Biceps Tendonitis is an inflammation in the string-like structures called tendons that link the bicep muscles with the shoulder bone and arm. Tendonitis in bicep tendons can also be related to the irritation that is caused by variable reasons. If you feel weakness in the muscles and experience consistent pain in the front of the arms, then there are chances of biceps tendinitis. (1) The condition is treatable but needs proper diagnosis before the therapy can be initiated.
What is Biceps Tendonitis?
Tendonitis or tendinitis in the biceps can occur simply because of the overuse of the bicep muscles. Although this structure is tough, it is still at risk of damage and tear if overused. Micro tears in the tendon can cause immense pain and make the movement of the forearm difficult or impossible. People who are involved in activities that include repetitive motions of the arms are more likely to develop this condition. Sports players and professionals in swimming, basketball, badminton, and golfers use their upper arm strength which puts them at risk of developing tendonitis in the arms, shoulder, and elbows. (2) Momentous load on the tendon located on the front of the shoulder with great intensity can cause tendinitis too. Rotator cuff tendonitis and biceps tendonitis can occur together but the rotator cuff cannot develop tendonitis at the same time as the tendonitis in the shoulders.
It is important to learn the anatomy of the forearm, shoulder, and elbow joints to understand how tendonitis in this area affects the overall health and range of motion of the patient. The shoulder joint is connected with the scapula and clavicle and gives a ball and socket joint for the humerus bone (forearm). The socket of the humerus is called the glenoid, which is covered with cartilage called labrum to help it fit into the joint. Some certain muscles and tendons line with this shoulder joint called the rotator cuff. The bicep muscles are located on the forearm bone. Its origin point is the shoulder joint and its insertion point is the elbow joint, making a short head and a long head of the biceps brachii. The cords that attach these biceps to the joints are called bicep tendons.
Injuries Related to Biceps Tendonitis
This condition most commonly affects the tendons that support the long head of the biceps tendon (LHB). The tendonitis can either be associated with acute inflammatory conditions or degeneration of tendons i.e. degenerative tendinopathy(3) Primary bicipital tendonitis occurs less commonly and so is not completely understood, however, secondary causes of biceps tendonitis are more prevalent in general. Secondary causes are more often linked to rotator cuff (RC) tendinopathy. Bicep tendon injuries can be classified as proximal and distal bicep tendonitis or tear. (4)
The associated pathologies include:
- Dislocation of LHB tendons
- The physical trauma of the forearm
- Arthritis in the Glenohumeral region
- Internal and external Impingement of the shoulder
- Chronic Shoulder instabilities
- Chronic RC tendinopathies e.g. rotator cuff tears
- Inflammatory conditions
Clinical examination of biceps tendonitis
The clinical examination of a disease is very important to detect the real reason for the pain in the forearm and shoulder pain. The clinical examination will include the assessment of the symptoms followed by physical and radiological examination. (5)
Signs and Symptoms
The signs and symptoms of this disease condition include:
- Unexpected pain in the proximal biceps and the anterior portion of the arm.
- Exacerbation in pain when involved in physical activity
- Irradiating or moving pain from the shoulder to the elbow
- Popping sounds from the biceps indicate muscle and tendon instability
- Consistent pain even during rest
- Physically active and strenuous patient occupation
- Changed contour and shape of the anterior bicep called Popeye muscle
When you will visit your doctor, he will most likely ask you questions about what the pain feels like to match it with the list of symptoms of biceps tendonitis. He will start with inquiries about your age and occupation to get to know your lifestyle better. The Physical exam then extends towards a few physical tests to assess your pain intensity, range of motion, and strength and function of your soft tissues and muscles. (6)
There are many conditions and shoulder problems that can overlap while diagnosing biceps tendonitis, for example, sub-acromial impingement syndrome, adhesive capsulitis, labrum lesions, and cervical spine pathologies. So, it is important to differentiate these conditions by taking an extensive patient history and taking a radiological exam.
These include imaging procedures like magnetic resonance imaging, x-rays, and ultrasound. If the pain involves the bones only, an x-ray is a feasible option but it cannot detect soft tissues, so MRI is used to view biceps tendinopathy. Tendinosis should be assessed with radiological reports and risk factors analyzed by previously conducted physiological examinations should be combined to make a final diagnosis.
Other Diagnostic Procedures for biceps tendonitis
Arthroscopy is the latest diagnostic technique available in advanced healthcare which involves an incision in the joint area to check the condition of the tendons, muscles, and bones. The arthroscopic technique is the most successful way of making the right diagnosis when it comes to biceps tenodesis and other tendinopathies. (7)
The American Academy of Orthopaedic Surgeons has defined the diagnostic criteria based on tendon sheath swelling and tendon sheath fluid accumulation
Treatment for biceps tendonitis
Biceps tendon rupture, biceps tendon tears, tendonitis, and all other tendinopathies can be resolved by either surgical or non-surgical procedures.
LHB-related tendinopathy needs physical therapy for treatment, a non-surgical, non-medicated option highly used in sports medicine. The goal is to relieve pain slowly and make amends for the limited range of motion due to the condition. The physical therapy is initiated by unloading and reloading the tendon. The therapy is also regarded as tendinopathy rehabilitation. The activities include strengthening exercises, stretching of the muscles, and also other modalities like iontophoresis, friction massage, hyperthermia, and laser therapies.
