Although we don’t all have Popeye the sailor’s massive bicep muscle, we can all suffer from bicep tendonitis. Bend or straightening your elbow becomes painful and is one of the many Bicep tendonitis symptoms. Lifting groceries, shifting gears and reaching behind your back is immensely painful, not to mention any type of shoulder exercise. Your bicep tendonitis pain limits not only how high you can lift your arm, but also how much you can lift. Upper arm tendonitis can be painful to the point of wearing a sling or avoiding crowded places so that no one can bump into you. The most effective Bicep tendonitis treatment includes physiotherapy which firstly gets a clear diagnosis of your problem.

Everybody’s case is unique. Bicep tendonitis affects people of all ages and activity levels, from the iron pumper to the new mum. Let us get to the bottom of your bicep tendonitis problem.

What is the bicep tendon?

Tendon attaches muscle to bone in our bodies. The bicep tendon is where the bicep brachii muscle attaches at the top to the humerus, and at the bottom to the radius. The bicep muscle’s name is descriptive as it refers to the two heads of the muscle. The long head of biceps originates from the supraglenoid tubercle on the scapula and inserts with the short head of the biceps muscle on the radial tuberosity. The short head of biceps originates from the coracoid process on the scapula. Both parts of the bicep muscle are innervated by the musculocutaneous nerve from nerve roots C5 & C6 from the cervical spine.

The long head of biceps lies within a special groove in the humerus, almost like a rope within a pulley system. This groove is shallow and narrow and anything that occupies space, like inflammation or scar tissue, can result in compression or pinching. This makes the long head of the bicep tendon more susceptible to tendonitis. The bicep tendon is kept in the groove by the transverse humeral ligament.

What does the bicep tendon do?

The anchor sites of the bicep muscle’s different heads form a leverage system across the shoulder and the elbow. The main function of the bicep muscle is bending your elbow, brings your hand towards your shoulder. The bicep muscle also assists with shoulder flexion, lifting the arm overhead, and supination of the forearm at the radioulnar joint. This is the movement of bringing the palms of the hands to face upward, like splashing water on your face. The bicep muscle also decelerates elbow extension by working eccentrically, like when you slowly lower a heavy weight back down by straightening your elbow.

How does bicep tendonitis happen?

The bicep musculotendinous junction is put under a lot of different forces moving through its attachment site. Even if you do not do any classic weight lifting training in the gym, you definitely lift your shoulder multiple times during the day, when washing your hair or picking up groceries or kids. Pushing or pulling actions, like planking, pushups or moving heavy loads on a trolley in (checkers & makro), all accumulate forces through the shoulder and bicep tendon. Excessive forces that you are not used to, like starting a new exercise routine or hanging curtains, can cause micro-tears and irritation in and around the bicep tendon. This combination of overload and overuse leads to swelling of the tendon which further impedes it’s recovery, leaving you stuck in a cycle of tissue decay. This causes bicep tendonitis.

Injury to the transverse humeral ligament, which keeps the bicep tendon within the groove of the humerus, can cause the tendon to dislodge and slide in and out. This friction can cause bicep tendonitis.

If you train or work in a bad position, like most of us do these days, hunched over steering wheels or screens all day, we increase our risk of developing bicep tendonitis. Bad posture pulls your shoulder joint forward. The shoulder blade lifts and rotates on the ribcage, changing the angle from where the bicep tendon generates its force. When you now load this joint even more, think chaturanga descends or lowering into a pushup, you load an already lengthened bicep tendon expecting it to lift you back up. No wonder injury to the bicep tendon is common, leading to bicep tendonitis.

Laxity of the ligaments or instability of the joint leads to excessive translation of the humeral head on the glenoid fossa and increases the force that the bicep needs to generate from a lengthened position. This can cause bicep tendonitis.

Previous injuries, like rotator cuff strains or tears and glenoid labrum tears can put you at higher risk of developing a bicep tendonitis.

Causes of bicep tendonitis

  • Repetitive movements, like throwing, rowing, weight training, swimming or hair styling
  • Faulty biomechanics when exercising, from protracted shoulders
  • Sudden forceful unaccustomed movement, like grabbing hold of something heavy that falls
  • Poor posture
  • Rotator cuff injury
  • Coracoacromial ligament thickening
  • Impingement in the sub-acromial space
  • Acromial apophysis fusion
  • Overhead sports, like tennis, volleyball, cricket and swimming

Bicep tendonitis symptoms

Mild

  • Dull ache at the front of your shoulder.
  • Lifting your shoulder is painful.
  • Slightly swollen at the front of your shoulder.
  • Mild tenderness over the area.
  • No bruising.
  • Able to pinpoint the area of your pain quite specifically.
  • Pain comes & goes, usually after strenuous exercise or heavy lifting.
  • Stiffness in your shoulder, as the muscle around the shoulder, start to cause protective spasm.

