I treat biceps tendinopathy everyday because I usually have at least one shoulder patient everyday. The biceps is usually affected when there is a rotator cuff injury, surgery, labral tear, or other shoulder pathology. Luckily I have a lot of success calming down the biceps tendon and addressing the underlying cause. Read on to learn more about biceps tendinopathy. Let’s start with anatomy.
The shoulder joint
The main shoulder joint is called the glenohumeral joint. It is the joint that is made when the humerus (upper arm bone) and the scapula (shoulder blade) come together. It is a ball and socket joint and has the most movement of any joint in the body. However, it has the least stability, and this is what tends to get the shoulder joint in trouble.
The biceps
The biceps is a muscle located on the humerus (upper arm bone). Its main function is to bend the elbow and rotate the forearm. The biceps has two muscle bellies. These muscle bellies are called the long head and the short head. The short head of the biceps attaches to a piece of bone that juts off of the shoulder blade called the coracoid process. The coracoid process is located just below the collarbone near the shoulder joint. The long head of the bicep travels through a groove near the top of the humerus and attaches inside the shoulder joint itself. Both of these come together and attach just below the elbow onto the radius which is one the forearm bones. The long head of the biceps tends to be the troublemaker.
What is going on with the long head of the biceps?
The problem area of the biceps is where the tendon of the long head goes through the groove on the humerus and attaches into the shoulder joint. This area tends to become irritated. This irritation leads to tendinopathy and to tenosynovitis. Let’s look further into both of these conditions.
What is tendinopathy?
Before delving into the biceps tendinopathy, let’s review tendons. A tendon is the connective tissue that attaches the muscle to the bone. The area where the tendon connects to the bone is more susceptible to irritation and injury because of it’s limited blood supply.
Tendinopathy is a term used to encompass any issue with the tendon. This includes tendonitis and tendinosis. There is a difference between tendonitis and tendinosis. Many of the conditions that were previously thought to be tendonitis are actually tendinosis. However, because we do not necessarily know if the tendon has tendonitis or tendinosis, we refer to the condition as tendinopathy.
Tendons can get inflamed with a force that is too strong or quick. This tensile force on the tendon can cause micro-tears in the tendons. This is tendonitis. It is postulated that untreated tendonitis can become tendinosis. Tendonitis is an inflammatory condition and will respond to anti-inflammatory medication. It typically has a recovery period of 1-6 weeks.
Tendinosos is a degeneration of the tendon’s collagen proteins. This is hypothesized to occur after a period of untreated tendonitis. Collagen provides the tendon with durability and strength. Tendinosis is caused by chronic overload of the tendon without sufficient time to rest and heal. The tendon becomes enlarged and irritated. It does not have signs of acute inflammation and is not improved with anti-inflammatory medication such as ibuprofen. Early-stage tendinosis can heal within 6 to 10 weeks, but chronic stage can take 3 to 6 months. Tendinosis is probably more common than tendonitis, but the term tendonitis is often used to encompass both.
What is tenosynivitis?
The tendon of the long head of the biceps is covered in a sheath as it travels through the groove on the humerus. This tendon sheath decreases the friction between the tendon and the bone. The lining of the tendon sheath produces fluid that greases the tendon. Tenosynivitis is an inflammation of the tendon sheath. This inflammation will cause the sheath to become thickened and fibrotic. This thickening of the sheath will compromise the tendon’s mobility.
Symptoms of biceps tendinopathy
There are several symptoms associated with biceps tendinopathy. These include:
- Pain in the front of the shoulder
- This pain might radiate up towards the neck or down the upper arm
- Pain with reaching overhead, behind back, or across the body
- Clicking, popping, or catching sensation
- Weakness in shoulder when lifting, carrying, or reaching overhead
- Pain at rest and at night
Who gets biceps tendinopathy?
Anyone can get biceps tendinopathy. Interestingly enough, biceps tendinopathy is usually associated with other shoulder injuries. I treat the biceps all the time. However it is usually in conjunction with a rotator cuff injury or impingement syndrome. I may have treated a handful of patients for their biceps alone without any other shoulder pathology. In fact, only about 5% of overall biceps tendinopathy cases do not involve any other structure of the shoulder. These cases are typically young athletes who play overhead sports.
Risk factors
There are several risk factors associated with biceps tendinopathy. These include:
- Currently or formerly active in overhead sports such as
- Baseball
- Volleyball
- Softball
- Gymnastics
- Swimming
- Currently or formerly worked in physical labor
- Rotator cuff tears or other shoulder injuries
- Weakness in the rotator cuff and the muscles around the shoulder blade
- Hyper mobility of the shoulder joint
- Sudden increase in activity, sport, or exercise
Who should I see?
- Physical therapy – This would be my first stop. Physical therapy can help decrease pain and inflammation with techniques including manual therapy and dry needling. They can also evaluate your shoulder to determine if you have associated shoulder pathologies such as irritation at the rotator cuff. PT can evaluate and address abnormal joint mobility, muscle weakness, and flexibility. With biceps tendinopathy it is important to slowly increase the load on your tendons. Your PT can help you add appropriate exercises at the appropriate time without overloading the biceps. They can assess your training schedule and technique to prevent the problem from happening again.
- Orthopedic physician – An orthopedist might be necessary if the condition is not responding to physical therapy or if another shoulder injury is suspected. Your physician can prescribe medication, give a steroid injection, or order imaging if needed.
What can I do?
- Relative rest – Resting the area to decrease further pain and damage from occurring is one of the best ways to treat biceps tendinopathy. Basically, stay away from the activities that are causing pain. This gives the tendons time to rest and heal. If you keep doing what is causing the injury, it is not going to get better. This might include not participating in your sport or activity for a period or time. If you are not able to participate in your activity, then you can supplement with non-irritating activities such as biking, walking, or jogging while your tendon is healing.
- Ice – Ice can help decrease pain and swelling in the tendon. Ice the painful area for 15 to 20 minutes at a time. I would recommend using an ice pack several times per day if the pain is constant or is preventing you from participating in an activity. Ice immediately after activity.
- Posture – Having forward, rounded shoulders causes muscular imbalances in the shoulder. It stretches out the rotator cuff and scapular stabilizing muscles which are important for shoulder stabilization. It also shortens the pectoralis major, pectoralis minor, and the biceps and causes them to get tight. Below is a video showing how to use a stretch the pecs and biceps and also how to use a wall to check your posture.
- Soft tissue mobilization – Soft tissue mobilization helps release the muscles around the shoulder and decrease the stress on the biceps tendon. Use a massage ball or lacrosse ball to roll on the painful areas all around the shoulder. Spend a good 3 to 5 minutes rolling. Do not roll so hard that you bruise the area, but it should be a pretty painful sensation. Roll out the area no more than a few times a week. See the video below.
- Strengthen the rotator cuff and scapular stabilizers – I find that overuse of the biceps occurs because of weakness and/or lack of use of the rotator cuff and scapular stabilizers. These are the stabilizing muscles of the shoulder that allow the shoulder to reach and lift without injury or irritation. Using loop resistance bands and resistance bands can increase strength and difficulty.
- Strengthen the biceps – You will need to strengthen the biceps as well. This is to be slowly as to not place too much stress on the tendon too quickly. This is why having a physical therapist to guide you through the rehab process is essential. The first video is isometrics and elbow range of motion and can be done at the beginning of your healing process. The next video is more mid-stage strengthening and should only be performed when the pain has subsided significantly. There should be minimal soreness when performing the exercises and no pain afterwards. Using resistance bands can increase strength and difficulty of the exercises. See the videos below.
In review
- The bicep is a muscle located on the humerus (upper arm bone).
- It’s main function is to bend the elbow and rotate the forearm.
- The biceps has two muscle bellies. These muscle bellies are called the long head and the short head.
- The long head of the bicep travels through a groove near the top of the humerus and attaches inside the shoulder joint itself.
- The long head of the biceps is the troublemaker.
- Biceps tendinopathy is caused by an overuse of the biceps without proper time to heal. The tendon becomes enlarged and irritated.
- The tendon of the long head of the biceps is covered in a sheath as it travels through the groove on the humerus.
- The sheath will become thickened and fibrotic.
- This thickening of the sheath will compromise the tendon’s mobility.
- Symptoms of biceps tendinopathy include pain in the front of the shoulder with reaching overhead, behind back, or across the body.
- Biceps tendinopathy is usually associated with other shoulder injuries.
- Physical therapy is very successful at treating this condition.
- An orthopedist would be needed if the shoulder is not responding to physical therapy.
- There are thing that you can do to help. These include:
- Relative rest
- Ice
- Soft tissue mobilization
- Posture
- Stretching
- Strengthening
As always, If you have questions about the content of this post or any other musculoskeletal questions, please e-mail me.
Additional resources
https://www.ncbi.nlm.nih.gov/books/NBK533002/
https://www.physio-pedia.com/Biceps_Tendinopathy
https://www.choosept.com/guide/physical-therapy-guide-biceps-tendinitis