Likely Diagnosis

• Pain on shoulder abduction → subacromial impingement / rotator cuff pathology
• Pain on elbow flexion → biceps tendon (long head) involvement
• 6 months duration → chronic / subacute presentation

Differential Diagnosis

Per Harrison's Principles of Internal Medicine (p. 631): Mechanical shoulder pain is often worse at night, aggravated by passive abduction, internal rotation, or extension of the arm. If neurological signs are absent, the differential includes bicipital tendinitis, frozen shoulder, bursitis, rotator cuff tear, and impingement.

Clinical Tests to Perform

• Speed's test — resisted forward flexion with elbow extended; positive = anterior shoulder pain → bicipital tendinitis
• Yergason's test — resisted supination with elbow at 90°; positive = bicipital groove pain
• Neer's sign — passive forward flexion with internal rotation; positive = impingement
• Hawkins-Kennedy test — internal rotation at 90° abduction; positive = impingement
• Empty can test — weakness/pain = supraspinatus tear
• Painful arc — pain between 60–120° = subacromial pathology

Investigations

Patient Management

1. Conservative (First-line, 6–12 weeks)

• Activity modification — avoid provocative movements (overhead work, heavy lifting)
• NSAIDs — oral (e.g., ibuprofen 400–600 mg TID, naproxen 500 mg BD) for 2–4 weeks
• Physiotherapy — cornerstone of management:
  • Rotator cuff strengthening
  • Scapular stabilization exercises
  • Posterior capsule stretching
  • Pendulum exercises if ROM limited
• Ice/Heat — ice in acute flares, heat for chronic stiffness

2. Injection Therapy (if inadequate response at 4–6 weeks)

• Subacromial corticosteroid injection — for bursitis/impingement (ultrasound-guided preferred)
• Bicipital groove injection — for isolated bicipital tendinitis (peritendinous, NOT intratendinous)
• Limit to 2–3 injections; avoid repeated injections (tendon rupture risk)

3. Surgical Referral (if conservative fails at 3–6 months)

• Arthroscopic subacromial decompression (acromioplasty) for refractory impingement
• Rotator cuff repair if tear confirmed on imaging
• Biceps tenodesis or tenotomy for recalcitrant bicipital tendinopathy

Red Flags to Rule Out

Bicipital Tendinitis (Long Head of Biceps Tendinitis)

Anatomy & Pathophysiology

• Repetitive overhead activity (throwing, swimming, weightlifting)
• Impingement from adjacent structures (acromion, rotator cuff)
• Instability — tendon slipping out of the bicipital groove
• Degenerative change (tendinosis in chronic cases)

Clinical Features

Clinical Tests

Per Chronic Shoulder Pain Guidelines (p. 6): The upper cut test should be used as the screening test, and Speed's + Yergason's as confirmatory tests for biceps tendon disorders.

MRI Findings

Investigations

Management

Step 1 — Conservative (4–6 weeks, first-line)

• Rest + activity modification — avoid overhead and repetitive arm use
• NSAIDs — ibuprofen 400–600 mg TID or naproxen 500 mg BD for 2–4 weeks
• Ice (acute) / Heat (chronic stiffness)
• Physiotherapy:
  • Pendulum exercises (early)
  • Rotator cuff strengthening (supraspinatus, infraspinatus)
  • Biceps eccentric exercises
  • Scapular stabilization
  • Posterior capsule stretching

Step 2 — Injection Therapy (if no improvement at 4–6 weeks)

• Peritendinous corticosteroid injection into the bicipital groove sheath (ultrasound-guided preferred)
• Avoid intratendinous injection — risk of tendon rupture
• Limit to 1–2 injections

Step 3 — Surgical (if refractory > 3–6 months)

Complications of Untreated Disease

• Progression to tendinosis (degenerative, non-inflammatory)
• Partial or complete tendon rupture — sudden "pop," ecchymosis, Popeye sign (distal biceps bunching)
• Development of adhesive capsulitis (frozen shoulder)

Key Takeaway

Posterior Capsular Stretch (Sleeper Stretch)

Purpose

• Subacromial impingement
• Rotator cuff pathology
• Bicipital tendinitis
• GIRD (Glenohumeral Internal Rotation Deficit) — especially in overhead athletes

Technique — Sleeper Stretch

1. Position — Lie on the affected side (lateral decubitus) with a rolled towel under the head
2. Arm position — Affected shoulder abducted to 90°, elbow flexed to 90° (forearm pointing upward)
3. Apply stretch — Use the opposite hand to gently press the forearm downward toward the table, promoting passive internal rotation of the glenohumeral joint
4. Hold — 30 seconds per repetition
5. Repeat — 3–5 reps, 1–2 times daily

Key Points

Important Cautions

• Do not force — stretch should be gentle, a pulling sensation only — no sharp pain
• Avoid if there is an acute rotator cuff tear or shoulder instability (anterior laxity)
• Stabilize the scapula against the table — do not allow it to roll forward (this substitutes scapular movement for true glenohumeral stretch)
• Stop if pain radiates down the arm (may indicate nerve irritation)

Other Posterior Capsule Stretches