Biceps Tendinopathy


Biceps tendinopathy is the inflammation of the tendon around the long head of the biceps muscle. Acute biceps tendinopathy may occur because of sudden overuse, especially among athletic patients aged over 35 and any patient aged over 65. For shoulder pain patients, biceps tendinopathy can be one of numerous etiologies and can accompany other pathologies of the shoulder.[1]

Clinically Relevant Anatomy

Biceps brachii is innervated by the musculocutaneus nerve (C5, C6 and C7). It flexes and supinates the forarm as well as flexion at the elbow and shoulder. It also has a very important role in the stabilization of the humerus in the cavitas glenoidalis. The biceps has two proximal attachments:

  • Caput longum: originates from the supraglenoid tubercle of the scapula and crosses over the head of the humerus within the glenohumeral joint cavity, which is the intra-articular portion. The tendon then descends down the humerus via the intertubercular sulcus while encased in a synovial membrane, which is the extra-articular portion. The transverse humeral ligament helps secure the tendon in place by running from the greater to the lesser tubercle, creating a canal-like structure over the intertubercular groove, as well as the biceps pulley or “sling” which is a capsuloligamentous complex composed of the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon. The tendon of the caput longum slides passively on the humeral head during abduction or rotation, in the active state it only contributes for 10% of the power for abduction with the arm in external rotation ( which is a not common movement in ADL).[2][3]
  • Caput breve: The short head of the biceps begins at the tip of the coracoid process of the scapula and is not usually susceptible to tendonitis.

Other structures that lie in close contact with the biceps tendon include the anterior and posterior portions of the glenoid labrum and fibers of the subscapularis and supraspinatus tendons[2]. The long head of the biceps tendon also acts as a stabiliser for the antero-superior portion of the rotator cuff, as well as aiding the rotator cuff in maintaining an intimate relationship between the humeral head and the glenoid fossa[3]. The close articulation of the long head of the biceps tendon to other structures around the glenohumeral joint make it likely to be associated with rotator cuff and labral pathologies.[2]

Mechanism of Injury / Pathological Process

Previous studies have listed the following biomechanical causes for biceps tendinopathy:

  1. Coracoacromial ligament thickening,
  2. Impingement in the supacromial space
  3. Acromial apophysis fusion
  4. has been shown to be associated with rotator cuff tears, particularly those that involve the subscapularis tendon[3]
  5. chronic rotator cuff tears (> 3 months) there most likely will be some degree of macroscopic biceps abnormality.[4]

These pathologies can lead to biceps tendinopathy due to the repeated trauma by overuse and improper biomechanical circumstances movement patterns.[1]

As the long head of the biceps tendon rests encased in its synovial sheath within the intertubercular sulcus of the humerus, the transverse humeral ligament covering this sulcus can rupture, causing it to slide back and forth, leading to a wear and tear effect on the long head of the biceps tendon. Repetitive microtrauma (commonly seen in overhead-throwing or racquet athletes) can also lead to inflammation of the tendon.[1] Complete rupture of the tendon can occasionally occur from a state of chronic inflammation or from a traumatic event (such as forceful elbow movements often associated with weightlifting).[4] Anatomical morphology responsible for a rigid or narrow intertubercular sulcus may also inflame the biceps tendon;[1] however, this correlation has been disputed in the literature.[5

The relationship between intertubercular sulcus integrity and biceps tendinitis has been controversial in the literature. Recent evidence shows that MRI-measured morphology of the intertubercular sulcus is not a significant predictor of either biceps tendinopathy or a rotator cuff pathology[5].[5]

Overall, biceps tendinopathy likely will present with concomitant shoulder pathologies, such as subacromial impingement, rotator cuff tears, instability or tensile injury. The injury cascade of shoulder impingement resulting in rotator cuff injury is a common sequelae that often leads to long head of the biceps tendon involvement.[3]

