Outcomes Following Astym Treatment in a 58 Year Old Female with Biceps Long Head

Tendonitis: A Case Study

Regan Heafy, SPT; Mark Erickson PT, DScPT, MA, OCS

Carroll University, Waukesha, WI

Abstract

Upper extremity tendinitis is a common injury for which patients are referred to physical

therapy. Research has looked at the effectiveness of soft tissue massage techniques in

conjunction with strengthening for the treatment of tendinitis. Astym is a soft tissue technique

that theoretically allows for the healing and reduction of scar tissue within the body.

The subject in this case report was a 58 year old female with right biceps long head

tendinitis, no previous history of shoulder injuries, and a past medical history significant for

diabetes mellitus and hypertension. Baseline measurements of upper extremity A/PROM and

strength were determined prior to implementing a comprehensive physical therapy plan of care

integrating Astym with scapular and upper extremity strengthening interventions.

Following the four week intervention, the subject was able to complete all work activities

without an increase in shoulder pain greater than 1/10 on the visual analog scale. The subject

reported she was functioning at 90% of her normal level of activity. The subject’s score on the

Upper Extremity Functional Scale improved from 51/80 at evaluation to 77/80 at discharge.

The results from this case report suggest the use of Astym, in addition to postural

awareness education, upper extremity and scapular stability strengthening, may have contributed

to improved strength, range of motion, and pain levels in an individual with biceps long head

tendinitis. The clinical relevance of this study proposes that Astym in combination with other

interventions may effectively treat impairments associated with biceps long head tendinitis.

I. Background and Purpose

Tendinitis is a prevalent diagnosis in today’s population. A study by Walker-Bone et. al.

researched upper limb pain and the specific pain source. Of the subjects found to have site-

specific pathologies, tendinitis was the second most common diagnosis after adhesive capsulitis1.

Tendinitis is typically described as an overuse injury and anti-inflammatory remedies such as

rest, ice, pain medication, and corticosteroid injections along with physical therapy are utilized

for treatment2. This diagnosis, if not properly treated, can result in a worsening of the tendinitis

leading to tendinosis or tendinopathy, often which are irreversible and require surgical

interventions2.

Soft tissue mobilization is often prescribed by physical therapists during treatment with

individuals who have limitations based on muscular impairments such as muscle trigger points,

increased tone, and pain. Soft tissue massage techniques have been shown to be beneficial for

individuals with tendinitis and there are currently a variety of different massage techniques used

by physical therapists for the treatment of tendinitis3,4.

Astym is a soft tissue technique that theoretically allows for the healing and reduction of

scar tissue within the body by promoting a physiological healing response of the soft tissues5.

The pressure applied to the abnormal tissue through the Astym instruments is thought to cause an

increase of inflammatory mediators and start fibroblast activity to result in collagen synthesis.

The use of Astym achieves the desired results in approximately 8-10 visits. A case report by

McCormack found that Astym along with the use of eccentric strengthening was an effective

treatment for hamstring tendinopathy6.

There is currently a limited amount of research for the use of Astym applied to patients

with upper extremity tendonitis. Specifically, there is a lack of knowledge of the use of Astym

along with strengthening for an individual with biceps long head tendinitis. The purpose of this

case report is to describe the outcomes and discuss the potential mechanism of effect of Astym

treatment for an individual with biceps long head tendinitis.

II. Case Description

The subject of this case report was a 58 year old right hand dominant female referred to

physical therapy with a diagnosis of right biceps long head tendinitis. The subject worked as a

cook and fell onto her right arm while at work two weeks prior to her physical therapy

evaluation. The subject denied any similar injuries in the past. The subject’s chief complaints

included pain in the anterior proximal bicep region, decreased motion, and decreased strength.

Past medical history was significant for diabetes mellitus and hypertension.

The subject’s goals for physical therapy included decreasing her pain and regaining her

motion and strength in her arm. She wished to return to her normal method of completing daily

activities and work requirements. She stated it was difficult for her to complete her normal

activities due to the pain and inability to move her right arm.

III. Clinical Impression

The subject in this case report was a good candidate for Astym treatment along with

strengthening interventions because Astym has been found to be effective for the treatment of

patients with tendinitis in other regions of the body in the past6. Additionally, because this was

not a chronic issue for the subject there will not be conflicting underlying issues to complicate

the interventions implemented for the subject.