Moderate

  • Limited range of movement. Specific point when the pain comes as you lift your arm the pain starts.
  • Neck stiffness or headache on the same side as the painful shoulder.
  • Pain through the whole range of movement, lifting your shoulder up, sideways or rotating the arm to throw a ball.
  • The shoulder may feel unstable.
  • Pain worse when taking weight on the affected side, like pushing a heavy troley/pram or in a side plank.
  • Twisting movements increase pain, like reaching behind your back to put on a jacket.
  • Tucking in your shirt in or Loosening your bra strap, gives a sharp sting pain

Serious

  • Severe, constant pain not improved by any change in position, heat or medication.
  • Sharp pain when moving, even small movements, like pulling up the covers in bed.
  • Pain with pressure through the arm, like changing gears, opening the car door.
  • Cannot put weight on the affected arm when exercising.
  • Pain when lifting anything, even a kettle or cup of tea.
  • Unable to lift up your kid

Bicep tendonitis test you can perform at home

You can try the following self tests at home to compare your affected and unaffected side. If you experience your specific known symptoms while performing these test you may have a bicep tendonitis and it would be worth getting your shoulder assessed by a professional.

  • Stand in front of a mirror.
  • Lift your affected arm upwards, bend your elbow and reach your hand behind your neck.
  • Reach your unaffected arm behind your back.
  • Now attempt to reach the hands towards one another.
  • Change your angle to see in the mirror how close you can reach.
  • Now do the bicep tendonitis test the onther way around and compare sides.
  • If there is a big discrepency between how far you can reach or you experience your symptoms you may have bicep tendonitis.

  • Stand up straight with your palms turned forward.
  • Now lift your arms straight so that your hands are level with your shoulders.
  • If this is already painful, don’t continue the test.
  • Slide your affected hand on top of your unaffected hand.
  • Resist lifting your unaffected arm above shoulder level with the affected arm by applying counter pressure.
  • Now repeat with the affected side.
  • If you get sudden, sharp pain at the front of your shoulder you may have bicep tendonitis.

How bad is my bicep tendonitis?

Bicep tendonitis is an umbrella term used to cover any and all types of the pathology of the bicep tendon. The pain experienced may come and go and fluctuate in intensity, as your tendon transitions through the different phases of Bicep tendonitis. The three different stages are:

Phase 1

Reactive Bicep tendonitis is the first phase and happens when the tendon responds to sudden compressive or tensile overload. The cells adapt and cause the tendon to thicken by producing more protein, while the collagen integrity is maintained. This is like an “organised peaceful protest” within the tissue. Tendon thickening is not necessarily a bad thing, it shows that the body can alter as demand changes. You will feel acute pain when the bicep tendon is pressurised by movement, like a sharp sudden pain when you lift your arm. This phase is of short duration and the potential of the bicep tendon to heal completely is high.

Phase 2

Bicep tendon disrepair happens when the tendon is not offloaded and allowed adequate rest to complete the healing process. The increase in protein production persists and leads to collagen separation and disorganisation. The “peaceful protest” escalates to a “strike”. Vascularization and neural growth, where capillaries and nerve ending are formed within the tissue take place. The pain may become more constant and intense because of this. This phase tends to happen with repeat bicep tendon injuries. Your shoulder will feel less flexible now.

Phase 3

Degenerative bicep tendonitis is the final phase in the tendon continuum and unfortunately has a poor prognosis as the changes within the tendon are now irreversible. Let’s say the “strike” took a wrong turn and there were fatalities. Cell death has been found in this phase and grossly thickened tendon, where most fibres have morphed and only a small amount are normal. This happens when you neglect your bicep tendonitis for a long time. The pain will follow even the smallest of exertion and be felt chronic.

Chronic bicep tendonitis left untreated increase the risk of tendon rupture. Tendon strains are classified as grade I, II or III. Grade I injury involves a few microscopic tears of the tendon, approximately 20 % of the total tissue. A grade III strain or rupture is where 80% of the fibres are torn. This leads to disability because of weakness. The leverage system is compromised and the muscle cannot exert force on the joint to enable movement. Everything in between is classified as a grade II injury. Repetitive grade I or II strains lead to chronic bicep tendonitis, tendon weakening and the “perfect storm” to sustain a complete tendon rupture.

