Conditions & Treatments - Biceps Tendinitis



The biceps brachii muscle is a two-headed muscle responsible for flexing the elbow and supinating the forearm (1). The long head originates on the supraglenoid tubercle of the scapula and courses through the bicipital groove under the transverse humeral ligament (1). The short head originates on the coracoid process of the scapula (1). Both heads join near the insertion of the deltoid to form a common muscle belly (1,2). Distally, the muscle belly splits into two tendons with the stronger tendon attaching to the radial tuberosity and the other tendon attaching to the fascia of the forearm via the bicipital aponeurosis (1,2).

Biceps tendinitis vs. biceps tendinosis
The phrase tendinitis implies inflammation, while the phrase tendinosis implies collagen degeneration (3). Chronic tendinitis may require 4-6 weeks to completely heal, while chronic tendinosis may require 3-6 months for full recovery (3). According to an article by Khan et al., an increasing body of evidence supports that many overuse tendon injuries do not involve inflammation (3). Therefore, these tendon injuries should be labeled overuse tendinosis instead of overuse tendinitis.

Supporting the rarity of tendinitis discussed in the aforementioned Khan et al. article, Churgay estimates that approximately 5% of patients with proximal bicep tendon injuries suffer from primary biceps tendinitis, or inflammation of the biceps tendon within the bicipital groove (4). Overhead and repetitive shoulder rotation activities worsen the tendinitis, causing the tendon to degenerate, thicken, and become irregular (4). This collagen disorientation and disorganization is a histologic trademark of tendinosis (3). Churgay notes that athletes over age 35 or nonathletes are more likely to have biceps tendinosis as a result of overuse over time (4). Primary impingement, which occurs via mechanical compression of the rotator cuff, biceps long head, and subacromial bursa between the humeral head and the acromion, is considered the most common cause of biceps tendinosis (5,4).

Subjective Exam
Patients may complain of sharp pain in the front of the shoulder when reaching overhead, pain that radiates toward the neck or down the front of the arm, dull achy pain at the front of the shoulder after activity, and difficulty with daily activities such as putting dishes away in overhead cabinets (6). Patients with secondary impingement, which is a relative decrease in the subacromial space with excessive anterior and superior migration of the humeral head caused by instability in the glenohumeral joint, may complain of numbness and tingling into the arm, pain in the anterior/lateral shoulder, and pain in surrounding musculature (5).

Objective Exam
The most common finding of proximal biceps tendon injury is bicipital groove point tenderness (4). Many special tests, including Yergason, Neer, Hawkins, and Speed, are useful in implicating pathology of the biceps tendon (4). However, since these tests also create impingement under the coracoacromial arch, it is important to note that a rotator cuff lesion may also elicit pain and contribute to a positive test result (4).

Conservative Treatment
Conservative treatment consists of rest from overhead activity and ice (20 minutes at a time several times a day) (7). A doctor may also recommend NSAIDs to reduce pain and swelling, corticosteroid injections, and physical therapy (7).

Physical therapy management of proximal biceps tendon injuries typically consists of three phases: phase one (restoration of full PROM, pain management, and restoration of normal accessory motion), phase two (AROM exercises and early strengthening), and phase three (rotator cuff and periscapular strength training, with a focus on enhancing dynamic stability) (2). For athletes, a return to sport phase is initiated upon completion of the rotator cuff and periscapular strength training phase (2). Advancement through the phases depends on the chronicity and irritability of the injury. A physical therapist will be best able to guide patients through the proper exercise progression based on pain, swelling, and motion. The American Academy of Orthopaedic Surgeons has created a detailed handout that clinicians and patients alike may find helpful titled "Shoulder and Rotator Cuff Exercise Conditioning Program" (8). This handout is available online at:

Surgical Management
If a patient fails three months of conservative treatment, surgery may be considered (4). During surgery, structures causing impingement may be removed and the tendon may be debrided (4). For serious tears or complete ruptures of the biceps long head tendon, a biceps tenodesis may be performed (4). This operation involves attaching the cut biceps tendon to the bicipital groove or transverse humeral ligament with sutures or anchors (4). A biceps tenotomy may also be performed (4). This operation involves removal of the ruptured biceps tendon from the glenohumeral joint and is "the procedure of choice" for inactive patients over the age of 60 with a completely ruptured biceps tendon (4).


Last revised: August 19, 2014
by Michelle Kornder, DPT


1) Wheeless' Textbook of Orthopaedics. Duke Orthopaedics. Updated October 16, 2013. Accessed August 18, 2014.
2) Manske, RC. Shoulder Injuries. In: Pepper D, Ball T, eds. Clinical Orthopaedic Rehabilitation: An Evidence-Based Approach - Expert Consult. 3rd ed. Philadelphia, PA: Elsevier; 2011: 171-385.
3) Khan KM, Cook JL, Taunton JE, Bonar F. Overuse Tendinosis, Not tendinitis. The Physician and Sports Medicine. 2000;28(5). Available from University of Wisconsin Madison, Madison, WI. Accessed August 17, 2014.
4) Churgay, CA. Diagnosis and Treatment of Biceps Tendinitis and Tendinosis. Am Fam Physician. 2009;80(5):470-476. Available from University of Wisconsin Madison, Madison, WI. Accessed August 17, 2014.
5) Hallisy, Thein-Nissenbaum. PT 677 -MS Dysfunction: Examination, Diagnosis, & Management II. Madison, WI: Department of Physical Therapy; 2013.
6) Physical Therapist's Guide to Biceps Tendinitis. American Physical Therapy Association Move Forward Guide. Accessed August 17, 2014.
7) Tendinitis of the Long Head of the Biceps-OrthoInfo-AAOS. American Academy of Orthopaedic Surgeons. Updated October, 2009. Accessed August 17, 2014.
8) Rotator Cuff and Shoulder Conditioning Program-OrthoInfo-AAOS. American Academy of Orthopaedic Surgeons. Accessed August 17, 2014.


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