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Biceps Tendinopathy

You may be noticing pain in the front of the shoulder especially when reaching overhead. It could be a rotator cuff injury or it could be biceps tendinopathy.

What is it?

Bicep tendinopathy describes a painful inflammation or degeneration of the long head tendon of the bicep muscle. The inflammation can usually only be seen in the acute phase. Many cases present without inflammation and are a result of chronic overload which leads to micro tearing, failed healing, and degeneration in the tendon. This is especially true with cases that have been present for over three months.

The action of the bicep includes forearm supination and elbow flexion. The long head of the bicep also helps with shoulder stability during arm elevation.

The condition often results from repetitive overhead activity, including throwing, swimming, gymnastics, martial arts, racquet sports, and contact sports. Additional biomechanical risk factors for the development of biceps tendinopathy include repetitive shoulder or elbow flexion, repetitive overhead activity, improper lifting technique, shoulder girdle muscle imbalances, poor posture, inflexibility, scapulothoracic or glenohumeral instability, repetitive eccentric overload, trauma, and osseous anatomical abnormalities that narrow the bicipital groove, including fracture, osteoarthritis, and congenital variations.

Bicep tendinopathy is most common within the ages of 18 and 35. Smoking is a known risk factor of bicep tendinopathy.

Subacromial impingement is the most common cause of shoulder complaints that can lead to many other problems including bicep tendinopathy. About 95% of patients with shoulder impingement have bicep tendinopathy as well. Bicep tendinopathy rarely occurs in isolation and is paired up with shoulder pathologies such as rotator cuff tendinopathy/tears, labral tear, and shoulder instability.

Clinical Presentation

Patients with bicep tendinopathy often complain of a deep throbbing ache over the anterior shoulder or bicipital groove. The pain can also refer to the deltoid and less frequently toward the elbow or hand in the radial distribution. Pain and symptoms are often provoked by repetitive overhead activity and movements that require forearm supination, shoulder flexion, or elbow flexion.

Nocturnal symptoms are common, particularly when sleeping on the affected shoulder.

Clinical evaluation of bicep tendinopathy will often demonstrate limited range of motion. Active or resisted movements may provoke pain with forearm supination, elbow flexion, and shoulder flexion. Palpation is a great way to diagnose bicep tendinopathy, which will show tenderness in the rotator interval and bicipital groove.

Some musculoskeletal problems may be directly impacted by dysfunction in other sites along with biomechanical chains. Clinicians should carefully assess for dysfunction in the cervical and thoracic spine. They should also identify biomechanical faults including scapular dyskinesis and upper cross syndrome.


Plain film imaging has little value for the assessment of the bicep tendon but can help identify impingement or other bony pathologies. Ultrasound is a useful imaging technique for looking at the bicep tendon. MRI may help to identify ruptures of the tendon or concurrent pathology, including rotator cuff lesions and labral tears. Overall, the evidence suggests that ultrasound and MRI are similar for assessing patients with suspected biceps abnormalities.


Conservative care is the most appropriate management for the majority of biceps tendinopathy patients. Traditional conservative measures include moderate rest, ice, activity modification, and functional retraining.

The first phase of treatment is directed towards pain relief and restoration of normal range of motion. Patients should limit activities that require repetitive overhead activity, elbow flexion, or forearm supination. The first phase of treatment should include early scapular stabilization exercises, which should activate lower trapezius and serratus anterior.

The goal of rehab should be to establish a full, balanced, pain-free range of motion. Soft tissue techniques may include transverse friction massage or IASTM over the bicep tendon. Myofascial release and stretching exercises may be appropriate for the biceps, cervical spine, shoulders, and periscapular musculature.

As patients recover, strengthening may progress from isometric to concentric, then eccentric, and finally, sports specific rehab. Early exercises may include resisted internal and external rotation, low rows, and concentric bicep strengthening. Eccentric loading for the management of tendinopathies is a proven beneficial strategy and may be implemented as the patient shows improvement.

Clinicians must address associated biomechanical deficits, including spinal joint dysfunction, scapular dyskinesis, and upper cross syndrome. Limited cervicothoracic mobility, including a forward flexed posture, limits normal scapulohumeral rhythm and predisposes the shoulder to impingement related disorders.

There is evidence to suggest that cervicothoracic and thoracic spine manipulation is appropriate for patients with shoulder pain. Spinal manipulation may help decrease shoulder pain while improving mobility and function.

Surgery is generally not considered for bicep tendinopathy unless prolonged, greater than three months, conservative measures have failed. Even in the cases of a tendon rupture, the value of surgery is questionable. Surgical repair of tendinopathies are usually reserved for younger individuals, athletes, and manual workers.

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