Diagnosis of bicep tendonitis

We will make use of clinical tests to load the bicep tendon during your physical examination. This enables us to know the state of your bicep tendonitis and how severe your problem is. During our assessment, we will also evaluate your neck, shoulder and thoracic areas to know if any restriction here is contributing to your symptoms. We are skilled to address your bicep tendonitis in its entirety so that the problem is sorted once and for all. If necessary we can refer you for the following diagnostic images to confirm your bicep tendonitis.

X ray

The bicep tendon cannot be visualised on a X ray. The bones of the glenohumeral joint, the scapula, clavicle and humerus, the joint space and shape of the acromion can be seen with X ray. This is of value, but a X ray is not the image of choice to diagnose a bicep tendonitis.

Sonar

Diagnostic ultrasound is the image of choice to diagnose bicep tendonitis because the bicep tendon can be visualised  from the bicep muscle belly to the shoulder cuff. Any pathology or injury inside of the joint will not be visible.

MRI

Magnetic resonance imaging enables us to see inside of the joint. This is a costly investigation that can only be ordered by a specialist. Traumatic shoulder injuries, like dislocation, that do not respond to conservative treatment can be viewed with an MRI to detetmine injury to structutes within the joint. It is not necessary for diagnosing bicep tendonitis.

Why is my bicep tendonitis symptoms not going away?

Bicep tendonitis is usually the victim and not the offender. Treating the bicep tendon in isolation will rarely give you permanent symptom relief.

Poor posture influences shoulder strength and endurance. This happens because the length-tension relationship of your stabilizing muscles is compromised when you are hunched over a screen or steering wheel all day. Your rhomboids, lats and cuff muscle become weaker and weaker and are then unable to get your shoulder into a good position when you want to exercise or lift a heavy load. The stability of the entire shoulder girdle needs to be addressed for long term relief.

Limited range of motion or stiffness of your shoulder or upper back can cause biceps tendonitis. When some muscles are restricted in how much they can lengthen, their opposing partners are overloaded. Excessive range or hypermobility can also cause bicep tendonitis. This is mostly because of more collagen in connective tissue. Weak stabilizing muscles cause the muscles to contract in a range that the muscle has no control over. Repetitively doing this can lead to bicep tendonitis.

Your treatment needs to address the whole problem and all contributing factors. You need to commit to long term rehabilitation to get to the root of your bicep tendonitis and prevent it from recurring.

What NOT to do

  • Anti-inflammatory medications

  • Stretch your shoulder through the pain, even if it feels tight. Tightness is a sensation generated by the nervous system and muscles to prevent further injury to the structure being protected.

  • Train, lift and carry through the pain.

  • Do not ignore shoulder pain that gets worse (it could be an sign of a deeper problem).

  • Leave it untreated, if you are uncertain of the diagnosis, rather call us and be safe.

What you should do

  • Follow a home treatment regimen (discussed below) to initiate tissue healing:

    • protect
    • rest
    • avoid anti-inflammatories
    • ice
    • compression
    • responsible loading.

  • Make an appointment to confirm the diagnosis and determine the severity of your problem.

  • Break household tasks into parts or scatter throughout the week so that you can have efficient rest between tasks.

Making your bicep tendonitis worse

  • Continuously “testing” your shoulder to assess your pain by repeating the same positions multiple times during the day.

  • Pushups

  • Overhead activities like painting the ceiling, hanging laudry or blow drying your hair.

  • Weighted overhead training, like pull ups and shoulder presses.

  • Slouched forward prolonged computer work.

  • Weighted shoulder or chest strenghtening, like bench press.

  • Sleeping on the affected side.

  • Repetitive small movements, like cleaning a work surface, ironing or changing gears in the car.

  • Lifting heavy loads, like a full kettle or groceries.

A big problem we see with bicep tendonitis

Bicep tendonitis is a common injury, it can affect people of all ages and fitness levels. One dimensional treatment approaches, that are focused only on the tendon, gives patients short term relief of their symptoms. If all aspects of the injury is not addressed your bicep tendonitis is bound to happen again.

Treatment abandonment is a big problem we see with bicep tendonitis. As soon as symptomatic relief is gained, people tend to stop their rehabilitation all together. If muscle imbalance, lack of stability and optimization of movement patterns where not achieved with your treatment your bicep tendonitis will probably return. Unfortunately there is no quick fix, you need to commit to the therapy, be patient and work hard. Patience and persistence will get you there.

Physiotherapy bicep tendonitis treatment

We have the skills to test all the different structures in & around your shoulder to establish the cause of your pain and get a diagnosis. From here we can address any contributing factors, muscle imbalance, and faulty movement patterns to get you on the road to recovery as fast as possible. We consider the whole of you and what your life requires of your shoulder, we will get you back to painting, training, or whatever it is you love to do.

With physiotherapy treatment for a bicep tendonitis, we aim to give your tendon the right environment to heal. Your body can heal given the right circumstances, resting from aggravating activities while we encourage tissue regeneration of the bicep tendon. That’s only the first step, there’s so much to do and so little time.

We are skilled to evaluate and diagnose your bicep tendonitis. Our physiotherapists can identify other contributing factors and address that through your bicep tendonitis treatment to enable you to get back to what you love doing in as little time as possible.

Phases of bicep tendonitis treatment

1st Phase: Protection and initial healing

Protect

Stop doing aggravating activities to protect the bicep tendon.

Rest

Rest from activities that are worsening your pain. Give it time to heal. Don’t continuously test your bicep tendon pain.

Avoid anti-inflammatory mendication

The use of anti-inflammatory medication should be avoided, especially during the first 48 hours after injury. Inflammation is the body’s way of getting all the supplies needed for healing at the site of injury. If you hamper this process you can delay healing taking place.

Compression and ice

Strapping or taping can relieve your pain by supporting the shoulder joint and limiting movement. Ice can aid in relieving your pain by limiting inflammation.

Information & Load

It is important to understand what is going on in your body to make informed decisions. We are happy to answer all your questions. It is important to avoid movement and activities that aggravate your symptoms, but not moving at all is equally harmful. You need to find the sweet spot between the two to fast track the healing process without causing unnecessary delays.

2nd Phase: Establish pain free range of movement

During your examination, it will be clear what you are able to do, and what you should avoid. We identify factors that contribute to your pain, specific to your case. There is a pain free range of movement that is safe to move in, and our exercises will be targeted between these boundaries, i.e usually 0 – 60 degrees of forward and sideways shoulder movement. On completion of this phase of your bicep tendonitis treatment, you should be able to lift your arm to shoulder level, like moving the steering wheel in the car.  As your rehabilitation progress, we aim to gain a larger pain free range of movement, to ultimately reach overhead to wash your hair or hang laundry.

3rd Phase: Tendon tissue healing

All tissue heal by means of scar tissue. It is like having a scab on the inside. We monitor the progress of the fibrous tissue formation of the “scar” around your bicep tendoninits treatment. On a cellular level, we are able to accelerate tissue healing by using electrotherapy, like Laser and Ultrasound, and specific exercises that increase circulation without the risk of overloading the bicep tendon.

4th Phase: Tendon Stress

During each bicep tendonitis treatment session, we check that you are achieving the targets to ensure that the bicep tendon can handle tensile, elastic and compression forces. That you are able to push through the arm, like pushing a trolley and pull through the arm, like changing gears. We teach you to do isometric muscle contractions. These are muscle contractions without movement, like imaginary movements that keep the surrounding muscles active without compromising your injury site, by increasing circulation while maintaining strength. You can expect to be pressing into a wall in all directions during this phase. It is pain free to do and can relieve pain too.

5th Phase: Shoulder stability

Any contributing muscle imbalance and postural problems that influence your shoulder joint will be addressed with exercise. Weight bearing exercises in kneeling or plank will be introduced to increase shoulder stability under load. Our physiotherapist guides you to reengage in safe increments, and adjust where necessary. We’ll follow your progress and adapt where needed.

On completion of this phase, you should be able to identify correct shoulder blade placement for exercise and maintain this position.

6th Phase: Muscle Strength & Full Range of Movement

The most important component of rehabilitation is to regain full range of movement of the muscle fibres. The scar tissue that forms within the bicep tendon must be able to lengthen and move in the same orientation as the bicep muscle. We use massage, stretches and neurodynamic mobilizations to achieve full range of movement during your bicep tendonitis treatment.

On completion of this phase you should be able to lift your arms overhead without any pain to reach the shelf or wave.