The plan for the examination of this subject to determine if appropriate for the

intervention described above included ruling out other pathologies such as a rotator cuff tear or

instability or degeneration at the glenohumeral or acromioclavicular joints. Additionally, the plan

for examination included gathering subjective and objective measures to determine an

appropriate and accurate problem list to determine if the subject would benefit from Astym

treatment.

IV. Examination

The subject reported the pain in her right arm ranged from a 2/10 while at rest to an 8/10

with performing lifting or overhead tasks. Prior to starting physical therapy, the subject had been

self-managing her pain with an over the counter non-steroidal anti-inflammatory drug (NSAID)

in combination with heat which had intermittently alleviated her pain levels. The subject stated

the pain in her arm was limiting her ability to sleep at night and complete her job duties at work.

She reported waking on average 4 times per night due to the pain and felt she was functioning at

50% of her normal level of activity while performing work duties.

Observation of the subject’s sitting posture noted increased thoracic kyphosis, protracted

shoulders, and a forward head. The subject completed the Upper Extremity Functional Scale and

received a score of 51/80. Cervical active range of motion was within normal limits and pain

free. Objective measurements were taken at the initial examination and can be seen in Tables 1

and 2. Flexion and abduction active range of motion (AROM) were measured in standing and

internal and external rotation in supine. Passive range of motion (PROM) was measured in

supine and included flexion, abduction, internal and external rotation. Hawkins Kennedy and

Speeds tests were positive indicating that the biceps long head (BLH) tendon was a pain source.

Hawkins Kennedy was found by Hegedus to have a 79% sensitivity for diagnosing primary

impingement, of which BLH can be a pain source7. Research conducted by Bennett found the

Speeds test to have a 90% sensitivity for evaluation of the BLH tendon8. Manual muscle testing

was used to assess the subject’s strength deficits including GH flexors, abductors, internal

rotators, external rotators, and elbow flexors. Right upper extremity strength was decreased with

MMT grades ranging from 2/5 to 3+/5.

The prognosis was good based on age, co-morbidities, and other lifestyle factors for

return to prior level of function in six weeks. The subject led an active lifestyle playing with her

grandchildren and working a job that had physically demanding work duties. While research

specifically on the impact of diabetes mellitus and hypertension for BLH tendinitis has not been

conducted, research has shown that diabetes mellitus does affect the healing rate of other

shoulder pathologies such as rotator cuff injuries9. Chung et. al. found that the failed healing rate

of individuals with rotator cuff tears and diabetes mellitus was significantly higher than those

without diabetes mellitus9.

The plan of care was determined based on the subject’s impairments and included Astym,

soft tissue mobilization, therapeutic exercises for range of motion, and therapeutic exercises for

strengthening of the upper extremities and scapular stabilizers. Treatment sessions initially

focused more on manual therapy including the Astym treatments and soft tissue mobilization. As

the subject’s pain levels improved more exercises were added into the treatment sessions.

V. Clinical Impression

Astym was chosen as a primary intervention for a number of reasons. Firstly, the subject

was having pain in the shoulder and biceps long head region limiting her ability to lift her arm

and carry objects. Secondly, the subject did not have a history of shoulder injuries or pain and

the physical therapist identified increased tone through the biceps region during examination.

Her stated goal was to return to her prior level of function as soon as possible and the treating

physical therapist reasoned it was necessary to initially focus on pain reduction before

implementing range of motion and strength interventions.

As the subject progressed, subjective responses and objective tests and measures were

used to evaluate the effectiveness of Astym. In addition to the subject’s subjective information,

palpation of the subject’s muscle tissue from the therapist performing the Astym was used to

determine if the treatment was effective.

VI. Intervention

Over the 4 week intervention period the plan of care focused on the use of Astym in

conjunction with therapeutic exercises targeting postural awareness, strengthening of the

scapular and upper extremity musculature. The subject was seen twice per week in an outpatient

physical therapy clinic and completed a home exercise program 5 days per week targeting

improving postural awareness and increasing her scapular stability. The home exercise program

was reviewed during treatment sessions to ensure the subject was completing the exercises

correctly at home. See Table 3 for the home exercise program. As the subject progressed through

the plan of care more exercises were added or modified to become more challenging. Appendix

A includes images of the exercises used during the intervention.

