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ESSENTIAL SKILLS Maintain this grip as you pull your hand anteriorly toward yourself, then release the pressure slightly, move your hand back toward the bone, and repeat. location and Friction of the lower biceps tendon Sit either beside or facing the client. To locate the tendon, place the client's arm at a right angle and have the person flex the elbow against resistance. You will see and feel the tendon as it crosses the elbow joint. Follow the tendon with your finger then have the client relax the arm and apply several friction strokes to locate the most painful areas. At each of these areas, use the tip of your thumb to apply friction across the tendon fibers. Alternatively, you can use your thumb to apply pressure on the medial aspect of the tendon and then rotate the forearm; the tendon will snap back and forth as you do this. location and Friction of the lower biceps attachment Sit beside or facing the client, and use the method described above to locate the lower biceps tendon. Follow the tendon to its attachment at the radial tuberosity, about one-half to three-quarters of an inch distal to the elbow crease. Then place the tip of your thumb at the tenoperiosteal junction, bracing with your other fingers at the back of the forearm, and apply friction across the tendon fibers. Alternatively, you can apply pressure on the tendon with your thumb and rotate the forearm between full supination and half pronation. EXERCISES For the rehabilitation of any muscle- tendon injury, it's most effective to combine strength building with stretching. Have clients start out using a light weight, just 1 or 2 pounds, and work their way up. The weighted exercises should cause fatigue after 20 or so repetitions out of a total of 30; if the person tires before 20 repetitions, decrease the amount of weight. It's important to stretch both before and after performing the exercises. One good biceps stretch to give to your clients is described below. For a more thorough series of stretches, I recommend those devised by Aaron Mattes as part of his Active Isolated Stretching (see Mattes, A. Active Isolated Stretching: The Mattes Method. Sarasota, FL: Aaron Mattes Therapy, 2000, pages 20 and 89. biceps Curls From a standing position, hold a weight in the hand on your injured side. With your arm hanging straight down, palm facing forward, bend the elbow to bring the hand toward the shoulder. Then uncurl the arm slowly; performing this eccentric contraction (in which the muscle fibers slowly lengthen as they contract) builds strength more effectively than concentric contraction alone (in which the muscle fibers shorten as they contract). Do three sets of 10 repetitions. supination Hold the weight with your elbow bent at a 90º angle and your palm facing the floor, and then rotate the palm toward the ceiling. Repeat for three sets of 10. stretch With your arm reaching out straight behind you, elbow extended, place the palm of your hand on a countertop. Now bend your knees to stretch the biceps (for some people, this is easier to perform in a lunge position). Hold the stretch for two seconds and repeat 15–20 times. INJECTIONS While most biceps injuries respond well to rest or to friction, exercise, and massage therapy, there is one notable exception. The part of the biceps tendon that passes through the shoulder joint is too deep to reach with the fingers. When that area is injured, corticosteroid and/ or proliferant injections may be the only effective treatment. CONCLUSION While biceps strains aren't among the most common injuries we see, failure to understand them can lead practitioners into trouble. Without proper treatment, a biceps injury may heal improperly, leading to a buildup of adhesive scar tissue that causes a chronic pattern of recurring pain. Assessment tests and palpation are critical in identifying which portions of the biceps muscle-tendon unit are injured, or—in some cases—demonstrating that injury to another structure (such as the subscapularis or brachialis) is mimicking a biceps strain. So although building your biceps knowledge won't make you stronger or improve your physique, it will help make you a more effective massage therapist. education and sports medicine. He is founder of the Muscular Therapy Institute. Benjamin has been in private practice for more than 45 years and has taught communication skills as a trainer and coach for more than 25 years. He teaches extensively across the country on topics including SAVI communications, ethics, and orthopedic massage, and is the author of Listen to Your Pain, Are You Tense? and Exercise Without Injury and coauthor of The Ethics of Touch. He can be contacted at bbby@mtti.com. Editor's note: Massage & Bodywork is dedicated to educating readers within the scope of practice for massage therapy. Essential Skills is based on author Ben E. Benjamin's years of experience and education. The column is meant to add to readers' knowledge, not to dictate their treatment protocols. Ben E. Benjamin, PhD, holds a doctorate in visit massageandbodywork.com to access your digital magazine 109