Updated: Jul 3
Biceps Tendonitis Cause
Before we get started, it is important to make one point about the naming of this pathology. Biceps tendonitis is actually biceps tendinopathy, similar to what I previously discussed in my post on achilles tendinopathy. The reason for this is that tendonitis refers to inflammation of the tendon being the sole issue and cause of pain. Tendinopathy describes a continuum of issues that include inflammation but also breakdown of the tendon, which is more commonly the cause of pain and dysfunction. I will continue to use biceps tendonitis because it is more common, but it is important to understand the actual pathology.
Understanding the anatomy of the biceps is crucial, so we will start with the basics. There are two heads to the biceps muscle: the long head (red) and the short head (green). The long head originates from the top of the scapula, while the short head attaches to the coracoid process, a lower part of the scapula. Both muscles come together and insert into the radius of your forearm. Their primary action is to flex and supinate the forearm, but they also flex the entire arm as well. The flexing of the entire arm is solely provided by the long head of the biceps.
The long head of the biceps tendon originates from the scapula, but it runs through the bicipital groove, which is a notch formed by the humerus bone. The picture below courtesy of shoulder-pain-explained.com provides an excellent visual.
There is limited space in the bicipital groove, so irritation of the tendon can have significant consequences. Inflammation of the tendon or its sheath can cause the tendon to rub against the bone repeatedly, resulting in more swelling and degeneration. This leads to further inflammation, creating a feedback loop that can result in chronic pain and dysfunction.
The long head of the biceps actually originates from the synovial lining of the glenohumeral joint of the shoulder. This means that any problems with the shoulder can manifest into stress on the long head of the biceps tendon. Many times this can be a result of rotator cuff pathologies or other destabilizing issues in the shoulder.
Repetitive overhead motions can stress the biceps tendon and shoulder, causing irritation in the bicipital groove. Throwing a baseball is a stressful, repetitive, overhead movement that is a common cause of biceps tendon pathologies. In addition, the eccentric stress to the biceps from throwing a baseball can create further damage in the area. The biceps work to decelerate the arm after throwing, creating damage to the muscles and tendon eccentrically.
Tendons can also suffer damage as we age. They can become thinner and lose their recovery abilities, leading to more injuries. Older pitchers are more likely to suffer from biceps tendonitis for these reasons.
Biceps Tendonitis Symptoms
Biceps tendonitis symptoms are relatively easy to differentiate due to their location and nature. Pain will typically be worse with overhead activities such as throwing. Additionally, the pain will often be localized at the bicipital groove. This pain can be provoked by palpating the area and some popping may occur with movements as the tendon slides in and out of the groove. Pain can radiate down the front of the arm, following the path of the biceps. Symptoms can also worsen at night with lying on the affected side.
There are many shoulder pathologies that refer pain to the front of the shoulder and the biceps tendon is often blamed for any pain in that area. However, a healthcare provider who can palpate the affected area and has good differential diagnosis skills should be able to conclude whether or not biceps tendonitis is the cause of symptoms.
Biceps Tendonitis Test
Testing for biceps tendonitis requires a thorough evaluation. There is no single test with good reliability. The most important step is a thorough history to determine when the pain began and what can exacerbate it. Pitchers who had dramatic spikes in workload or changed their mechanics can often irritate the tendon, so it is important to know about any changes on the field.
Palpating the area involves an understanding of the anatomy in the anterior shoulder. The bicipital groove can be felt and the long head of the biceps tendon can be isolated to determine pain and reproduction of symptoms. Blindly poking in the front of the shoulder will inevitably lead to a false positive result, as there are many sensitive structures in the area.
The first special test that can be performed is Yergason’s Test. The image below courtesy of healthjade.net shows the maneuver being performed.
The healthcare provider resists the patient from rotating their arm in the manner shown. If there is pain in the bicipital groove or associated areas, then the test is considered positive.
Speed’s Test is another maneuver to stress the long head of the biceps tendon. It involves the patient raising their arm to 90 degrees in front of them and turning their palm towards the sky. The healthcare provider tries to push their arm down while they resist it. As previously mentioned, the long head of the biceps flexes the forearm and upper arm, so this test provides significant strain on the tendon. The image below courtesy of physiotutors.com shows the test being performed.
Another special test that I like to perform for baseball players is the Biceps Load II Test shown below courtesy of researchgate.net.
The patient can be seated or lying on their back and their shoulder is brought to approximately 90 degrees with their elbow at 90 degrees and palm facing their head. The provider should try to pull the hand away from their head to stress the biceps in an externally rotated position. This is traditionally a test for SLAP tears (read more about those here), but I utilize it for biceps tendonitis as well. The position mimics the stress of throwing in an overhead position and is more useful in baseball athletes.