The Astym treatment was completed for a total of 6 sessions with the subject in a seated

position with a pillow supporting her right arm during the treatments. Specific Astym tools used

for the subject’s treatment include the evaluator and the localizer. Each tool was used by

completing 3 strokes both toward and away from the muscle insertion site in a direction parallel

to the muscle fibers at a rate of 6-7 inches per second with the tools held at a 70 degree angle in

relation to the subject’s skin. A fan or multidirectional stroke was used over the distal aspect of

the biceps long head insertion and the origin of the deltoid. The pressure of the strokes varied

based on subject tolerance and objective examination findings. The specific areas targeted with

the Astym included the right biceps, deltoid, pectoralis major, and upper trapezius. All Astym

treatments were completed by a therapist certified in Astym.

The progression of strengthening exercises included throughout the intervention period

can be seen in table 4. During the fourth week of the intervention period, the subject was set up

with an independent exercise program using Precor brand weight machines as that was what was

present in the wellness center where the subject was a member.

VII. Outcomes

Throughout the 4 week intervention period, physical therapy and patient goals were met.

At discharge, the subject was able to complete all work activities without increased shoulder pain

greater than 1/10 on the visual analog scale. Pain was no longer waking her during the night or

limiting her ability to complete household tasks such as cleaning. She attributed her gains

primarily to physical therapy intervention using Astym technique. Comparisons between

objective measurements collected at evaluation and discharge can be seen in Table 5 and Table

6. Abduction AROM increased 37% from 104 degrees to 171 degrees at discharge and the Upper

Extremity Functional Index score improved from 51/80 at evaluation to 77/80. The subject

verbalized she experienced improved postural awareness and focused on correcting both her

sitting and standing posture when she noticed herself having poor posture. The subject also

stated she felt her level of functional activity had improved to 90% as compared to 50% at

evaluation. After discharge the subject planned to perform her home exercise program 3 times

per week at a wellness center to maintain the gains she made during physical therapy.

Objective measurements used in this case report to monitor the subject’s progress

included measuring range of motion, manual muscle testing, and the Upper Extremity Functional

Index. Manual muscle testing was performed based on the procedures outlined by Berryman and

Reese10. Inter-rater reliability for use of manual muscle testing in the upper extremity was found

to be moderate-to-good by Jepsen11. The Upper Extremity Functional Index was found to have

excellent test-retest reliability12. Range of motion measurements were obtained following

procedures outlined by Norkin and White13. According to Norkin and White, measurement of

joint position and ROM through use of a universal goniometer has been demonstrated to have

good-to-excellent reliability13. Additionally, with goniometric measurements, intra-tester

reliability has been found to be higher compared to inter-tester reliability12.

VIII. Discussion

This case report describes outcomes for a 58 year old female with biceps long head

tendinitis achieved by prescribing Astym with strengthening exercises. The interventions used

targeted the subject’s complaints of pain in addition to the findings of increased muscular tone

by incorporating postural awareness and strengthening the musculature surrounding the shoulder

to avoid future related injuries. The interventions implemented seem to have aided in symptom

management and restoration to the subject’s prior level of function.

A case study by McCormack found that the use of Astym with eccentric strengthening

was a beneficial treatment for hamstring tendinopathy6. While there is a limited amount of

literature currently published on the use of Astym for treatment of tendinitis, the results of this

study suggest that Astym and strengthening may be beneficial for impairments caused by biceps

long head tendinitis. As reported by Sharma et. al., it is important during tendon healing to

mobilize the tendon in order to prevent scar tissue adhesions from forming14. Hypothetically, the

use of Astym allowed for the mechanical loading and mobilization of the injured tendon without

interfering with the physiological healing process. Other factors outside of physical therapy may

have impacted the subject’s improvement in symptoms. The subject’s date of injury was 2 weeks

prior to beginning therapy, therefore putting her at 6 weeks after injury at discharge from

therapy. Based on the physiologic healing process, the maturation phase of healing occurs at

approximately 6 weeks which could account for the resolution of the subject’s symptoms.