The therapy focuses on extending the movement possibility by ameliorating pain, easing mobilization, and redeveloping the scapulothoracic rhythm. The exercises are increased gradually so overhead motion and strenuous exercises should be avoided in the beginning.
The first option for pain management is always paracetamol. It works if the pain only occurs during the flexion of the muscles. However, as this condition involves inflammation of the tendons, the use of nonsteroidal anti-inflammatory drugs becomes mandatory. Ibuprofen is the safest option among NSAIDs with the least possible drug interactions. If the pain persists for a long time, the use of corticosteroids is also an option. Steroid injections are commonly used to treat these types of conditions. It is possible to get a private injection, but only upon the orthopedic expert opinion.
Musculoskeletal issues are sensitive and need to be dealt with with the utmost care when it comes to surgery. Wrong surgical operations can cause damage to the nearby blood vessels and nerves. (8) These surgeries are usually done using arthroscopes. This involves the use of a small camera that is inserted in the affected area by applying an incision. The camera shows the inner condition of the bone, muscle, and tendons or ligaments.
If the tendon is attached to the glenoid already, it has the potential to heal itself. Otherwise, the affected part of the biceps is cut and removed, and the healthy portion of the muscle is reattached to the joint. This is called biceps tenodesis. Another option is tenotomy which is opted if the long head of the bicep is damaged and tenodesis is not possible. This might result in the damaged contour of the muscle but the patient manages to restore the normal strength of the muscle with time.
Nonsurgical treatment also includes therapies like the use of ice and heat packs. These are among the safest treatment options because they do not involve incision or medication. Resting is the best advice because it helps to restore muscular and tendon health. Using ice packs and heat packs helps with the management of pain.
Frequently Asked Questions
- How long does it take biceps tendonitis to heal?
Biceps tendonitis takes as long as six weeks to a few months to heal completely. There are usually no long-term problems or complications and the recovery is easily observed with time.
- How do I know if I have bicep tendonitis?
The diagnosis of bicep tendonitis cannot be confirmed by the patient himself or herself. However, you can suspect the possible condition by assessing pain and tenderness from the anterior portion of the biceps. If the pain exacerbates while lifting objects, there are chances of bicep tendon damage.
- Should you massage bicep tendonitis?
The massage of bicep tendonitis should not be done in the earlier stages of diagnosis. The tendinopathy should be allowed to heal itself till the first few weeks. After three weeks, the professionals suggest that massaging can speed up recovery and help relieve pain.
- Is heat good for bicep tendonitis?
Heat relaxes the muscle, relieves pain, and speeds up the healing and recovery process of the muscle. So, yes using heat is good for chronic bicep tendonitis.
- How should I sleep with bicep tendonitis?
Sleeping on your back is the best way to lie for sleeping if you suffer from bicep tendonitis. In this way, the muscle won’t get compressed and speed up recovery.
- Can I work out with bicep tendonitis?
The initial stages of bicep tendonitis require rest so that the injured muscle and tendon can heal. Later on, working out is a good option so that the muscles get more oxygen and blood supply, making the muscle strong, flexible, and overall healthy.
- Boileau, P., Ahrens, P. M., & Hatzidakis, A. M. (2004). Entrapment of the long head of the biceps tendon: the hourglass biceps—a cause of pain and locking of the shoulder. Journal of Shoulder and Elbow Surgery, 13(3), 249–257. https://doi.org/10.1016/j.jse.2004.01.001
- Hinchey, J. W., Aronowitz, J. G., Sanchez-Sotelo, J., & Morrey, B. F. (2014). Re-rupture rate of primarily repaired distal biceps tendon injuries. Journal of Shoulder and Elbow Surgery, 23(6), 850–854. https://doi.org/10.1016/j.jse.2014.02.006
- Miyamoto, R. G., Elser, F., & Millett, P. J. (2010). Distal Biceps Tendon Injuries. JBJS, 92(11), 2128–2138. https://doi.org/10.2106/JBJS.I.01213
- Friedman, D. J., Dunn, J. C., Higgins, L. D., & Warner, J. J. P. (2008). Proximal Biceps Tendon. Sports Medicine and Arthroscopy Review, 16(3), 162–169. https://doi.org/10.1097/jsa.0b013e318184f549
- Krupp, R. J., Kevern, M. A., Gaines, M. D., Kotara, S., & Singleton, S. B. (2009). Long Head of the Biceps Tendon Pain: Differential Diagnosis and Treatment. Journal of Orthopaedic & Sports Physical Therapy, 39(2), 55–70. https://doi.org/10.2519/jospt.2009.2802
- N. Reiff, S., & J. Nho, S. (2010). A Case Report & Literature Review. https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/039070061e.pdf
- Curtis, A. S., & Snyder, S. J. (1993). Evaluation and Treatment of Biceps Tendon Pathology. Orthopedic Clinics of North America, 24(1), 33–43. https://doi.org/10.1016/S0030-5898(21)00033-X
- Nho, S. J., Reiff, S. N., Verma, N. N., Slabaugh, M. A., Mazzocca, A. D., & Romeo, A. A. (2010). Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery. Journal of Shoulder and Elbow Surgery, 19(5), 764–768. https://doi.org/10.1016/j.jse.2010.01.024