Biceps Tendinopathy
1. Introduction
Bicep tendinopathy is an overload/overuse condition of the long head of the biceps tendon which originates from the cartilage structure on the shoulder socket (labrum) and is positioned within a groove in the upper arm bone (humerus) known as the bicipital groove. Sudden bicep tendinopathy may occur because of overuse due to a sudden increase in activity, especially among athletic patients aged 18- 35, and any patient aged over 65. It can accompany other shoulder related pathologies.
Frequently Asked Questions
- Biceps tendinopathy is a term that is often misused to describe three slightly different conditions that occur in the same area of the shoulder, which is an inflamed tendon/tendon sheath (outer layer) or non-inflamed degenerative tendon.
- It is rare in the general population (1).
- It is more common in those performing repeated throwing actions. This movement, where the arm is outstretched and rotated backwards, can compress the biceps tendon causing irritation and compression (1).
- It is most common in the sporting population aged 18- 35 (2).
- No.
- In most cases biceps tendinopathy can be managed conservatively with an appropriate rehabilitation programme and physiotherapy (3).
- Biceps tendinopathy is not linked to any serious medical conditions.
- Sporting population over the aged 18- 35 (4).
- People aged over 65.
- Overhead and throwing athletes.
- Pain with overhead activity.
- Gradual symptom onset though a period of increased activity/load in the affected shoulder.
- Usually reported as a deep, throbbing pain located in the front of the shoulder.
- Symptoms provoked with overhead activity, lifting, pulling and repeated movements.
- Worse overnight, notably when lying on the affected side.
- In some cases, a ‘popping’ or ‘clicking’ sensation when moving the shoulder.
- Allow appropriate rest and recovery time to not overstress healing tissues.
- In most cases a musculoskeletal physiotherapist can help by prescribing a rehabilitation programme that can aid recovery (4).
- Most people will show a good level of improvement within 3 months with conservative management and physiotherapy (5).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
- Gradual symptom onset through a period of increased activity/load in the affected shoulder.
- Usually reported as a deep, throbbing pain located in the anterior (front) region of the shoulder.
- Symptoms provoked with overhead activity, lifting, pulling and repeated movements.
- Worse overnight, notably when lying on the affected side.
- In some cases, a ‘popping’ or ‘clicking’ sensation when moving the shoulder.
- Active elbow flexion may also provoke pain.
3. Causes
- Relative sudden overload or increase in activity, particularly overhead (1).
- Rotator cuff tears, particularly those that involve the subscapularis tendon (3).
- Persistent rotator cuff tears (>3 months) (5).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing biceps tendinopathy. It does not mean everyone with these risk factors will develop symptoms.
- Age.
- Sport – particularly overhead and throwing activities.
- Previous shoulder injury.
- Repeated rotator cuff tears.
- Previous shoulder instability.
5. Prevalence
The exact incidence of biceps tendinopathy is unknown, however usually we see degenerative (wear and tear) or reactive (overload) tendinopathy of the bicep which commonly affect slightly different age groups.
- Degenerative tendinopathy – most common in people over the age of 65 as part of the normal ageing process and can be improved with physiotherapy and strength-based rehabilitation.
- Reactive tendinopathy – most common in overhead and throwing athletes aged 18-35 and is usually seen in conjunction with an increase in training or play, or a return to sport following an absence.
6. Assessment & Diagnosis
Musculoskeletal physiotherapists and other appropriately qualified healthcare professionals can provide you with a diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other potentially involved structures and gain a greater understanding of your physical abilities to help facilitate an accurate working diagnosis.
Your treating clinician will want to know how your condition affects you day-to-day so that treatment can be tailored to your needs and personalised goals can be established. Intermittent reassessment will ascertain if you are making progress towards your goals and allow appropriate adjustments to your treatment to be made. Imaging studies like MRI or ultrasound scans are usually not required to achieve a working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
Initially reducing pain, reducing the load on the tissue through activity modification and avoiding aggravating activities where possible. Your physiotherapist will guide you on how to reduce load safely and effectively whilst maintaining activity.
