Last month, on his 30th birthday, Scott Gams, a physical therapist in Greenville, SC, celebrated it with a SNAP! However, what is not immediately evident is that his traumatic injury may have been years in the making and could have been prevented. Scott was kind enough to share his experience in dealing with the injury, as well as offer his advice and perspective on biceps tendinitis / tendinosis, based on his clinical and anatomical expertise.
How did you rupture your biceps tendon and what did it feel like?
Following a physical therapy session, I was escorting my patient out. Unfortunately, she lost balance and was falling forward. In an attempt to stabilize her or at least reduce the impact of the fall, I reached out around her hips. During the process I felt a pop. Tending to the patient following the fall (the patient was unharmed), I noticed a little bit of pain in my right elbow. After trying to shake it off a few times, I looked down at my right arm and noticed a distinct bulge in the biceps region, consistent with a "Popeye sign" for a biceps rupture. My fear that I had ruptured the distal biceps tendon was confirmed following a trip to the orthopedic specialist later that day. Although the distal bicep tendon rarely ruptures, the quick eccentric load with my elbows slightly bent was the typical mechanism of injury for the tear. Luckily there was minimal pain associated with the rupture because it was a complete tear. I did experience mild swelling in the arm and weakness with elbow flexion / forearm supination.
One of the main points I'd like to emphasize this post is that this may have began with a bout of tendinitis. When did you first develop distal biceps tendinitis and how did it start?
I began experiencing distal biceps tendinitis four years ago in both arms. It started following a routine of low repetition / high weight strength training.
How did you try managing and treating the biceps tendinitis before it finally ruptured?
Initially, I addressed flexibility limitations in my biceps, shoulder, forearm, and scapular regions with stretching. I also started taking over the counter NSAID's to address any inflammatory process. As the symptoms lingered and became more chronic, I began light eccentrics in elbow flexion to address the likelihood of tendinosis. I also stopped resistance training in both upper extremities. Additionally I began soft tissue mobilization to the biceps tendon with Graston techniques. Unfortunately it took nearly 3 months for symptoms to resolve and 6 months before I could start strength training at prior intensity levels. Over the past three years I have not experienced biceps tendinitis with my recreational activities including weight lifting, kettle bell training, running, and playing tennis.
Would you mind explaining the difference between tendinitis and tendinosis?
Tendinitis is acute inflammation of a tendon resulting from overuse and microtrauma, causing pain, tenderness with movement, and swelling. Tendinosis is a chronic condition with absence of inflammation. It is marked by degeneration of the collagen fibers and abnormal healing of the tendon. Tendinitis is typically managed with ice, NSAIDs, relative rest, and stretching that usually resolves within 3-6 weeks. Tendinosis is more of a chronic condition that responds to treatments re-initiating the healing response to address the abnormal collagen fibers. These treatments may include eccentrics, instrumented soft tissue mobilizations, intramuscular dry needling, and stretching.
Can you briefly outline what the recovery / rehab process is going to look like for you?
The biceps tendon was surgically repaired using an endobutton procedure. I was splinted in 90 degrees of elbow flexion and neutral forearm position for one week post surgery, then given an elbow brace locked in 90 degrees of flexion.
I started physical therapy post op week 2 for reduction of swelling, joint mobilizations, and passive range of motion to the elbow and forearm. Although the particular procedure I had allows for more aggressive rehabilitation including active range of motion as early as two weeks out, we decided to remain conservative.
Currently, I am five weeks post op and working on full passive and active range of motion in the right upper extremity. Strengthening will begin post op week 8 with a gradual progression to full work and recreational activities. The biggest pain is wearing the elbow brace, which is adjusted into 10 degrees of elbow extension per week. The brace is mainly needed at this point to prevent another unexpected eccentric weight load and reduce cyclical loading.
If you could do it all over again, is there anything different you would have tried to prevent the rupture?
I should have continued my flexibility program; however it is easy to stop stretching when you're feeling better. I also might have added intramuscular dry needling to the surrounding elbow complex. I believe the previous history of biceps tendinosis probably played a role in the rupture, but the mechanism of injury with a quick eccentric contraction and high load ultimately lead to the injury.
What's it like being a PT and attending PT?
It is a very strange feeling, but definitely in good hands with some of my colleagues taking on the case. It does provide me with perspective of what a patient is going through and will help as I return to treatment myself. I am considered a worker's compensation patient, so I've had fun role playing some of the traditional difficulties therapists deal with for a WC.
When do you expect to be back in the gym, doing biceps curls?
I can't wait until post op week 8 so I can start curling 1 # dumbbells. Hopefully at 12 weeks I can be back to light lifting in the gym.
Do you have any more advice for anyone who may be reading this?
If you think you have symptoms similar to tendinitis, address the condition before it becomes chronic or moves more toward a tendinosis. Have patience during your post operative rehabilitation process whatever you may be recovering from. I've been yelled at many times by my colleagues for trying to advance my rehabilitation, listen to your physical therapist! Advice others have given me: let the person fall next time …
If you are looking for an outstanding Physical Therapist in the Upstate area or have any more questions for Scott, please use his contact info listed below.
Dr. Scott Gams, DPT
Dr. Brandon Vaughn, DPT, Cert. SMT