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Tendonosis of long head of biceps 21-Apr-2012 At 5:27:05 PM elaine stevenson

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Hi Wendy,

If you're going to proceed with cortisone, then I'd certainly be advocating for use of imaging to make sure it gets the right area.

That said, I think you've probably got number of other options you should try out before heading down the cortisone path. Cortisone can be very effective, but repeated use actually weakens soft-tissue structures and as you're a climber I'd argue (as a fellow climber, epidemiologist and manual therapist) that's not at all where you want to head unless you absolutely have to.

Is there a good manual therapist (ie physio, myo, or osteo) in Nati or Horsham that you can see? Cortisone can be helpful in really tough cases, but it's invasive and can cause harm, not to mention potentially quite painful too (when they inject it), so give other things a go first.

The suggestions you've been given - dry needling, soft-tissue manipulation (ie massage PLUS other stuff), heat, ice etc are all good, but they need to be used appropriately, and with due consideration to other things you've got going on that are almost certainly contributing to the condition (biceps tendonosis often arises in response to or along with other other issues - eg shoulder impingement, muscle imbalances, issues with supraspinatus etc - and treating the biceps alone (possibly because that's what has shown up on an ultrasound) may leave you open for ongoing recurrences down the track).

Chances are you'd probably benefit from a combination of manual therapy - to biceps AND related structures, dry-needling, ice - for when it hurts and after exercise, along with some prescribed exercises - ie individually set by a physio, myo or osteo with specific training in rehabilitative exercise prescription that are specifically tailored for your specific presentation, ie not pulled out a book or taken from the internet. An exercise physiologist may be able to set you in the right direction too but I think you'd still need to see a physio, myo or osteo as you'll almost certainly need some level of palpatory assessment and hands-on treatment too, at least initially.

NSAIDS (eg ibuprofen etc) can also be helpful, in the short term to settle things down, but again, if you're to go down that path, do so with the involvement of a tertiary trained manual therapist (ie who understands tendon issues and pharmacology). There's lots of new thinking in this area (by people like Jill Cook, one of Australia's leading physio researchers) and I'm not sure whether that knowledge has made it's way into general practice land yet. Opinions vary considerably in terms of how long you need to take them for - some say one week, some say longer - and what you should be doing (eg rehab wise) while you're taking them.

As for Cortisone, you'll find heaps of posts here about it, both for and against. It's a treatment that many would argue has been overused in the past, particularly in general practice settings, and, in my opinion, should be set aside until such time as other less invasive options have been given due chance to work. Cortisone can be helpful - when accompanied by a physical therapy program which takes due advantage of the temporary pain relief it brings - however there are plenty of studies which show that repeated use of Cortisone is harmful (ie weakens the very muscles and tendons you're trying to fix) and therefore it's something we generally recommend people avoid wherever possible. (one shot is probably ok, however if one shot isn't enough then repeated treatments do happen (sometimes down the track) and as few as three or four treatments is felt by some to be sufficient to significantly increase the chance serious damage (eg ruptures) later on. In my practice, for example, we view it as being a significant risk factor when people present with muscle issues, especially nasty rupture, and therefore it's something we always ask about.

The other thing to note with Cortisone is that it involves injecting a foreign substance into the body with a reasonably sized needle and therefore is not without some risk (eg infection, damage to nearby structures, etc).

That said, dry needling also involves putting a needle into the tendon through the skin however the needles we use are tiny by comparison and often you don't feel them going in. They're solid, so it's only the needle, and the effect we get from comes both from direct stimulation of the affect tissues (which promotes healing) and centrally mediated pain relief triggered by stimulation of the local neuroreceptors which communicate via the spinal cord and facilitate the release of chemicals which desensitise the area. Even dry-needling has it's risks - infection being the most obvious (any injection or cut into the body carries risk which is why nurses etc will always swab an area first before injecting into it) - and therefore it's something I prefer to use sparingly in my practice and only when I feel it is the most appropriate technique for the condition I'm treating.

Taping may also be an option too. One of the more specialised taping techiniques that I use was developed for the Australian Ballet (lots of tendon problems there). It's called Functional Fascial Taping, and gets really good results, (there's a blurb on our website that gives details if anyone wants to check it out. see here for more info). Other taping techniques which may also be useful include KinesioTaping and Dynamic Taping. These techniques all revolve around reducing pain and facilitating rehabilitative/functional movement rather than restricting it in the way traditional ankle or shoulder taping would.

Hope that helps.

Cheers!
Elaine.

nb - To pick up on comment below re dry needling - those who've climbed with me, and /or been treated by me, will probably remember that as well being a manual therapist, I'm also an infectious diseases epidemiologist (specialist in population health), who specialised in blood-borne viruses all of which means that my perspective on the safety of needling (and anything that punctures the skin for that matter) is possibly a bit more on the conservative side, compared to others who haven't worked in those environments.

nnb - Wendy - please think carefully if you're going to take up the Cortisone option. Given the scenario you've painted, I really don't think it's the best option for you at this point. Have been reading up on the latest thinking re tendon issues these past few days (ie after writing the initial post) and would strongly suggest you get a second opinion, ideally from a Sports or Musculoskeletal Doc, if there's one available, alternatively from a specialist Musculoskeletal Physiotherapist or Sports Physiotherapist (probably more likely than the others I mentioned to be up to date in the latest research). I'm not sure if there's one in Nati or Horsham. If there's not, **email** me and I'll give you the name of someone who consults remotely and should able to help you out.