of the LHBT to the conjoint tendon is an appropriate and reliable intervention for active patients with chronic, refractory biceps pathology. There was no loss of strength for biceps curls. All patients reported no pain isolated to biceps muscle at rest. Ninety-seven percent of patients had resolution of their preoperative biceps symptoms.

Testing procedures for SLAP lesions of the shoulder involving contraction and torsion of biceps long head and glenohumeral glides

Testing procedures for SLAP lesions of the shoulder can combine resisted elbow flexion, forearm pronation and supination, and glenohumeral glides. These procedures reproduce symptoms by increasing biceps long head active tension or passive torsion, and by placing the shoulder in an unstable position. We compared activation of biceps long head and pain intensity, between supinated and pronated forearm positions, between different glides, and between individuals with and without shoulder impairment. A case control study. Twelve participants with suspected SLAP lesions and twelve with no history of shoulder injury volunteered. Electromyography measured muscle activity in biceps long head, normalised against maximum voluntary isometric contraction (MVIC). Subjective pain intensity scores were recorded. Biceps long head activity was greater in forearm supination (mean 39% MVIC) than pronation (mean 24% MVIC), but pain was higher in pronation (mean 4.5/10) than supination (3.2/10). Biceps long head activity was greater when testing without a glide, but there was no difference in pain comparing the glide conditions. The impaired group experienced more pain (mean 3.9/10) than controls (mean 0.3/10) but there was no difference in shoulder muscle activity. No one combination of testing procedures appeared to be diagnostic of SLAP lesions in our sample. This study supports the theory that biceps long head acts as a stabiliser of the shoulder, and suggests that clinical testing procedures for SLAP lesions may need to inhibit biceps long head activity. The addition of glides to SLAP testing procedures did not affect the reproduction of pain.

Patient-Related Factors and Complications After Arthroscopic Tenotomy of the Long Head of the Biceps Tendon

Background: Tenotomy of the long head of the biceps tendon (LHBT) has been reported to provide reliable pain relief and require little postoperative rehabilitation. Complications such as cosmetic deformity, decrease in elbow flexion strength, decrease in supination strength, and fatigue discomfort have been reported after tenotomy of the LHBT. Purpose: To evaluate the complications of arthroscopic tenotomy of the LHBT in the shoulder–specifically, cosmetic deformity, decreased elbow flexion strength, and a cramplike arm pain–and to identify the patient-related factors that affect the rate of complications after tenotomy, such as, age, sex, involvement of the dominant arm, and body mass index (BMI). Study Design: Case series; Level of evidence, 4. Methods: In sum, 132 patients were evaluated. They had a mean age of 63 years (range, 26 to 82 years) at the time of surgery and a mean follow-up of 21 months (range, 12 to 53 months). The presence of so-called Popeye deformity, a cramplike arm pain at resisted elbow flexion, and strength of elbow flexion were evaluated. The development of each complication was compared by age, sex, involvement of the dominant arm, and BMI. Results: Of the 132 patients, 60 (45%) had Popeye deformity, and it was significantly more frequent in men (76%) than women (31%) (P < .001). However, statistical analysis showed no difference in Popeye deformity frequency by age, arm dominance, or BMI. Male sex was found to be the only risk factor associated with the development of Popeye deformity, with an odds ratio of 10.21 versus women (95% confidence interval, 3.97 to 26.27; P < .001). Ten patients (8%) complained of a cramplike arm pain. Elbow flexion strength decreased in 60 patients (45%), although no intergroup differences were found for elbow flexion strength. Conclusion: The current study showed a 45% prevalence of Popeye deformity and 8% cramplike arm pain on exertion after tenotomy of the LHBT. Among patient factors such as sex, age, dominant arm relation, and body mass index, the male sex was the only factor correlated with occurrence of a Popeye deformity. Other factors did not show any correlation with deformity, elbow flexion strength, and cramplike arm pain.

Unilateral Arm Swelling-Weight Lifting

HISTORY: A 21 year old right hand dominant college student presented with left upper extremity swelling five days after heavy upper body weight lifting. He first noticed pain and decreased range of motion of the elbow the day after the first intensive upper body work-out. Despite these symptoms, he completed a second consecutive day of upper body lifting causing an increase in pain, further decrease in range of motion of the elbow, and slight swelling of the left arm. By day 3, the patient's pain and decreased range of motion had resolved, but he noticed worsening left arm swelling. The swelling continued to increase until presentation to the clinic on day 5. He denied numbness, tingling or weakness in the left arm. He did report taking creatine and protein supplements as well as a supplement containing androstenidione. PHYSICAL EXAMINATION: Examination revealed 2-3+ pitting edema from the mid forearm to mid biceps. No ecchymosis was present. No tenderness on palpation of biceps, triceps, brachioradialis, medial or lateral epicondyles, olecranon or radial head. Likewise, no palpable muscle deformities were appreciated. The patient had full range of motion at the elbow and wrist without pain, and strength was 5/5 with resisted elbow flexion, extension, pronation, supination, wrist extension and flexion. Sensation was intact to light touch over the left upper extremity. The radial pulse was present, but slightly diminished compared to the right side. Measurements: Biceps (left) = 34 cm (right) = 30 cm Forearm (left) = 31.5 cm (right) = 28.5 cm Wrist (left) = 18.5 cm (right) = 17.5 cm DIFFERENTIAL DIAGNOSIS: Exercise-induced upper extremity deep venous thrombosis (Paget-Schroetter syndrome) Isolated upper extremity rhabdomyolysis Muscle tear Acute Compartment Syndrome TEST AND RESULTS: Left upper extremity doppler ultrasound_no evidence of DVT Total CK: 30900 on day 6 (normal <200) BUN: 14 Creatinine: 1.0 FINAL WORKING DIAGNOSIS: Left upper extremity rhabdomyolysis TREATMENT AND OUTCOMES: Encouraged to increase oral fluid intake Instructed to abstain from upper body weight lifting Recommended Ace bandage wrap for compression Counseled to avoid use of testosterone precursors and other supplements Gradual decrease in swelling with complete return to baseline 7 days after initial presentation was noted

Arthroscopic Transfer of the Long Head of the Biceps Tendon: Functional Outcome and Clinical Results

We sought to evaluate clinical and functional outcome in a cohort of patients who underwent transfer of the long head of the biceps tendon (LHBT). Patients who were diagnosed with biceps pathology or instability underwent an arthroscopic assisted or all arthroscopic transfer LHBT as either an isolated procedure or part of another shoulder procedure by the senior author. The procedure was performed using a new arthroscopic subdeltoid technique. Forty shoulders in 39 patients were examined at a minimum of 2 years. Patients underwent complete shoulder evaluation and clinical outcomes were scored based on American Society of Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles (UCLA), and L'Insalata questionnaires. Ipsilateral and contralateral metrics were also evaluated. Forty shoulders (13 female, 26 male, 1 bilateral; average age, 38.5 years) were evaluated with L'Insalata, UCLA, and ASES questionnaires, scoring 75.57, 27.32, and 78.72, respectively. In the 25 patients who had an isolated LHBT transfer, the L'Insalata, UCLA, and ASES scores were 85.2, 29.5, and 84.8, respectively. Three patients had early traumatic failure related to noncompliance with postoperative rehabilitation protocol. This included the only 2 patients who had a Popeye sign at follow-up during active elbow flexion. There was not a statistically significant side-to-side strength difference using a 10-pound weight. Eighty percent of patients were self-rated as good to excellent, and 20% of patients were self-graded as fair or poor, which includes the 3 failures mentioned above. All of the patients reported no arm pain at rest with regard to the biceps. Ninety-five percent of patients reported no biceps tenderness upon palpation of the bicipital groove. Five patients complained of fatigue discomfort (soreness) isolated to the biceps muscle following resisted elbow flexion. Arthroscopic subdeltoid transfer of the LHBT is an appropriate and reliable intervention for active patients with chronic, refractory biceps pathology. There was no loss of strength for biceps curls. All patients reported no pain isolated to biceps muscle at rest. Ninety-five percent of patients had resolution of their preoperative biceps symptoms. Level IV, therapeutic case series.