For shoulder pain patients, biceps tendinopathy can be one of numerous etiologies and canaccompany other pathologies of the shoulder. Previous studies have listed the following biomechanical causes for biceps tendinitis: coracoacromial ligament thickening, impingement beneath the coracoacromial arch by a bone spur, and acromial apophysis infusion.These pathologies can lead to biceps tendinitis because of repeated trauma by overuse and improper biomechanical circumstances. The inflammation process can initially lead to biceps tendon hyperemia and subsequent swelling of the tendon sheath because of interstitial tissue osmolarity that is changed by the release of chemokine. In the end stage of chronic inflammation, scarring and adhesion of the biceps tendon in the bicipital groove can occur.These symptoms can be obstacles to activities of daily living, and correct diagnosis and early treatment of biceps tendinopathy are vital.True distal biceps tendinopathy is rare. More common are partial ruptures. Bourne and Morrey Originally described this entity in their case series of 3 patients with varying duration (1 day to 1 year) of symptoms. All the patients were noted to have partial tendon rupture with surrounding granulation, and scar tissue was noted at the time of surgery. Complete rupture of the distal biceps tendon from its insertion at the radial tuberosity is most common. Safran and Graham reported an overall incidence of 1.2 distal biceps ruptures per 100 000 patients per year. These injuries typically occur in the dominant arm of men between the ages of 40 and 50 years.Risk factors include smoking, anabolic steroid use, and previous distal biceps rupture.Smokers have a 7.5-times greater risk than nonsmokers. While bilateral injuries make up arare subset of patients, Green and colleagues found of an 8% cumulative incidence of bilateral ruptured among patients in their series of 321 consecutive patients. When compared with the 0.0012% incidence in the general population, it was deduced that prior distal biceps tendon rupture is an independent risk factor for subsequent contralateral injury. [5] level of evidence 4The distal biceps tendon is most commonly injured when an eccentric force is applied to the flexed elbow, with patients typically complaining of a sudden, sharp, and painful tearing sensation in the antecubital region. Vanhees M, van Riet R.P. Reconstruction after distal biceps tendon rupture. Journal of Orthopaedics, Trauma and Rehabilitation. 2011;doi:10.1016/j.jotr.2011.07.00) There are two main theories explaining possible predisposition of the distal aspect of the biceps to injury. The first deals with the vascular supply of the distal biceps.Proximally, the biceps brachii receives branches of the brachial artery, but the distal vascular supply comes from the smaller posterior interosseous artery. There is an approximate 2.14 cmzone of avascularity that can predispose the distal biceps tendon to injury. The second theorized predisposition for distal tendon degeneration involves mechanical impingement of the biceps tendon at the proximal radioulnar joint. With the forearm in a fully pronated position, the distance between the lateral border of the ulna and the radial tuberosity is 48%less than the distance with the forearm fully supinated, thus decreasing the available space for the tendon. Also, with the forearm pronated, the biceps tendon occupied on average 85% of the radioulnar space at the level of the tuberosity. While these theories have not been determined to be definite causes of biceps tendon pathology, they are the most widely reported in literature to date. Referentie bij plaatsen

Bicipital tendinopathy may be related to shoulder laxity and instability. Tendinopathy at the proximal end of the biceps may be related to traction overload tendinopathy. The biceps long head acts asa humeral stabilizer as well as a decelerator of elbow extension. When there is increased translation of the humeral head with activities, more stress is placed on the biceps and ligamentous structures. Activities that include repeated shoulder abduction with external rotation such as throwing may result in impingement of the biceps tendon in the bicipital groove beneath eh accordion. Some possibles causes of discomfort that have been observed with ultrasound include synovitis or effusion of the bicipital groove, mineralization of the transverse ligament, subluxing biceps tendon, and cyst of the tendon. Referentie bij plaatsen