8. Rehabilitation
Rehabilitation should focus on active recovery and returning to activity in a gradual way.
- Focus on restoring normal range of movement.
- Graded exposure to aggravating activity.
- Strength training (4).
9. Biceps Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This programme focuses on maintaining range of movement within the shoulder, appropriate loading of the affected tendon and maintenance of upper limb strength and stability. We suggest you carry this out once a day for approximately 2-6 weeks as pain allows. We can work into pain during these exercises but ideally this should not exceed any more than 4/10 on your self-perceived pain scale (7).
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next progression. More focus is given to progressive loading of the tendon and upper limb strengthening. As with the early programme, some pain is to be expected but ideally, we do not want this to be any more than 4/10.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This programme is a further progression with challenging progressive loading of the affected tendon complex. Again, some pain is acceptable but ideally, we do not want it to exceed 4/10.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from further assessment to ensure you are making progress and to establish appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future reoccurrence.
11. Other Treatment Options
- Surgery may be considered in traumatic cases, or if conservative management has shown no improvement after 3 months (6).
- Non-steroidal anti-inflammatory drugs (NSAIDs) can be helpful for management of pain.
- Steroid injections can be considered secondary to active rehabilitation.
12. Links for Further Reading
References
- Snyder, G. M., Mair, S. D., & Lattermann, C. (2012). Tendinopathy of the long head of the biceps. Rotator Cuff Tear: Karger Publishers, 57, 76-89.
- Ahrens PM, Boileau P. (2007) The long head of biceps and associated tendinopathy. The Journal of bone and joint surgery. 89, 1001-9.
- Nakata W, Katou S, Fujita A, Nakata M, Lefor AT, Sugimoto H. (2011)Biceps pulley: normal anatomy and associated lesions at MR arthrography. Radiographics. 31, 791-810.
- Thomas R. Baechle.(2008). Essentials Of Strength Training And Conditioning. National Strength and Conditioning Association. Human kinetic.
- Salim M. Hayek,Binit J. Shah,Mehul J. Desai,Thomas C. Chelimsky. (2015). Pain Medicine An Interdisciplinary Case-Based Approach. OUP USA.
- Churgay CA. (2009). Diagnosis and treatment of biceps tendinitis and tendinosis. Am Fam Physician. 1;80, 470-6.
- Silbernagel, K. G., Thomeé, R., Eriksson, B. I., Karlsson, J., Sahlgrenska akademin, Institute of Clinical Sciences, Sahlgrenska Academy. (2007). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with achilles tendinopathy: A randomized controlled study. The American Journal of Sports Medicine, 35, 897-906. doi:10.1177/0363546506298279.
Other Conditions in
Shoulders, Upper Arms
Whiplash Disorders
An injury which typically occurs following a road traffic collision, often affecting the soft tissues of the neck.
Thoracic Outlet Syndrome
A condition presenting with pain in the arm as a result of compression of structures around the neck/shoulder.
Shoulder Osteoarthritis (OA)
Age and activity related changes to the joints of the shoulder which can lead to pain and stiffness.
Shoulder Impingement
Shoulder impingement is an umbrella term used to describe a variety of conditions that can cause pain in the shoulder.
Shoulder Dislocation
An injury in which your upper arm bone ‘pops out’ of the cup-shaped socket of your shoulder blade.
Rotator Cuff Tendinopathy
Pain and weakness affecting the shoulder and limiting function.
Frozen Shoulder
An insidious (no clear cause), painful/stiff condition of the shoulder persisting for more than 3 months.
Calcific Tendinopathy
A rare condition causing pain and loss of free movement in tendons and joints.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Acute Torticollis
Sometimes referred to as “wry neck”, this is a condition causing muscle spasms and associated neck pain.
Acromioclavicular Joint Injury
Injury to a small joint at the end of the collar bone (clavicle)/top of your shoulder.