Activation of Brachioradialis Muscles Transferred to Restore Lateral Pinch in Tetraplegia

Surgical transfers of muscles are used to restore lateral pinch in tetraplegia; however, outcomes are variable. The purpose of this study was to compare activation of the brachioradialis (Br) after transfer to the flexor pollicis longus during maximum effort in its primary function (elbow flexion) with maximum effort in its postoperative function (lateral pinch) and to record Br activation during functional tasks. Fine-wire electrodes recorded activation of the Br in 11 arms with tetraplegia. Subjects produced maximum lateral pinch force with and without elbow stabilization and were classified according to elbow strength. The elbow was stabilized by supporting the arm and limiting elbow motion. A force sensor mounted on a custom grip recorded the pinch force. Electromyographic (EMG) signals recorded during lateral pinch were expressed as a percentage of the maximum voluntary contraction recorded during maximum-effort elbow flexion. The EMG activation was significantly lower during lateral pinch compared with resisted elbow flexion. The mean EMG during lateral pinch in the self-supported elbow condition was 34% of the maximum voluntary contraction; with the elbow stabilized the EMG increased to 55% of the maximum voluntary contraction. Postoperative pinch-force magnitude was 14 N with self-support and 20 N with the elbow stabilized. Subjects with weak elbow extension strength produced significantly lower pinch forces compared with subjects with strong elbow extension but had similar ability to activate the Br. The Br activation was higher when the pinch tasks were performed successfully. These findings suggest a reduced ability to activate the transferred muscle fully in lateral pinch function after surgery, even with the addition of elbow support. The Br activation is linked to successful performance of lateral pinch tasks. The subjects' inability to activate the transferred muscle fully may be affected by postoperative muscle re-education and contribute to postoperative weakness.

Arthroscopic Release of the Long Head of the Biceps Tendon

Background Treatment of chronic, refractory biceps tendinitis remains controversial. The authors sought to evaluate clinical and functional outcomes of arthroscopic release of the long head of the biceps tendon. Hypothesis In specific cases of refractory biceps tendinitis, site-specific release of the long head of the biceps tendon may yield relief of pain and symptoms. Study Design Case series; Level of evidence, 4. Methods Fifty-four patients diagnosed with biceps tendinitis underwent arthroscopic release of the long head of the biceps tendon as an isolated procedure or as part of a concomitant shoulder procedure over a 2-year period. Patients were not excluded for concomitant shoulder abnormality, including degenerative joint disease, rotator cuff tears, Bankart lesions, or instability. Nine of 40 patients had an isolated arthroscopic release of the biceps tendon. At a minimum of 2 years, the American Shoulder and Elbow Surgeons; the University of California, Los Angeles; and the L'Insalata shoulder questionnaires as well as ipsilateral and contralateral metrics were used for evaluation. Results The L'Insalata; University of California, Los Angeles; and American Shoulder and Elbow Surgeons scores were 77.6, 27.6, and 75.6, respectively. Seventy percent had a Popeye sign at rest or during active elbow flexion; 82.7% of men and 36.5% of women had a positive Popeye sign (P <. 05); 68% were rated as good, very good, or excellent. No patient reported arm pain at rest distally or proximally; 38% of patients complained of fatigue discomfort (soreness) isolated to the biceps muscle after resisted elbow flexion. Conclusion Arthroscopic release of the long head of the biceps tendon is an appropriate and reliable intervention for patients with chronic, refractory biceps tendinitis. Cosmetic deformity presenting as a positive Popeye sign and fatigue discomfort were the primary complaints. Clinical Relevance Although tenotomy is not the ideal intervention for patients of all ages with various shoulder abnormalities, data suggest that it may be an acceptable surgical intervention for a specifically selected cohort of individuals.

