Issue link: https://www.massageandbodyworkdigital.com/i/230373
CLINICAL APPS 4 Active engagement lengthening to biceps brachii. Image courtesy Whitney Lowe. The greatest increase in Melvin's pain comes with shoulder flexion, and palpation shows pain in the anterior shoulder. These findings call attention to the long head of the biceps brachii (Image 3, page 101). In addition, this muscle-tendon unit is used during active and resisted forward flexion motions of the shoulder. What seems odd is that pain is felt during passive flexion at the end range, as well. If the condition is a muscle-tendon injury, it should not be painful when the muscle and tendon are being passively shortened as they are during forward shoulder flexion. These results follow the findings of our earlier palpation. However, there are unique anatomical features of the anterior and lateral shoulder region. The biceps brachii tendon is enclosed in a synovial sheath as it courses through the bicipital groove on the anterior humerus. When the shoulder is brought into flexion, especially near the far end range of flexion, the tendon can get compressed against the underside of the acromion process or the coracoacromial ligament. Consequently, this is a unique anatomical situation where a muscle-tendon unit is being stressed (by compression) during a passive shortening movement. Mechanical pinching of the tendon and synovial sheath are producing stress on the tendon, which is why it is also painful during a passive movement. Due to the nature of his activities and the results from these evaluation procedures (history, palpation, testing), it appears likely that Melvin may be experiencing some type of chronic overuse disorder with the biceps brachii long head tendon or the synovial sheath surrounding the tendon. Chronic overuse of the tendon (tendinosis) is caused by a breakdown in the collagen matrix of the tendon. The problem could also be in the synovial sheath. Most tendons that have a surrounding synovial sheath are in the distal extremities (wrists, hands, ankles, and 102 massage & bodywork january/february 2014 feet). The synovial sheath is designed to help reduce friction when the tendon has to make a significant bend across multiple joints. There are very few tendons in other parts of the body that have these sharp angles, but the biceps brachii makes a right-angle turn across the top of the humerus before coursing down the upper arm. As a result, it needs protection from friction against the humeral head or bicipital groove. Inflammation and irritation sometimes develop between the tendon and the surrounding synovial sheath as a result of overuse. This is a condition known as tenosynovitis. It is similar to tendinosis but with the addition of inflammatory reactions in the tissue, which tendinosis does not include. It may be difficult to determine whether tendinosis or tenosynovitis is the primary problem. Fortunately, for the purposes of massage treatment, these two problems can be addressed in a similar fashion. TREATMENT CONSIDERATIONS Based on the findings from our history and comprehensive assessment, it seems likely that Melvin's shoulder pain involves a chronic overuse tendon disorder. Now, we should determine if massage is appropriate to address this problem and, if so, how to proceed. The first step is to determine if there are any reasons we should not perform massage. A chronic tendon overuse pathology should respond well to massage, and there are no significant contraindications in Melvin's case. It is important to monitor the treatment to ensure there is progress and that no symptoms are being aggravated and no new symptoms or contraindications emerge. Treatment can begin with superficial work on the deltoid and pectoralis major in order to relax these muscles so that the deeper biceps tendon that lies underneath them may be addressed. A key part of the strategy in Melvin's case is to reduce tightness in the biceps brachii muscle so it does not pull on the tendon and cause excess friction in the bicipital groove. Deep, longitudinal stripping techniques applied to the biceps brachii are particularly helpful to encourage elongation and reduce chronic tightness in this muscle. Active engagement (AE) lengthening techniques are valuable for addressing the dysfunctions associated with chronic overuse problems. AE lengthening is performed by having the client repeatedly flex and extend the forearm while deep stripping techniques are performed on the biceps brachii each time the forearm moves in extension (Image 4). This technique is even more effective if there is additional resistance on the biceps from a resistance