A limitation of this study was the outcome measure used. Based on a literature review

conducted, the Upper Extremity Functional Index is lacking in research related to the reliability

and validity of this measure. Another limitation of this study was the lack of quality literature

found for the use of Astym for treatment of tendinitis. The research currently published on

Astym for the treatment of tendinitis includes case reports; no randomized control trials have

been published in this area. Further research in this area will aid in the development of more

valid outcomes from use of this intervention. The use of a handheld dynamometer would have

improved the reliability of manual muscle testing values as dynamometer use had a higher intra-

rater and intersession reliability as compared to using MMT grades8. While this study does have

some limitations, the results of this case report suggest that the use of Astym with strengthening

exercises may be a useful intervention as part of a comprehensive physical therapy plan of care

to effectively treat individuals with biceps long head tendinitis. Future research is needed to

determine if these interventions are appropriate for treating tendinitis in other regions of the

body. In future studies, utilizing a larger sample size will also increase the validity of the use of

Astym and strengthening for treatment of individuals with tendinitis.

Table 1. Range of Motion of the Shoulders (Measured in degrees)

Right Left

Flexion AROM 0-146* 0-158

Flexion PROM 0-148*, pain before

resistance, empty end feel

Not Measured

Abduction AROM 0-104* 0-161

Abduction PROM 0-106*, pain before

resistance, empty end feel

Not Measured

Internal Rotation AROM 0-40* 0-65

Internal Rotation PROM 0-46*, pain equal to

resistance, firm end feel

Not Measured

External Rotation AROM 0-50 0-78

External Rotation PROM 0-57, firm end feel Not Measured

*Pt reported pain at end range

Table 2. Strength (Graded with the Manual Muscle Testing Scores)

Right Left

GH Flexors 2+/5* 5/5

GH Abductors 2/5* 5/5

GH Internal Rotators 2+/5* 5/5

GH External Rotators 2+/5* 5/5

Elbow Flexors 3+/5* 5/5

*Pt reported pain with MMT

Table 3. Home Exercise Program

Exercise Dosage

Doorway pectoral stretch 3 sets of 30 seconds

Seated scapular retraction 2 sets of 15

Shoulder pull downs (with red theraband) 2 sets of 10

Shoulder horizontal abduction (with red

theraband)

2 sets of 10

Table 4. Treatment Strengthening Exercises

Exercise Dosage

Week One Interventions

Bent over rows* 10 repetitions

Bent over horizontal abduction* 10 repetitions

Bent over extension* 10 repetitions

Standing D1 PNF diagonal pattern 10 repetitions with 1 lb.

Standing D2 PNF diagonal pattern 10 repetitions with 1 lb.

Standing abduction 10 repetitions with 1 lb.

Week Two Intervention Additions

Pull down 10 repetitions with 10 lb. on cable column

machine

Horizontal abduction 10 repetitions with 5 lb. on cable column

machine

Week Three Intervention Additions

Arm ergometer 4 minutes

Standing scaption 10 repetitions with 1 lb.

Pull down 2 sets of 10 repetitions with 10 lb. on cable

column machine

Horizontal abduction 2 sets of 10 repetitions with 5 lb. on cable

column machine

Chest press 10 repetitions with 25 lb. on Precor machine

Bicep curl 10 repetitions with 10 lb. on Precor machine

Tricep extension 10 repetitions with 25 lb. on Precor machine

Seated row 10 repetitions with 20 lb. on Precor machine

Week Four Intervention Additions

Pec fly 10 repetitions with 10 lb. on Precor machine

Rear deltoid reverse fly 10 repetitions with 10 lb. on Precor machine

Shoulder press 10 repetitions with 20 lb. on Precor machine

*Bent over exercises were completed with subject in a standing position with approximately 30

degrees of hip flexion, one hand planted on the mat table, and shoulders in a position parallel to

the mat table.

Table 5. Range of Motion Results (Measured in degrees)

Right- Evaluation Right- Discharge Percent Change

Flexion AROM 0-146* 0-162 8.9% increase

Abduction AROM 0-104* 0-171 37% increase

Internal Rotation

AROM

0-40* 0-50 14% increase

External Rotation

AROM

0-50 0-56 7.5% increase

*Pt reported pain at end range

Table 6. MMT Results

Right- Evaluation Right- Discharge

GH Flexors 2+/5* 4/5

GH Abductors 2/5* 4-/5*

GH Internal

Rotators

2+/5* 4/5

GH External

Rotators

2+/5* 4+/5

Elbow Flexors 3+/5* 4/5*

*Pt reported pain with MMT

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Appendix A: