Biceps Tendinitis in the Shoulder: Symptoms and Treatment

Biceps tendinitis in the shoulder

Biceps tendinitis (or long head of the biceps tendinopathy) is an inflammation or degeneration of the tendon of the long head of the biceps brachii muscle in its proximal portion, within the shoulder. It represents a frequent cause of anterior shoulder pain, present in 5-10% of patients with shoulder pain. In most cases (95%), it does not occur in isolation but is associated with other shoulder pathologies, particularly impingement, rotator cuff tears, and superior glenoid labrum lesions (SLAP).

Biceps tendinitis generally responds well to conservative treatment with physiotherapy, exercises, and relative rest, with symptom resolution in 70-80% of cases.

Anatomy of the Biceps Tendon

The biceps brachii muscle has two proximal heads:

Long Head of the Biceps (LHB)

• Origin: supraglenoid tubercle of the scapula and superior glenoid labrum (bicipital anchor)
• Intra-articular course: the tendon crosses the glenohumeral joint, passing over the head of the humerus
• Bicipital groove (intertubercular sulcus): the tendon exits the joint and runs in the bicipital groove of the humerus, held in place by the transverse humeral ligament and the rotator pulley (formed by the tendons of the subscapularis and supraspinatus)
• Intra-articular tendon length: approximately 9 cm

Short Head of the Biceps

• Origin: coracoid process of the scapula
• It is rarely involved in pathology

Function of the LHB

The long head of the biceps has a debated role in shoulder biomechanics:

• Humeral head depressor: counteracts superior migration during abduction
• Anterior stabilizer: especially in external rotation
• Elbow flexor and forearm supinator: the primary function of the biceps

Causes and Mechanisms

Primary Tendinitis (5%)

Rare as an isolated pathology. It occurs in:

• Overhead athletes: swimmers, throwers, tennis players — repetitive microtrauma to the tendon during sports activity
• Weightlifting: repetitive stress during curls and pulling movements

Secondary Tendinitis (95%)

In the vast majority of cases, biceps tendinitis is secondary to other pathologies:

• Subacromial impingement: the tendon is compressed in the subacromial space along with the rotator cuff
• Rotator cuff tears: rotator cuff dysfunction alters biomechanics and overloads the biceps (which must compensate as a stabilizer)
• Tendon instability in the groove: subluxation or dislocation of the tendon from the bicipital groove due to rotator pulley injury (subscapularis)
• SLAP lesions (Superior Labrum Anterior to Posterior): the tendon’s insertion point on the labrum is damaged

Evolution of the Pathology

LHB pathology generally follows a progression:

• Tendinitis: acute inflammation of the tendon and synovial sheath
• Tendinosis: chronic degeneration with disorganization of collagen fibers
• Partial tear: rupture of a portion of the tendon fibers
• Complete rupture: the tendon tears — can occur spontaneously or after exertion (the classic “Popeye sign”)

Risk Factors

• Age > 40 years: tendon degeneration increases with aging
• Overhead sports: volleyball, tennis, swimming, throwing
• Jobs with arms overhead: painters, electricians, warehouse workers
• Rotator cuff pathologies: compensatory overload on the biceps
• Shoulder instability: overload of the biceps as a stabilizer
• Smoking: reduces tendon vascularization
• Diabetes: associated with diffuse tendinopathies

Symptoms

Pain

• Location: anterior shoulder pain, in the region of the bicipital groove (anterior part of the humerus). The pain is typically pinpoint and the patient indicates it precisely
• Radiation: can radiate along the biceps belly down to the elbow
• Character: dull pain at rest, sharp during specific movements
• Aggravated by: lifting objects with the arm extended, overhead movements, carrying heavy bags with the palm up (supination), throwing movements, reaching behind the back
• Night pain: possible, especially when sleeping on the affected side

Weakness

• Reduced strength in elbow flexion and forearm supination
• Sensation of giving way when lifting loads

Specific Signs

• Anterior click or snapping: if the tendon is unstable in the groove and subluxes during movement
• “Popeye sign”: in case of complete LHB rupture, the muscle belly of the biceps retracts distally, creating a characteristic “ball” in the arm. Paradoxically, tendon rupture often resolves the pain

Diagnosis

Clinical Examination

Several specific tests can be performed:

