Armored Heat X Tread Athletics: 2 Types Of Biceps Tendonitis In A Throwing Arm
This is a really unique type of post as we teamed up with Ben Brewster from Tread Athletics to give everybody an in depth look at Biceps Tendonitis through our two respective lenses.
ARMORED HEAT: RYAN YOSHIDA PT, DPT, CSCS
Biceps Tendonitis is one of the most common issues we see in the throwing shoulder. It commonly occurs to the proximal, long head tendon which is the one the runs right over the front of the shoulder attaching the biceps muscle to the superior glenoid (Top Rim of the shoulder)
Assuming the correct diagnosis, we start off by bucketing the issue into 2 common categories that we see:
TENSILE BICEPS TENDONITIS: (Think the same mechanism as Achilles and Patellar Tendonopathies) Usually felt at and after ball release
LESS COMMON IN OUR POPULATION
BASEBALL SPECIFIC TENDONITIS: (Anterior Shear Based) Usually felt at Max ER and Transition to Acceleration
THIS IS BY FAR THE MOST COMMON TYPE WE SEE
TENSILE BICEPS TENDONITIS: Typically presents like most other tendonopathies in the body. That is, when the biceps pulls at a very high force, the tendon is most irritated. This highest muscular demand of the biceps muscle during the throw, is during the deceleration portion (at and just after ball release). The discomfort can usually be reproduced with high effort bicep curls or pulling exercises as well. This “Tensile” tendonitis is the less common of the two that we see.
Clinical Nugget: Your special test must match the type/mechanism of the tendonopathy. This is why Speed’s Test may do a good job of identifying these tensile based symptoms, but a pretty poor job of identifying the shear based type with a ton of false negatives there
BASEBALL SPECIFIC TENDONITIS: Typically presents more as a position based issue than a biceps contraction based issue. It is usually present on the positions lead to the most anterior translation of the humerus (Think Max ER or the bottom of a deep bench press/dip). The consistent drift forward of the humerus applies excessive stress to the Biceps Tendon irritating it and restarting the inflammation process over and over again. It is very common to see absolutely no symptoms with max loading of the biceps due to the underlying mechanism of the issue. This is unlike most other tendonopathies throughout the body.
Clinical Nugget: As always, we HAVE to test out hypothesis! A good way to test if it is truly the anterior shear that is driving the issues locally is to use this combination of tests:
1) Does the Jobe Reclocation Test (Adding a Firm Posterior Glide and Preventing the translation) improve symptoms in passive ER?
2) Does performing the ER in Scaption Plane produce less symptoms than at the standard 90/90 Postion? Bringing the elbow forward into the Scaption plane will decrease sheer forces which can give us more info on the comparison between the two positions
3) Have the Athlete Maximally Squeeze Scaps and retest 90/90 ER while doing so
In the big picture view, it is important not to treat these two “types” of biceps tendonitis the same exact way. It is common to see to the typical: Soft tissue work, Biceps Isometrics, and Biceps eccentrics used as the treatment here. That would be a great option for the standard tendonitis, however, it does not address the underlying cause of the Baseball Specific version. We believe this is why this continues to be such a pesky and recurring issue in some arms.
When treating the underlying factor, it is important to understand what drives anterior shear. The two primary drivers are
Excessive Local Horizontal Abduction without optimal control
Excessive Local ER without optimal control
This would lead us to our goals to address the underlying factors:
Avoid contstant re-irration if possible
Improve T Spine/Ribcage Mobility into Extension and Arm Side Rotation
Improve Scapular External Rotation (Sets the Base For Horizontal And)
Improve Scapular Posterior Tilt (Sets the Base for ER)
Improve End Range Control of Glenohumeral (Local Shoulder Joint)
Address any mechanical issue that can be playing a part in this: Ben will go in depth on this aspect
Tread Athletics: Ben Brewster
Disclaimer: I am not a medical professional. The following practical application is through the lens of a pitching coach / strength & conditioning coach. While we have trained 4,000+ pitchers, much of these theories have yet to be validated in the research.
As with any injury, it is perhaps most useful to first ask the question: why is this structure being asked to pay this particular cost?
Too often, the biceps is blamed, despite it being a victim of its circumstances.
Ryan has outlined an alternative mechanism by which the bicep tendon may become loaded and irritated – anterior translation of the humeral head, also known as humeral anterior glide.
This anterior translation can happen in a number of contexts
Lifting considerations
Personally, I have suffered multiple chronic bouts of bicep tendonitis in my career, and both arose from improper lifting where I was doing push-ups on rings or handles and seeking to get to maximum depth.
Consider the following example of anterior translation vs maintaining humeral centration (optimal depth/positioning):
Pitchers in particular tend to have quite a bit of anterior shoulder laxity, and may not be able to “get away” with such extreme loading of the anterior structures as other types of athletes.
In the weight room context, we seek to maintain a centrated humeral positioning on all upper body movements – especially pressing variations.
Lifting with improper positioning won’t always lead to immediate aggravation (although in both of my cases it did), but rather it is the cumulative effect of hundreds or thousands of poor lifting reps over months and years that begin to compound alongside the stresses of throwing.
For what it’s worth, I would recommend avoiding loading dips, extreme-depth pressing, etc. Some would argue that this is a range to be “bulletproofed”, but I would exert caution loading deep hyperextension with anteriorly lax population.
