Biceps tendinopathy: What you need to know

What is biceps tendinopathy?

The biceps muscle is located in the front of the upper arm, and is used when lifting, bending the elbow, and reaching up over the head. The upper portion of the biceps muscle attaches to the front of the shoulder in two places, and the lower portion attaches to a bone in the forearm. Lifting, pulling, reaching, or throwing repeatedly can lead to biceps tendinopathy or even tears of the upper biceps tendon.

Types

• For tendinopathy of long head of biceps
  • Primary biceps tendinopathy 1,2,3
    • isolated pathology of biceps tendon in bicipital groove (no associated shoulder pathology)
    • reported in 5% of cases
  • Secondary biceps tendinopathy2,3
    • pathology of biceps tendon associated with shoulder pathology (such as impingement syndrome or rotator cuff injury)
    • most common form of biceps tendinopathy, reported in 95% of cases

Anatomy of biceps tendinopathy

There are two heads of the biceps brachii; the long head and the short head. The short head attaches to the coracoid process which is a prominence at the front of the shoulder blade.  The long head of the attaches to the front of the glenoid which is the socket of the ball and socket joint.  The biceps tendon sits in the bicipital groove which is a channel at the front of the shoulder.

What Causes Biceps Tendinopathy?

Biceps tendinopathy is rare in isolation. Overuse, tendon impingement, shoulder joint instability or trauma predispose you. Therefore, it coexists with other shoulder pathologies, including rotator cuff impingement syndrome, rotator cuff tears, labral tears, SLAP lesions and shoulder instability. It is common in sports that involve throwing, swimmers, gymnasts and some contact sports. Occupations that require overhead shoulder work or heavy lifting are at risk

Risk factors

People may develop bicep tendonitis as a form of repetitive strain injury. If they have poor technique while playing a sport, or if they have poor posture while working, they may tear the tendons in their biceps.

Other risk factors include:

• Age: Older adults have more wear and tear on their tendons, as they have more years of use.
• Activities requiring overhead heavy lifting: Whether it is as part of work, sports, or exercise, people who lift heavy things over their heads, such as weightlifters or those with jobs requiring heavy labor, can cause extra wear and tear on their tendons.
• Repetitive shoulder use: Sports that require repetitive overhead movements, such as swimming or tennis, can cause a tendon to wear more.
• Smoking: According to the American Academy of Orthopaedic Surgeons (AAOS), there is a link between the use of nicotine and poor tendon quality and strength.

It is important to warm up well before any form of exercise and take regular breaks from any repetitive movements, especially overhead ones.

People should also make sure they are performing any movement safely and are not putting themselves at risk of injury. For example, if a person is playing a new sport, they might want to consider taking some lessons first to ensure they have proper technique.

What are the Symptoms of Biceps Tendinopathy?

Bicep tendonitis and tendinopathy sufferers will commonly report:

• Pain in the anterior shoulder region located over the bicipital groove, occasionally radiating down to the elbow.
• Overhead activities usually reproduce pain, especially those positions that combine abduction and external rotation, e.g. cocking to throw.
• The pain aggravates with shoulder flexion, forearm supination, or elbow flexion.
• Some patients describe muscle weakness and clicking or snapping with shoulder movements.
• The symptoms alleviate with rest and ice.

How is Bicep Tendinopathy Diagnosed?

Based on your symptoms and history, your physiotherapist or doctor may suggest biceps tendinopathy. Ultrasonography and MRI are the best investigations to confirm the diagnosis.

Bicep Tendinopathy Treatment

Treatment depends on the type of tendinopathy. Notably, the cause of your tendinopathy needs addressing.

Biceps tendonitis/tendinitis (inflammed tendon), Biceps tenosynovitis (inflammed tendon sheath).

Due to the inflammatory nature, tendonitis may respond favourably to non-steroidal anti-inflammatory medications (NSAIDs) or cortisone injections. Ice may relieve pain and reduce swelling.

Pain Relief

You’ll most likely be unable to lift your arm or sleep comfortably fully in the early phase. The first aim is to provide you with some active rest from pain-provoking postures and movements. Active rest means that you should stop doing the action or activity that provoked the shoulder pain in the first place and avoid doing anything that causes pain in your shoulder.

You may need to have your shoulder specially taped to provide pain relief. In some cases, it may mean that you need to sleep relatively upright or with pillow support. Your physiotherapist will guide you.

Ice is a simple and effective modality to reduce your pain and swelling. Please apply for 20-30 minutes each 2 to 4 hours during the initial phase or when you notice that your injury is warm or hot.

Your physiotherapist will utilise a range of pain-relieving techniques, including joint mobilisations, massage, acupuncture or dry needling, to assist you during this pain-full phase.

Patient Education & Technique Correction

You must understand why you have developed bicipital tendinopathy. Your physiotherapist will discuss with you what activities and postures are likely to aggravate your condition. They may also need to modify your technique or training/work volume.

Range of Motion & Flexibility

Your physiotherapist will assess your muscle and joint flexibility and prescribe exercises or recommend massage to attain a reasonable range of motion.

Improve Joint Stability & Strength

Your physiotherapist will need to address your scapulohumeral and scapulothoracic stability and movement function. Since glenohumeral joint instability is a significant cause of bicipital tendinopathy, exercises may include:

• Biceps strengthening
• Rotator cuff strengthening.
• Scapular stabilisation
• Periscapular strengthing
• Scapulohumeral rhythm correction.

In severe cases, surgical stabilisation may correct significant passive instability, e.g. previous dislocation.

Neck & Thoracic Posture & Mobility

Your neck and upper back have a link to your shoulder blade posture and dynamic control. In some cases, joint stiffness or pain referred from inflammed neck joints can directly alter shoulder pain and function. Your physiotherapist is skilled at the assessment and treatment of neck and upper back dysfunction. Ask them for more specific advice.

Restore Normal Function: Speed, Load, Power & Proprioception

Your physiotherapy treatment will vary depending on the functional requirements that you specifically need for your shoulder.

If your shoulder injury has a sporting origin, it is usually during high-speed activities, which place enormous forces on your body (contractile and non-contractile) or repetitive actions.

To prevent a recurrence as you return to sport, your physiotherapist will guide you with exercises to address these critical components of rehabilitation to avoid repeat episodes and improve your sporting performance.

Depending on what your sport or lifestyle entails, to prepare you for light sport-specific training, you may require a speed, agility, proprioception and power program.

Prognosis

Most cases will recover well with no complications. Small prorportion of cases may develop recurrent or chronic pain at the affected site or some weakness.

Chronic cases are at an increased risk of having a biceps tendon rupture.