7th Phase: Concentric Muscle Strength

Shortening of the muscle during a contraction involves strength and power exercises that will be progressed gradually as healing takes place. This will be tested frequently to determine if you can progress from short lever (bent arm) to long lever (straight arm) exercises. Our physiotherapist will guide and monitor your shoulder’s ability to maintain stability under load.

On completion of this phase, you should be able to do a weighted shoulder press pain free.

8th Phase: Eccentric Muscle Strength

Muscle contraction works in two directions:

  • Concentric contraction is when the muscle shortens, and
  • Eccentric contraction is when the muscle lengthens.

Concentric contraction enables powerful lifting from the shoulder, while eccentric contraction enables you to control the descend of a heavy object. Its common to feel some pain when we start contracting the muscles – this is due to breaking down abnormal fibrous tissue adhesions. On completion of this phase of your bicep tendonitis treatment, you should be able to control returning shoulder movements with weights or resistance bands.

9th Phase: Return to activity

The shoulder muscles must be tested under high load and speed to ensure that the muscles will be able to keep up with the demand of your life. During this phase our physiotherapist will guide you to return to normal activities, this includes challenging your muscle past its ‘normal’ boundaries to determine how it reacts to different forces. Ultimately we prepare you to return to hobbies, painting, walking the dogs or weight training.

10th Phase: Sport Specific Training

This is the final stage of rehabilitation that can last anything from 2-4 weeks. Our Physio will still commence with myofascial release, trigger point release and electrotherapy modalities where needed, but functional rehabilitation is most important during this final phase of your bicep tendonitis treatment.

Depending on your sport, our physiotherapist will tailor specific exercises that will help strengthen the muscles pertaining to your sport. A successful outcome is when you have gained knowledge throughout the rehabilitation program and can participate at full power and speed, not to mention the benefits of minimizing your chance of future injury.

How long does bicep tendonitis take to heal?

A first time reactive tendinopathy may heal within 6 weeks, while degenerative bicep tendinopathy takes up to 6 months to gain improvements in strength and function and never be completely symptom free. It is best to have your shoulder evaluated before change to the tendon integrity is no longer possible.

Other medical treatment for bicep tendonitis

Your GP can prescribe oral medication, like analgesics, anti inflammatories or muscle relaxants, to decrease your pain. This is for short term management as all medication has side effects, be it minor or major ones. When your pain is under control it is a great time to begin your rehabilitation.

A subacromial cortisone injection may be considered for chronic bicep tendonitis when followed up with rehabilitation. This can be done by an orthopaedic surgeon in the consultation room.

Chiropractic manipulation may give you pain relief, but it cannot change the joint space in the long run. You need to follow up treatment with rehabilitation.

Biokinetic rehabilitation programs are great to maintain the changes you gain in the treatment room.

Surgery for bicep tendonitis

Bicep tenodesis surgery can be considered if non-surgical treatment in not successful. The surgical procedure can be aimed at the bicep tendon or the humerus, depending on your case. The recovery from bicep tendon surgery is 20 weeks in total, the first 6 weeks you will be immobilised in a sling. After surgery you will definitely need to undergo an intensive rehabilitation program. Even surgery is not a quick fix. Outcome of surgery varies greatly between different cases, how long you have had symptoms, how active you are and how old you are. Bicep tenodesis have been found to increase your risk for bicep tendon rupture in the long run.

Glenoid labrum injuries, or SLAP lesion (superior labrum anterior and posterior) involve the bicep tendon and do need surgical repair.

Bicep tendonitis is also known as:

  • Bicep tendinopathy
  • Shoulder tendon pain
  • Bicep tendinitis
  • Bicipital tendinopathy

What else could your bicep tendonitis symptoms be?

  • Supraspinatus tendinitis

The supraspinatus tendon is in close proximity to the bicep tendon and the two may present together. Symptoms are very similar, with increased pain when reaching behind the back.

Insidious onset of severe stiffness accompanied by pain when moving may be the start of adhesive capsulitis.

ACJ dislocation or clavicle fracture can happen with a fall directly onto the side of the shoulder. Immediate severe pain, bruising or a step may be visible.

Injury to the neck discs may refer pain to the shoulder. Headaches and neck pain may also be present.

Rotator cuff tears or rupture usually occur with a traumatic injury and sound of the tendon tearing. Extreme weakness or an inability to move the arm may be present.

Traumatic or repetitive injuries that cause clicking or grinding on a specific movement can be a labrum injury.

Trauma (whiplash) or traction may cause injury to the brachial plexus that causes pins & needles into the shoulder and down the arm.