Conservative treatment of bicipital tendonitis proves successful with rehabilitation

Though describing a very active house pet, this case represents one possible approach to treating a common condition in many sporting dog breeds, bicipital tendonitis. This case will describe a conservative pre-operative approach to treatment of bicipital tendonitis. In addition, post-operative rehabilitation after biceps tendon release surgery will be discussed.

Photo 1: Arthroscopic evidence of synovitis and inflammation of the biceps tendon.

Signalment: "Sunflower", 3-year-old, female spayed, Labrador Retriever.

History: Per owner's report, Sunflower has been intermittently lame for three to four months. Sunflower enjoys chasing squirrels and will jump up and "hang" on a chain-link fence during pursuits. Though she has never displayed complete non-weightbearing lameness, the lameness increased with increased activity. The owner has found that giving an Ascriptin as needed, in addition to restricting activity, generally reduced Sunflower's discomfort. Sunflower underwent a series of radiographs to confirm her diagnosis of bicipital tendonitis. No calcification was seen on the tendon itself or on the supraglenoid tubercle and no osteophytes were present in the intertubercular groove. Sunflower's history, insignificant radiographs and pain on shoulder flexion was consistent with biceps tendonitis, and differential diagnoses of supraspinatus calcification, sarcomas, neurofibromas and OCD was ruled out by the referring veterinarian.

• Presenting complaint: The owner, a physical therapist, wanted to pursue conservative treatment options before using any invasive techniques, such as steroid injection and/or surgery. The physical therapist's evaluation indicated the neurologic examination was normal. Mild muscle atrophy was visualized and palpated in the spinati muscle groups. Though no vocalization was made, Sunflower showed discomfort, when compared to the opposite limb, by muscle guarding and pulling away upon stretching of the biceps tendon (deep point palpation of the tendon in the intertubercular groove when simultaneously flexing the shoulder and extending the elbow). Her stride length on the affected forelimb (left) was 75 percent that of her right forelimb stride length. Stance was normal and a mild limp was noted at a walk, though she was partial to full-weightbearing on 100 percent of strides. Range of motion was within normal limits, though uncomfortable at end range of shoulder flexion.

• Treatment: The owner chose to carry out a home program as in-patient treatment was not an option due to excessive travel time. Sunflower's owner was instructed to perform the following therapeutic activities twice daily for the first four weeks.

• Gentle cross-friction massage: With the biceps tendon on stretch to Sunflower's tolerance, gentle friction massage was applied across the intertubercular groove for about five to 10 minutes, twice daily.

• Ice packs: 15-20 minutes, at least twice daily following cross-friction massage.

• Restricted activity: The mechanism of injury of Sunflower's tendonitis was likely due to her passion to "hang" from a fence in her attempts to capture squirrels. Sunflower's owner was instructed to eliminate this activity completely from Sunflower's daily routine. Activity was limited to short (about five minutes) bathroom breaks, on a leash, three to four times daily.

• Ultrasound*: 3 MHz, 1.0 W/cm2 X 5 minutes, pulsed for six to eight treatments, directly over the intertubercular groove. *Ultrasound therapy was not actually performed, as Sunflower's owner was unable to acquire an ultrasound machine and unable to bring Sunflower into the clinic as an in-patient on a regular basis.

· Re-evaluation: At four weeks, Sunflower was less tender to the cross-friction massage and tolerating the full 10-minute treatments twice daily. Her lameness had significantly decreased, though reappeared on a few occasions when she was accidentally left unattended and sprinted across the yard after a squirrel. At this time, Sunflower's owner was instructed to gradually increase her activity level. This included longer leash walks, increasing the time to tolerance. Higher level activities were gradually added, again to tolerance, (at approximately four to six weeks post initial evaluation) including incorporating hills and inclines into her walking program, ascending and descending stairs slowly, and controlled ball playing for five to 10 minutes every other day for one week, gradually increasing her time off-leash.

Figure 1: Radiographic (CP/CD - cranioproximal/craniodistal) evidence of large osteophyte (bony proliferation) associated with bicipital groove.

• Follow-up: By 12 weeks post initial evaluation, Sunflower reportedly is tolerating stairs and off-leash running in an open field without any incidence of lameness. Evidence of discomfort and intermittent lameness still remains should she attempt fence hanging, though resolves more quickly than in past episodes. Aside from those few accidental incidents, Sunflower's activity level has significantly improved and her lameness is no longer evident.

• Comments: It is impossible to determine whether Sunflower would be completely sound, even with her "fence-hanging" episodes, should ultrasound have been incorporated into her rehabilitation regime. This case represents preliminary success in treating bicipital tendonitis. Complete resolution of lameness continues to be investigated in other cases through a variety of additional treatment options including ultrasound and transdermal administration (IontopatchTM) of non-steroidal anti-inflammatory medication.

• Discussion: Rehabilitation following a post-surgical treatment option for bicipital tendonitis could be: A relatively new surgical approach is an arthroscopic biceps tenotomy in which the tendon of the biceps is arthroscopically transected near its origin at the supraglenoid tubercle. The biceps brachii is the primary muscle used in elbow flexion. With its loss, the brachialis, a secondary elbow flexor, must take over the action of flexing the elbow. Immediately after surgery, these dogs will typically demonstrate a circumducting gait pattern following transection of the biceps tendon. At this point in the rehabilitation phase, use of electrical stimulation to provide strength directly to the brachialis appears beneficial. Passive range of motion can also benefit joint nutrition and circulation, though most dogs are at least partially weightbearing right out of surgery. Be cautious to not overstress or stretch the biceps as part of the success of this surgery is to allow a few weeks of healing and fibrosis of the muscle. The owner should be instructed to avoid any high level activities for at least the first two weeks. Activities to avoid include running, jumping and any off-leash activity. Short, frequent leash walks (about five to 10 minutes, three to four times daily) are adequate. After suture removal, encourage the dog to ascend and descend stairs to enhance elbow flexion and brachialis strength. Gradually increase length of leash walks to tolerance. Hydrotherapy, at about two to three weeks after surgery, also provides excellent resistance to encourage active strengthening of the brachialis muscle. Full return to function will vary depending on the dog's tolerance and usually occurs anywhere from six to 12 weeks post-operatively.