What is the Biceps Tendon?
A tendon is a flexible and strong cord made up of the protein, collagen, as well as blood vessels and nerves. It connects the muscle to the bone. Tendons allow for the movement of limbs: as muscles contract, they pull on the tendon and accordingly make the bones attached to the other end of the tendon move. Tendons also act as shock absorbers for muscles during activities such as playing sports. However, tendons are not elastic and are susceptible to injuries such as tears when stretched.
The biceps muscle, a muscle located on the upper arm, is attached to two bones, the radius, a bone located in the lower half of the arm, and the scapula, the shoulder bone. The biceps muscle consists of the long head and the short head, both of which are attached to different parts of the clavicle and join together and attach to the radius. A total of three tendons are used for muscle-bone attachment- two are attached to the shoulder (proximal biceps tendons) and one is attached to the radius (distal biceps tendon).
What is Biceps Tendinitis?
Biceps tendinitis is the inflammation of the biceps tendon caused by micro tears of the tendon. These micro tears are caused by repetitive motions such as swinging or throwing, sustaining a sudden large force that exceeds the strength of the tendon. It may also be caused by aging. Biceps tendinitis also refers to the degeneration of the biceps tendon over time, or tendinosis. Tendinosis is most commonly caused by impingement of the biceps tendon by a bone spur on the top edge of the scapula, a lack of fusion between the acromion and acromion bone outgrowths (apophysis), bone spurs, or thickening of the coracoacromial tendon, tissue that connects the acromion to the coracoid process.
Biceps tendinitis can occur at the shoulder or the elbow. Most commonly it occurs at the shoulder in the long head biceps tendon. Inflammation of the biceps tendon within the bicipital groove, is known as primary biceps tendonitis. Once the tendon is inflamed, its increase in size may cause it to rub against the bicipital groove, a groove in the head of the humerus that the tendon passes through, further exacerbating the problem. Patients without primary biceps tendinitis generally have an accompanying rotator cuff tear or a SLAP lesion (tear of the glenohumeral labrum). Early stages of biceps tendinitis include inflammation and swelling. Over time, the tendon will increase in size, and the tendon sheath, or tissue that covers the tendon, may thicken. During the late stages, the tendon may be a dark red color and may tear.
Who is more likely to experience Biceps Tendinitis?
Patients who experience biceps tendinitis are often between ages 18 to 35 and who are involved in sports. Athletes over 35 years-old or nonathletes over 56 years-old may experience acute biceps tendinitis from sudden overuse or tendinosis.
Symptoms of Biceps Tendinitis
Patients with biceps tendinitis complain of shoulder stiffness and/or an aching pain at the front of their shoulder and that moves down or radiates to the hand. Pain may be worse at night, especially if the patient rests on the affected shoulder and may also worsen with repetitively lifting the arm overhead, throwing motions, turning a screwdriver, or pulling or lifting objects. There may be point tenderness over the bicipital groove. If the tendon is unstable, patients may feel or hear a snap when moving the arm. In more extreme cases, if the tendon ruptures or tears, the patient will hear a popping noise as well as feel pain. The front of the shoulder may be bruised and there may be a bulge on the upper arm or bicep called the “Popeye muscle.” Popping, clicking, or latching in the shoulder may be indicative of a SLAP lesion.
How is Biceps Tendonitis Diagnosed:
The physician will look at a shoulder’s range of motion, strength, and for any signs of instability during examination. There are several tests that may be performed to confirm biceps tendonitis:
The Yergason test: the patient places their arm at the side, bending their arm at a ninety degree angle (ninety degrees of elbow flexion). The patient is then asked to turn the arm so that the palm is facing upwards (supination), while the physician holds the arm in place, providing resistance. Pain at the bicipital groove is indicative of biceps tendinitis.
The Neer test: the physician stabilizes the patient’s shoulder with one hand and lifts the patient’s arm above their head while the arm is rotated towards the body (internally rotated). Pain with this movement is indicative of impingement of the tendon.
The Hawkins test: the physician holds the patient's arm in front of the patient, forming a ninety degree angle between the arm and the patient’s torso (forward flexion to ninety degrees), bends the elbow inwards, and rotates the upper arm towards the body (internal rotation). Pain at the bicipital groove indicates biceps tendinitis.
The Speed’s test: the patient holds the arm straight in front of them, aligning the arm with the shoulder to form a straight line (shoulder flexion and elbow extension). The forearm and palm of their hand is facing upwards (supination), and the physician pushes the arm downwards. Pain with performing this test is indicative of impingement of the biceps tendon.
The Anterior Slide test: the patient places both of their hands on their hips. The physician on top of the shoulder and applies an upwards force to the front of the elbow (anterior-superior force) with the other hand . If the physician feels or hears a popping sensation in the acromion or front of the shoulder, it may be indicative of a SLAP lesion.
In addition to these tests, pain relief felt after a steroid injection, performed with the guidance of an ultrasound, to the biceps tendon sheath may also be indicative of tendonitis. Impingement of the biceps tendon can be ruled out with x-rays of the shoulder. Further examination can then be performed with the use of an ultrasound to visualize the biceps tendon. Investigations of accompanying injuries can be done with an MRI or CT scan, and neuropathy (pain due to nerve damage) can be ruled out with electromyography.
How is Biceps Tendonitis Treated?
Biceps tendonitis can be treated conservatively with rest, icing the affected area for 20 minutes, several times a day, attending physical therapy, taking NSAIDs, or with the administration of steroid injections.
If conservative treatment fails after three months of use, surgical treatment may be considered. Surgeries are usually performed using an arthroscope, a small camera that allows the physician to see the inside of a joint and operate with small surgical instruments. In some cases, the tendon can be repaired where it attaches to the glenohumeral joint. This is called a Biceps Tendon Repair. Another surgery that may be performed, in the case of serious tears or ruptures, is a Biceps Tenodesis. The remaining part of the biceps tendon is attached to the bicipital groove using screws or suture anchors. In cases where the biceps is beyond repair and cannot be attached, the physician may remove the tendon entirely in a procedure called a Biceps Tenotomy. A Biceps Tenotomy is recommended for inactive patients 60-years-old and older while a Biceps Tenodesis is recommended for younger patients or those who are active. Possible risks and complications include infections, bleeding, and stiffness. Post-operatively, patients may need to wear a sling for a few weeks and are restricted from participating in certain activities. The patient will then be instructed to do flexibility exercises and will gradually start strengthening exercises.
- Tiwana MS, Charlick M, Varacallo M. Anatomy, Shoulder and Upper Limb, Biceps Muscle. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519538/
- Rothenberg A, Gasbarro G, Chlebeck J, Lin A. The Coracoacromial Ligament: Anatomy, Function, and Clinical Significance. Orthop J Sports Med. 2017;5(4):2325967117703398. Published 2017 Apr 27. doi:10.1177/2325967117703398