could create hypermobile joints and result in injury.
FIGURE 5-31
Contract-Relax Stretch, Upper Biceps.
FIGURE 5-32 Distal Bicep Stretch.
Step 11: Stretching (During Therapy)
Goal: to create the normal 0-degree range of motion of elbow extension.
To stretch the distal biceps:
To stretch the lower fibers of the biceps, have the cli- ent move so that the shoulder and humerus are still supported on the table, but the forearm is off the table.
The client’s arm is straight at the side, palm facing up, supinated.
This may prevent bicipital tendon aponeurosis strain. Tendi- nosis to the distal biceps aponeurosis on the proximal head of the ulna can scar down the median nerve and create symptoms similar to medial epicondylitis and carpal tunnel syndrome.
Note: The test for bicipital aponeurosis tendinosis will be shown in Chapter 7, with elbow, forearm, wrist, and hand conditions. This is one of the contributing muscles creating pain in the area of the medial epicondyle. It is often generi- cally called medial epicondylitis, even though the biceps tendon and biceps apeneurosis attaches below the medial epicondyle. Make sure to restore normal muscle resting length to the biceps using this part of the shoulder protocol prior to treating that strain if the test for bicipital aponeu- rosis tendinosis is positive.
Step 8: Multidirectional Friction
A proximal biceps strain to the long head of the biceps in the bicipital groove or a strain to the coracobrachialis and short head of the biceps at the attachment on the coracoid process is much more common than a distal biceps strain involving the bicipital aponeurosis just below the elbow. The muscle
Step 9: Pain-Free Movement
Goal: to determine if the client can actively perform shoulder flexion and extension without pain. If so, this gives permission to proceed with pain-free eccentric scar tissue alignment techniques.
Have the client move the arm through shoulder flexion and extension several times. This begins the process of realign- ing the scar tissue.
Pain-free? Proceed to step 10.
Pain? Repeat step 8, working slower and deeper, but still pain-free. Repeat step 9 and then proceed to step 10 when there is no pain.
Step 10: Eccentric Scar Tissue Alignment
Goal: to apply pain-free eccentric muscle contraction by lengthening an injured biceps against mild resistance to realign or redirect the scar tissue (Figure 5-34 ■). resistance test will be for a proximal strain in the anterior
shoulder area.
Goal: to soften the collagen matrix by working in multi- ple directions to prepare for a more functional mobiliza- tion of biceps scar tissue fibers.
Disorganized scar tissue
FIGURE 5-33A
Biceps and Coracobrachialis Muscle Resistance Test.
FIGURE 5-33B
Multidirectional Friction, Bicipital Tendon.
CORE PRINCIPLE
If there is not a muscle–tendon strain or ligament sprain, multidirectional friction would not be part of the treatment.
During the upper or proximal biceps stretch, is there pain during the contraction against resistance, or increased pain during the deep part of the stretch? Ask the client to isolate the painful area by pointing to it (Figure 5-33A ■).
Place your finger on the spot and ask if the client feels pain directly under your finger. If so, this is most likely a muscle–tendon strain.
Relax the biceps and perform multidirectional friction on the exact spot for only 20 to 30 seconds each time. Use only enough pressure to soften the collagen matrix. Do not overwork the area (Figure 5-33B ■).
PRECAUTIONARY NOTE
Do not overwork the area and create inflammation.PRECAUTIONARY NOTE
After surgery, do not disrupt the proper healing of scar tissue by beginning this protocol too soon. Consult the client’s physician before treatment.The client’s shoulder is flexed 90 degrees, with the palm facing up and forearm supinated.
Have the client resist gentle shoulder extension per- formed by you. Make sure he or she does not flex the elbow.
Tell the client to “barely resist, but let me win.”
Start with a pressure of only two fingers and then if there is no pain, have the client increase resistance.
Repeat this several times, pain-free.
Step 4: Assess Resisted Range of Motion (RROM)
Goal: to reassess if there is still a biceps or coracobrachia- lis strain present and exactly where it is located.
FIGURE 5-34
Biceps and Coracobrachialis Eccentric Muscle Contraction.
CORE PRINCIPLE
The greatest error during the eccentric alignment proce- dure is being too aggressive and not keeping the tech- nique pain-free each time. Too much force in opposing directions can cause a new injury or reinjure the site.
PRECAUTIONARY NOTE
Do not move too fast, or use too much force while per- forming a resisted test.Perform the biceps resisted test again.
The client is supine, with the shoulder flexed 90 degrees, palm up (supinated).
Functional scar tissue Place your hands above and below the client’s elbow.
The client gently flexes the shoulder against your resistance. You control the force during the test.
Have the client point to the exact area of pain if pain still exists.
Pain? Repeat steps 8 through 10. Then perform the resisted test again.
Pain-free? Finish with step 11 when there is no longer any pain.