Paper #107 Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results

The treatment of chronic, refractory biceps tendinitis remains controversial. The etiology of biceps tendinitis may involve pathology within the tendon, specifically along its course in the bicipital groove or at its insertion on the labrum. In specific cases where all other pathologies have been ruled out, site specific release of the long head of the biceps (LHBT) may yield relief of pain and symptoms. We sought to evaluate clinical and functional outcome in a cohort of patients who underwent arthroscopic release of the LHBT. 54 patients diagnosed with biceps tendinitis or biceps tendon instability underwent an arthroscopic release of the LHBT as either as isolated procedure or as part of another shoulder procedure over a 2yr period. 36pts were available for follow-up at a minimum of 18 months. Patients were not excluded for concomitant shoulder pathology that included DJD, rotator cuff tears (RCT), Bankart lesions, or instability. 11/36 had isolated arthroscopic release of the biceps tendon. Patients underwent a complete shoulder exam by one surgeon who was different than the surgeon performing the surgery at our institution and were scored based on ASES, UCLA, and L”Insalata functional shoulder questionnaires. In addition, ipsilateral and contralateral metrics were evaluated. Results of 36pts(10F, 26M: 49yrs) were evaluated at 2.3 yrs post-op (range 18-42 mos). L’Insalata, UCLA, and ASES scores were 70.1, 25.8, and 75.4 respectively. 26% had no Popeye sign (PS) at rest or during active elbow flexion. 17% had a +PS during rest and elbow flexion. 57% had no PS at rest, but a +PS during active elbow flexion. Side to side strength difference was 2.5 reps (10 lbs weight). 57% were rated as good, very good, or excellent. 43% of pts were graded as fair (N = 4) or poor (N = 6).Of 6 pts with a poor result, 2 had DJD, 2 had RCT, 2 had an acromioplasty. None of the patients reported arm pain at rest or proximally. 36% of pts complained of fatigue discomfort (soreness) isolated to the biceps muscle following resisted elbow flexion. 96% had mild to no biceps tenderness upon palpation of the becipital groove.

Agonist contractions against electrically stimulated antagonists

Yanagi T, Shiba N, Maeda T, Iwasa K, Umezu Y, Tagawa Y, Matsuo S, Nagata K, Yamamoto T, Basford JR. Agonist contractions against electrically stimulated antagonists. Objective: To assess an exercise program that uses electrically stimulated antagonists to resist agonist muscle contractions. Design: In 1 limb, electrically stimulated antagonists resisted elbow flexion and extension. In the other, stimulation occurred without volitional muscle contraction. Setting: A biomechanics laboratory in Japan. Participants: Twelve men between the ages of 19 and 24 years. Subjects served as their own controls. Intervention: Subjects trained 3 times a week for 12 weeks. Each session consisted of 10 sets of 10 elbow flexor and extensor contractions. Main Outcome Measures: Isokinetic elbow extension and flexion torques. Biceps and triceps brachii cross-sectional areas. Results: Elbow extension torques increased (32.85% at 30°/s, 27.20% at 60°/s, 26.16% at 90°/s; all P≤.02) over the training period in limbs that trained against electrically stimulated antagonists. Control limb extension torque increases were smaller (8.52% –14.91%) and did not reach statistical significance. Elbow flexion torques improved in both groups, but the changes did not reach statistical significance. Cross-sectional areas increased in all muscles but were most marked in the antagonist stimulated limbs: triceps 16.20% versus 4.25% ( P=.01) and biceps 16.65% versus 7.00% ( P=.005). Conclusions: Exercises that use electrically stimulated antagonist muscles may be effective in increasing muscle strength and mass.

ARM PAIN - FITNESS

HISTORY - A 22 year old fitness enthusiast presented with a complaint of weakness and deformity of her right dominant arm. Six months earlier, during an exercise class, she performed “military-style” push-ups for 30–45 minutes as instructed by the leader. The following day, she said that she was unable to move her elbow due to distal arm pain. However, two days later she went rock climbing, and after that described the pain as “excruciating.” She sought treatment and was given a diagnosis of biceps tendonitis and prescribed to take NSAIDs. She was unable to move her arm for two weeks after the diagnosis. She had no parasthesias but had continued mild pain thereafter. She presented with continued weakness, pain, and a muscular deformity of her distal right arm. She had been in good health otherwise with no systemic illnesses. PHYSICAL EXAMINATION- The patient was in no acute distress. She had obvious atrophy of her right distal arm as compared to the left. She had full symmetric ROM of her shoulders and elbows. She was neurologically intact to sensory, motor, and reflex testing. Her biceps tendon was intact distally and she had no elbow effusion. She was slightly weaker to resisted elbow flexion, which produced distal arm pain. She had normal supination and pronation strength compared to the opposite side. She was slightly tender along her distal arm in the area of atrophy. She had no contractures and a negative Tinel's sign for all peripheral nerves. DIFFERENTIAL DIAGNOSIS 1. Congential brachialis muscle abnormality 2. Biceps or brachialis muscle or tendon partial tear 3. Compartment syndrome distal arm TESTS AND RESULTS 1. Plain radiographs of shoulder and arm: normal 2. EMG of upper extremity: normal (brachialis not tested) 3. Magnetic resonance imaging of arm: marked atrophy of right brachialis muscle as compared to left 4. Isokinetic testing: decreased flexion strength of 20% at 60° sec and 26% at 120°/sec FINAL/WORKING DIAGNOSIS Exertional compartment syndrome of flexor compartment of distal arm resulting in brachialis necrosis TREATMENT 1. Symptomatic treatment with NSAIDs 2. Return to athletics with no limitations 3. Referral to plastic surgery for options of cosmetic reconstruction.

Biceps load test II: A clinical test for SLAP lesions of the shoulder

Purpose: The purpose of this report is to describe the biceps load test II for evaluating the superior labral anterior and posterior (SLAP) lesions. Type of Study: This is a double-blind study in consecutive data, which includes diagnostic accuracy of a test using sensitivity, specificity, and interexaminer reliability. Methods: In the supine position, the arm is elevated to 120° and externally rotated to its maximal point, with the elbow in the 90° flexion and the forearm in the supinated position. The patient is asked to flex the elbow while resisting the elbow flexion by the examiner. The test is considered positive if the patient complains of pain during the resisted elbow flexion. The test is negative if pain is not elicited or if the pre-existing pain during the elevation and external rotation of the arm is unchanged or diminished by the resisted elbow flexion. A prospective study was performed in 127 patients to evaluate the diagnostic accuracy for the biceps load test II. Two independent examiners were assigned to perform the new diagnostic test. The results of the tests were confirmed during the arthroscopic examination. Results: A positive test result in 38 subjects correlated with a SLAP lesion in 35 patients and an intact biceps-superior labrum in 3 patients. A negative test result in 89 patients correlated with an intact superior labrum complex in 85 patients, whereas 4 patients with a negative test result had a type II SLAP lesion. The biceps load test II had a sensitivity of 89.7%, a specificity of 96.9%, a positive-predictive value of 92.1%, a negative-predictive value of 95.5%, and a kappa coefficient of 0.815. The abduction and external rotation of the shoulder during the test changes the relative direction of the biceps fiber in a position of oblique angle to the posterosuperior labrum. The resisted contraction of the biceps increases the pain generated on the superior labrum that is already peeled off the glenoid margin in the abducted and externally rotated position. Conclusions: The biceps load test II is an effective diagnostic test for SLAP lesions.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 2 (February), 2001: pp 160–164