Tendinopathy can also affect the triceps and the biceps tendons, although these injuries are much less common than medial and lateral epicondylitis. Tendinopathy at both of these sites can often be treated by rest and avoidance of activities that aggravate the athlete’s symptoms.inflammation of these tendons is often due to overuse and does not cause persistent symptoms. rupture of the bicipital tendon is difficult to diagnose and may often be confused with a strain of the elbow of forearm. the injury commonly presents as an acutely painful condition of the elbow. weakness may be difficult to demonstrate since other intact muscles,such as the brachial, can adequately flex the elbow without an intact biceps. athletes with this injury may have experienced bicipital tendinopathy prior to rupture. this condition may be a precursor to complete rupture. treatment of this injury is surgical. repair should be performed within 7 to 10 days of rupture. appropriate referral to an orthopedic surgeon is necessary.

Inflammation of the biceps tendon within the intertubercular (bicipital) groove is called primary biceps tendinopathy, which occurs in 5 percent of patients with biceps tendinopathy. The 95 percent of patients without primary biceps tendinopathy usually have an accompanying rotator cuff tear or a tear of the superior labrum anterior to posterior, known as a SLAP lesion. Pathology of the biceps tendon is most often found in patients 18 to 35 years of age who are involved in sports, including throwing and contact sports, swimming, gymnastics, and martial arts. These patients often have secondary impingement of the biceps tendon, which may be caused by scapular instability, shoulder ligamentous instability, anterior capsule laxity, or posterior capsule tightness. Secondary impingement may also be caused by soft tissue labral tears or rotator cuff tears that expose the biceps tendon to the coracoacromial arch.[6]

Clinical Presentation/ Characteristics

Patients will typically report an insidious onset of discomfort around the region of the involved tendon.[4] Patients with biceps tendinopathy often complain of a deep, throbbing pain in the anterior shoulder that is intensified when lifting. The pain is usually localised to the bicipital groove and might radiate toward the insertion of the deltoid muscle.[1]

This makes it difficult to distinguish from pain that is secondary to impingement or tendinopathy of the rotator cuff, or cervical spine pathology. Pain from biceps tendinopathy usually worsens at night, especially if the patient sleeps on the affected shoulder.[6] Pain may be aggravated by overhead reaching, pulling, lifting and repetitive activities..[3]

Active elbow flexion may also provoke pain; however, weakness associated with elbow flexion may not be a reliable measure for assessing the presence of biceps tendinopathy, as this motion involves contraction of the short head of the biceps brachii and the brachioradialis muscles.[3]

In cases associated with biceps instability, the patient may complain of an anterior shoulder “clicking” or “popping” sensation that may or may not be associated with throwing motions.[7]

Differential Diagnosis

Differential Diagnosis of Anterior Shoulder Pain:[6]

Diagnostic Procedures

Subjective assessment

Screening of the cervical spine

Objective assessment


Pain with palpation over the bicipital groove is a common physical finding for patients with biceps tendinopathy.[6][3]

Range of movement (ROM)

Testing of cervical, shoulder and elbow AROM should all be completed as well as PROM of shoulder and elbow.

Strength testing

Provocative tests:

If any of these tests is positive, it indicates that impingement is present, which can lead to biceps tendinopathy.

  • Yergasons test: Yergason's test requires the patient to place the arm at his or her side with the elbow flexed at 90 degrees, and supinate against resistance. The test is considered positive if pain is referred to the bicipital groove.
  • Neers test: involves internal rotation of the arm while in the forward flexed position. If the patient experiences pain, it is a positive sign of shoulder impingement syndrome or sub acromial pain syndrome.
  • Hawkins test: the patient flexes the elbow to 90 degrees while the physician elevates the patient's shoulder to 90 degrees and places the forearm in a neutral position. With the arm supported, the humerus is rotated internally. The test is positive if bicipital groove pain is present.
  • Speeds test: the patient tries to flex the shoulder against resistance with the elbow extended and the forearm supinated. A positive test is pain radiating to the bicipital groove..[2](level of evidence 5)[14]( level of evidence E)[1]level of evidence 1B)