Imaging of the biceps tendon can be helpful in diagnosing injury, particularly with an ultrasound or MRI. An ultrasound can show any tearing, inflammation, or thickening of the biceps tendon which can determine how much trauma is present. An MRI can do the same while also evaluating the shoulder and surrounding soft tissues to get a better picture of the area around the biceps tendon.
Biceps Tendonitis Treatment
Treatment of biceps tendonitis should encompass the entire spectrum of injury. First, it is important to look at workload. If it is the start of the season and a sudden spike in pitching led to the injury, a more gradual ramp up may be the only treatment needed. Similarly, a pitching coach should be involved regarding mechanics and possible steps to avoid stress on the shoulder by addressing the kinetic chain (read more about that here).
The first step involves limiting pain and dysfunction so that exercises can be progressed. Manual therapy including soft tissue mobilization and trigger point dry needling to the biceps muscle and surrounding muscles including the pecs, rotator cuff, etc. can allow for improved mobility and decreased stress on the tendon. Evaluation of the surrounding joints and structures including the cervical and thoracic spine along with the scapula can provide underlying causes of the tendonitis.
Physical therapy should be the first treatment strategy for biceps tendonitis. Injections including corticosteroids to decrease inflammation may prove beneficial to help improve tolerance to exercise. If no other options are available, biceps tenodesis is a last resort. This surgery involves cutting the long head of the biceps tendon and re-attaching it onto the humerus further down the arm. This prevents stress in the bicipital groove and can allow for normal return to function. Unfortunately, there are not good outcomes for baseball players following this procedure. This article by Chalmers discussed research that shows 80% of position players returning to professional baseball after biceps tenodesis surgery, but only 16% of pitchers returned to play. These are alarming numbers, although the sample size was only 17 players. Further research is needed, but this surgery is considered a last resort for pitchers for this reason.
Biceps Tendonitis Exercises
Exercises for the treatment of biceps tendonitis should address the biceps as well as the surrounding musculature based on individual assessments. Rotator cuff exercises can be tolerated early in rehabilitation, both open and close-chained movements such as shoulder taps in a high plank position as shown below courtesy of popsugar.co.uk.
This exercise is beneficial because the biceps is kept in an isometric position and does not receive significant load. Push-ups in general place little stress on the biceps and are fantastic for rotator cuff and shoulder strengthening.
Isometric biceps exercises can be introduced if pain is too great for more aggressive exercise. This exercise involves sitting at a desk and putting your palms on the bottom of the desk. Push up into the desk with as much force as you can without increasing your pain above 3-4 out of 10. The goal is to hold this position for 30-45 seconds and perform 5-10 repetitions, although you can start with less. Any object that will resist your motion can be utilized, but a desk is often easiest.
As your symptoms improve, rowing exercises can be progressed. Rows involve the activation of the biceps to pull the weight towards you, but your scapular muscles including your trapezius and rhomboids should provide support. TRX rows such as the one pictured below are useful, but a dumbbell or barbell can be effective as well.
Biceps eccentric exercises should be performed when able to mimic the stress of throwing a baseball, but also to build robustness of the muscle and tendon. Using a heavy dumbbell, you will start at the top position of a curl and slowly lower it. Use your other hand to bring it up to the starting position and repeat the movement. The weight should be too heavy for you to curl it up with a single arm. Eccentrics have been shown to be very beneficial for tendon pathologies and the goal is to make the weight as heavy as possible and move it as slowly as possible. Lower rep ranges of 4-6 can be good for this exercise with significant rest between sets.
Plyometric exercises can be added after eccentric strengthening of the muscle to mimic throwing. Heavier medicine balls can be used initially before transitioning to plyo balls to move closer to the weight of a baseball. A return to throw program can be devised to gradually increase the stress on the tendon and arm as a unit.
As always, if you are suffering from pain, nerve symptoms (numbness, tingling, or weakness), or anything else significant, please see a healthcare provider. This blog is meant to be educational and is not a substitute for medical advice.
Hopefully you learned something about biceps tendonitis and its symptoms and treatment. If you have interest in other elbow injuries, check out our elbow page. If you found this blog helpful, please share it with someone. We hope to continue to grow and help people better understand how our bodies move and work. If you want to subscribe so that you don’t miss any other posts, click the sign in button on the top right of this page. Once you have created an account, click the drop-down menu in the top right next to your name and go to your settings page. Click the subscribe button next to “Blog Subscription” and you won’t miss any future posts! If you are in the Sterling, Virginia area and would like to work with me or you have any questions, please email me at email@example.com or follow me on Instagram or Twitter @drdannydpt.