Note: I’m not saying not to lift through a full range of motion, just defining what “full” means in this context. Is squatting as deep as possible always better? I’ll bet you could get deeper if you rounded your back and caved your knees in, but that doesn’t make it better.
Instead, load pressing variations to the fullest range that an athlete can maintain humeral centration.
I used to program lots of neutral grip pressing and rowing, but observed that many athletes have a tendency to dump into the anterior shoulder with a neutral grip. I now coach athletes to get the elbow off the side in rows and presses to encourage true scapular retraction and centrated humeral positioning.
Once the scaps are touching, that’s as far as you can go – significantly deeper and you’ll be getting that extra range from the anterior structures – the ligaments, tendons and capsule – of the shoulder.
Throwing considerations
When it comes to throwing mechanics, there are three areas of interest that I’d like to highlight where the biceps tendon / anterior shoulder may become irritated.
The biceps is not the only structure that may become irritated from a lack of centration – these may be linked to nearby issues as the humeral head rides anteriorly (including anterior capsule sprains) or superiorly (impingement type symptoms - bursitis, supraspinatus, labrum).
From a coaching perspective, be aware that sometimes a pitcher’s arm action / timing / mechanics are part of what allow them to be successful. It’s worth taking extreme caution when changing how a player has thrown their entire careers – however, sometimes there is no choice.
Scap loading
Most pitchers and coaches are aware that the best players “Scap load,” and that this potentially allows for applying force to the baseball over a longer arc of motion – but there is some confusion about what this means. Just like there are multiple ways to row, there are multiple ways to get the arm behind the body.
1) One strategy Is to yank into the scap load out of hand break via the elbows, with relatively little contribution from scapular retraction.
2) Another Is to retract the scapula while keeping the humeral head centrated.
This is the same mechanism as the rowing example I outlined above. Here’s a video showing the difference.
https://twitter.com/TreadAthletics/vmP9MWvnnGZHGgaVRvP9gwstatus/1602348356000415744?s=20&t=
In practice, the yanking option often looks like the “Inverted W” position, but a pitcher doesn’t necessarily need to lift the elbow above the level of the shoulders to benefit from a more scap-driven path.
In these cases, I’ll try to communicate this idea of lifting with the scap vs the elbow, without fundamentally changing their arm path or timing itself.
Note: it’s worth noting that not all inverted Ws are inherently bad (or should be changed), and not all inverted W’s are even inverted W’s. For instance, a player with a more forward trunk posture loading his scaps more horizontally will appear as though his elbow is way above the acromial line, when in reality it just looks that way because he is more bent over.
Late arm / timing
As the trunk begins to rotate, the arm will be left behind for a split-second. This places a stretch through structures of the throwing shoulder.
Which structures are stretched depends on the positioning of the shoulder when the trunk begins to rotate.
This is easy to see on yourself if you do a pec wall stretch with a variety of different hand/arm positions. Turn against your arm and see how good it feels on the front of the shoulder when your arm is centrated and up vs down and dumping into the front of the shoulder.
If the arm is up and centrated, the forceful stretch will be directed through the pec, lat and subscap tendons. If the arm is late and not centrated, that forceful stretch will be directed through the anterior shoulder (capsule, bicep tendon, etc.)
If the pain is felt as soon as the trunk begins to rotate, this may be the mechanism.
While this is a very difficult thing to isolate in a study (it may never be proven to be fully correlated to injury), we have absolutely worked with players who had pain with a late arm, and immediately zero pain when you have them throw with their arm starting up and on time.
This is a great way to differentially diagnose what’s going on from a mechanical standpoint.
Again, we prefer not to have to fundamentally change a player’s arm timing unless we have to, but sometimes there is no choice.
It’s worth noting that why the arm might be late is a topic for another post. Leaking forward with the trunk, extending off the back leg, dumping anteriorly with the pelvis etc. may all contribute to the arm being late. It’s not as simple as just programming pivot pickoffs to fix.
Max ER
If pain is being felt at peak layback into ball release, now we get into the mechanism Ryan described above.
Ideally the arm was retracted, centrated and up/on time (45-90 degrees of ER at front foot strike).
This gives the player the best chance to have room to achieve clean, uninhibited lay back.
However, a scapula that won’t posterior tilt (or is just anteriorly tilted at that point in the throw i.e. timing), a thoracic spine that won’t (or can’t at that point in the throw) extend, a cuff that has poor motor control, or a pitcher with extreme anterior laxity and high velocities/workloads/fatigue can all lead to excess shear being put through the biceps tendon during ER.
Final considerations
In almost every case of biceps tendonitis that I’ve seen, there is also the consideration of allowing the hot structures to cool off...yeah, that thing called rest.
The #1 mistake I’ve seen therapists make here and that I’ve made myself is that they allow the pitcher to continue throwing through the irritation which just continues to pick at the scab. Some injuries can be worked through without shutting down, but that’s not my experience with this form of biceps tendonitis.
Speaking from my two bouts with biceps tendonitis (one at age 17 and one around 25), it wasn’t until I stopped messing with it, stopped throwing on it, and gave it a true 4-6 weeks off that it cleaned up both times.
PTs are often pressured by coaches to rush players back to the mound and begin throwing the same week that symptoms feel better. Maybe it’s from the extreme anterior laxity that higher level pitchers have, but it can be a very stubborn issue that lingers for months and months if the initial cool-off period from throwing isn’t included. It’s obvious, but often overlooked.