• Speed’s Test: arm elevated to 60°, elbow extended, palm up — the patient resists downward pressure. Pain in the groove = positive (sensitivity 63%, specificity 58%)
• Yergason’s Test: elbow at 90°, supination against resistance. Pain in the groove = positive (sensitivity 43%, specificity 79%)
• Palpation of the bicipital groove: pain on direct pressure over the groove with the arm in 10° external rotation (to bring the groove to an anterior position)
• Biceps instability test: in case of tendon subluxation, a “click” may be felt during shoulder rotation
• SLAP tests: O’Brien, crank test, biceps load test — for superior labrum lesions

Imaging

• Ultrasound: first-choice examination — can visualize the tendon in the groove, assess its thickness, the presence of peritendinous fluid, subluxation, and sheath effusion. Operator-dependent but very accurate (sensitivity 88-96%)
• Shoulder MRI: gold standard for complete evaluation — the tendon, rotator cuff, glenoid labrum, bony structures. Essential for therapeutic planning
• Arthro-MRI: with intra-articular contrast medium, improves sensitivity for SLAP lesions and partial tendon tears
• X-ray: useful for bone evaluation (groove morphology, calcifications) but does not visualize the tendon

Differential Diagnosis

• Subacromial impingement: often coexisting
• Adhesive capsulitis: global shoulder stiffness
• Rotator cuff tear: weakness in rotation
• SLAP lesion: deep pain with clicking
• Acromioclavicular osteoarthritis: superior shoulder pain

Conservative Treatment

The long head of the biceps tendon originates at the scapula’s supraglenoid tubercle, crosses the shoulder joint, and runs through the bicipital groove on the humerus, serving as a humeral head depressor and anterior stabilizer. Conservative treatment is the first approach and is successful in 70-80% of cases.

Acute Phase (0-2 weeks)

• Relative rest: avoid movements that cause pain (overhead, weightlifting, supination against resistance)
• NSAIDs: for 1-2 weeks to reduce inflammation
• Cryotherapy: ice 15 minutes, 3-4 times a day
• Avoid complete immobilization: the shoulder should be moved within pain-free ranges

Subacute Phase (2-6 weeks)

Instrumental Therapy

• Tecartherapy: to promote inflammation resolution and stimulate tendon repair
• Focused shockwave therapy: indicated in chronic tendinosis (> 3 months). 3-5 sessions weekly
• Ultrasound: anti-inflammatory and analgesic effect
• High-power laser: biostimulating effect on the tendon

Manual Therapy

• Shoulder mobilization: recovery of glenohumeral and scapulothoracic mobility
• Myofascial techniques: release of the biceps, anterior deltoid, pectoralis, and rotator cuff muscles
• Thoracic spine mobilization: thoracic stiffness is often a contributing factor to shoulder pathology

Strengthening Phase (6-12 weeks)

Biceps Exercises

• Isometric curl: elbow at 90°, hold the position with a light weight for 30 seconds. 3 sets. Progression: eccentric curl (controlled lowering phase in 4-5 seconds)
• Eccentric dumbbell curl: eccentric loading stimulates tendon remodeling. 3 sets of 10, slow load progression
• Eccentric dumbbell supination: 3 sets of 10

Rotator Cuff Strengthening

Essential to reduce overload on the biceps:

• External rotation with elastic band: elbow at side, 3 sets of 15
• Internal rotation with elastic band: 3 sets of 15
• Full can (elevation in the scapular plane): 3 sets of 12
• Prone Y-T-W: prone, perform movements with light dumbbells. 2 sets of 10

Scapular Stabilization

• Scapular retraction with elastic band: 3 sets of 15
• Push-up plus: for the serratus anterior. 3 sets of 12
• Row with elastic band: 3 sets of 12
• Wall slide: arms against the wall, slide up and down maintaining contact. 3 sets of 10

Stretching

• Biceps stretch: arm extended backward, palm against a wall, rotate the trunk away from the hand. 30 seconds, 3 repetitions
• Pectoralis stretch: in a corner of the wall. 30 seconds
• Posterior capsule stretch (sleeper stretch): lying on your side, arm at 90°, push the hand down with the other hand. 30 seconds, 3 repetitions

Infiltration

If pain does not respond after 4-6 weeks of therapy:

• Ultrasound-guided peritendinous corticosteroid injection: into the tendon sheath (NOT into the tendon itself, to avoid increasing the risk of rupture). Can provide significant relief for weeks-months
• PRP (platelet-rich plasma): growing evidence in chronic tendinosis, but not yet standard

Surgical Treatment

Indicated when conservative treatment fails after 3-6 months or in case of significant structural lesions.