ARM PAIN-FOOTBALL

840 HISTORY-A 20 year old lineman for a Division IA football team was injured in a game when he was blocking an opponent. His arm was pulled away from his body when he felt something pop in his left, non-dominant shoulder. He had immediate onset of pain but no parasthesias. He did not feel his shoulder subluxate or dislocate upon careful questioning. He had no previous problems whatsoever with that arm or shoulder. He noted immediate onset of swelling in his arm and went to the sidelines for evaluation. PHYSICAL EXAMINATION-The player was alert and oriented but was in moderate discomfort. He was neurologically intact distally with normal sensation, motion and strength in his hand and wrist. He had pain in his mid-arm with flexion and extension of his elbow but had no weakness to resisted elbow flexion. His shoulder pads were removed and he had no deformity. There was mild swelling about his proximal, medial arm. He had limited abduction to 120 degrees with pain. Muscle testing of his deltoid, supraspinatus, infraspinatus and triceps was normal. He had a palpable pectoralis tendon with resistance to the pectoralis muscle. He was tender to palpation lateral to his pectoralis insertion and along his proximal arm in this area. Due to his size it was difficult to assess whether there was a defect in his biceps region. He was removed from play, given a sling and ice was applied to his arm. DIFFERENTIAL DIAGNOSIS Fracture proximal humerus Rupture biceps tendon or coracobrachialis Pectoralis tendon rupture Occult subluxation shoulder TESTS AND RESULTS Plain radiographs of shoulder and arm: normal Magnetic resonance imaging of arm-ruptured long head of the biceps tendon. FINAL/WORKING DIAGNOSIS: Rupture long head of biceps tendon TREATMENT Symptomatic treatment with ice, NSAID's and range of motion exercises Surgical tenodesis of long head of biceps tendon one week later Immobilization with sling two weeks with no shoulder motion Rehabilitation progressing from range of motion to isometrics to light weights Gradual return to activities and sports

The pain of acute bursitis/tendinitis of the shoulder

T he head of the humerus is a relatively large, hemispheric “ball” that articulates within a shallow, nearly vertical, oval “socket,” the glenoid fossa. The large disparity between the articular surface area of the humeral head-which is many times greater than the glenoidpermits the wide range of motion normally possessed by the shoulder. With the exception of the coracohumeral ligament superiorly, the shoulder does not have the strong ligaments and capsular reinforcements that help stabilize other joints. Instead, the shoulder must be stabilized primarily by the muscles and tendons that cross the glenohumeral articulation, collectively referred to as the rotator cuff. Acute bursitis or tendinitis of the shoulder results from inflammation of one or more components of the rotator cuff, and includes bicipital tendinitis, subdeltoid bursitis, or supraspinatus tendinitis or bursitis. The pain associated with acute bursitis and tendinitis of the shoulder characteristically only occurs with certain movements and in certain ranges of motion. Patients with supraspinatus tendinitis, for example, experience pain between 70 degrees and 120 degrees of abduction. Night pain develops only upon rolling over onto the affected shoulder. In patients with supraspinatus tendinitis, localized pain occurs in the outer aspect of the shoulder, sometimes radiating down the outer aspect of the arm, as it does in subdeltoid (subacromial) bursitis. Pain due to bicipital tendinitis is localized anteriorly over the shoulder joint and may radiate down the anterior aspect of the upper arm. Shoulder pain exacerbated by resisted elbow flexion should always raise the suspicion of bicipital tendinitis. This suspicion can be strongly supported if resisted supination of the forearm also induces pain in a motionless shoulder. Management of the painful episode begins with rest and physical therapy. Although acute bursitis and tendinitis of the shoulder is a relatively self-limited disorder with a spontaneous recovery rate of 30 to 40 percent, most patients report severe pain during the first three days, requiring medication for relief of pain. Phenylbutazone and indomethacin have commonly been used to treat patients with acute bursitis and tendinitis; however, these drugs are associated with a high incidence of side effects, which may limit their usefulness. We conducted an open-label study with flurbiprofen-a potent butwell-toleratednewanalgesic/anti-inflammatoryagentfor the treatment of acute shoulder syndrome. In the range of 120 to 300 mg daily, flurbiprofen reduced tenderness and pain, both on motion and at rest, in 77 percent of patients. This initial study showed that the upper dosage regimen was more effective as an initial starting dose for this condition. Therefore, another study was undertaken to evaluate flurbiprofen in a similar group of patients using a higher starting dose. In the double-blind, randomized study described in the following article, 86 percent of flurbiprofen-treated patients were assessed as better, compared with only 59 percent of patients who had received placebo.