LHB Tenotomy

• Tendon sectioning via arthroscopy: the tendon is simply cut, allowing it to retract. Eliminates the source of pain
• Pros: simple and quick procedure, excellent pain relief
• Cons: possible “Popeye sign” (cosmetic deformity) and slight reduction in supination strength (10-20%)
• Indicated in: patients > 55-60 years old, low functional demands

LHB Tenodesis

• Tendon reinsertion outside the joint (in the bicipital groove or on the humerus) with an interference screw, button, or suture
• Pros: preserves muscle length (no deformity), maintains strength
• Cons: more complex, risk of fixation failure
• Indicated in: patients < 55 years old, athletes, manual laborers, patients who refuse cosmetic deformity

SLAP Repair

In case of a superior labrum lesion (SLAP), arthroscopic repair with suture anchors is indicated in young and athletic patients.

Prognosis

• Acute tendinitis: resolution in 4-8 weeks with conservative treatment in most cases
• Chronic tendinosis: slower improvement (3-6 months), but still favorable with eccentric exercises and instrumental therapy
• Complete LHB rupture: paradoxically, pain resolution is often immediate. Functional loss is generally modest (10-20% loss of supination strength)
• Post-surgical: return to full activity in 3-6 months

Frequently Asked Questions (FAQ)

Frequently Asked Questions

What are the typical symptoms of biceps tendinitis?

Biceps tendinitis commonly presents as anterior shoulder pain, which may worsen with overhead activities or lifting. This pain is often indicative of inflammation or degeneration of the long head of the biceps tendon. Weakness in the affected arm can also be a reported symptom.

How is biceps tendinitis commonly diagnosed?

Diagnosis typically involves a comprehensive clinical examination by a healthcare professional, assessing the shoulder’s range of motion, strength, and specific pain points. Imaging studies, such as ultrasound or MRI, may be utilized to confirm the diagnosis and identify any associated shoulder pathologies. A differential diagnosis is also performed to rule out other conditions.

How is biceps tendon pain treated? Will I need surgery?

Conservative treatment for biceps tendinitis often includes a structured program of physical therapy, incorporating specific exercises to improve strength and mobility. Appropriate rest from aggravating activities and anti-inflammatory measures are also crucial components. In some cases, infiltrations may be considered to manage symptoms.

Why is biceps tendinitis often associated with other shoulder conditions?

Biceps tendinitis frequently coexists with other shoulder pathologies, such as rotator cuff tears, shoulder impingement, or superior glenoid labrum lesions (SLAP tears). The long head of the biceps tendon shares anatomical space and biomechanical interactions with these structures, making it susceptible to secondary involvement when other issues are present. A comprehensive evaluation is therefore essential to address all contributing factors.

For a broader overview of related conditions, see our our comprehensive shoulder pain guide.

Sources and Scientific References

1. Liaghat B et al. (2023). Diagnosis, prevention and treatment of common shoulder injuries in sport: grading the evidence – a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF). Br J Sports Med. 57:408-416. DOI | PubMed
2. Kara D et al. (2024). Blood Flow Restriction Training in Patients With Rotator Cuff Tendinopathy: A Randomized, Assessor-Blinded, Controlled Trial. Clin J Sport Med. 34:10-16. DOI | PubMed
3. McDevitt AW et al. (2024). Physical therapy interventions used to treat individuals with biceps tendinopathy: a scoping review. Braz J Phys Ther. 28:100586. DOI | PubMed
4. Abrams GD et al. (2010). Diagnosis and management of superior labrum anterior posterior lesions in overhead athletes. Br J Sports Med. 44:311-8. DOI | PubMed
5. Zwerus EL et al. (2018). Physical examination of the elbow, what is the evidence? A systematic literature review. Br J Sports Med. 52:1253-1260. DOI | PubMed