To verify that we’re dealing with biceps tendinopathy, there exist different sorts of tests, such as:Comparative palpation of the biceps tendon along the intertubercular groove which is most felt in 10° of internal rotation: can induce tenderness, which is the most consistent finding on physical examination. (therapy-evidence = C) [4](level of evidence 2A) [2](level of evidence 5)

Radiologic imaging:

  • Arthrography
  • Bicipital groove view radiography
  • MRI
  • Radiography
  • Ultrasonography: is a good way to evaluate isolated tendinopathy extra-articulatory, and besides it’s the cheapest method. (US: evidence = C)[1](level of evidence 1B) [2] (Level of evidence 5)

No validated cluster of diagnostic tests is currently available for ruling in or out biceps tendinopathy specifically.[7] Therefore, these tests should be used to help guide the diagnosis. Due to the lack of specificity in differentiating between biceps tendon pathology, subacromial impingement syndromes, and rotator cuff pathology, it is important to take an extensive history upon evaluation and not use these tests solely to make a diagnosis.[2]The patient’s pain can often be elicited through palpation of the long head of the biceps tendon along the intertubercular groove on the anterior portion of the shoulder.[6] The Speed’s test and the Yergason’s test are the main tests for biceps tendinopathy and can be helpful in confirming your diagnosis.[4] Both tests can be used to rule in the presence of a biceps pathology (tendonitis or rupture), SLAP lesion, shoulder impingement or rotator cuff pathology.[7] It is important to remember that although these tests theoretically test the presence of a biceps tendon pathology, this relationship has not yet been examined in the literature.

Table 2: Special testsTest Sensitivity Specificity Speed's 32% 75%Yergason’s 43% 79%

Objective. To investigate the feasibility of grayscale quantitative diagnostic method for biceps tendinitis and determine the cut-off points of a quantitative biceps ultrasound (US) method to diagnose biceps tendinopathy.

The diagnostic criteria for biceps tendinopathy were defined as meeting at least one of the following: (1) tendon sheath swelling (transverse view: for women ≥4.6, for men ≥5.5!mm;longitudinal view: for women ≥2.5, for men ≥2.8!mm, as adopted from Schmidt et al.) and (2)tendon sheath fluid accumulation (abnormal hypoechoic or anechoic accumulation relative to the subdermal fat, although occasionally this could be isoechoic or hyperechoic) in intraarticular material that is displaceable and compressible and ≥3!mm, as adopted from Bruyn etal. In addition to the diagnostic criteria, increased color flow signals were recognized around the swollen biceps tendon as essential to a biceps tendinopathy diagnosis. All the involved with the musculoskeletal US examination reached a consensus on these diagnostic criteria for the purpose of avoiding operator-dependent misdiagnosis.[1] level of evidence 1B

Our technique uses a standard Allis clamp that is easily found in most basic orthopaedic surgical sets and that is included in our shoulder arthroscopy set for this purpose.The patient is placed in the beach-chair position with approximately 45° to 60° of hip flexion.The head is well secured, and the patient is prepared and draped in the standard fashion after initiation of general anesthesia. A 30° arthroscope is inserted into the standard posterior viewing portal, and an anterior portal is established in the rotator interval under direct visualization using a spinal needle to localize the position. Routine diagnostic arthroscopy was then performed. To increase the amount of the LHBT that can be evaluated, an Allis clamp is inserted, with its jaws closed, into the anterior portal without a cannula being present. We Rarely use cannulas during arthroscopy; however, if a cannula is used, it can easily be removed for this quick technique and then reinserted. The Allis clamp is opened while it is in the glenohumeral joint, placed around the LHBT, and then closed again (Fig 1). This causes trauma to the LHBT and allows the clamp to move freely around the tendon. The clamp is then rotated, causing the LHBT to wrap around itself, which brings more of the distal tendon into the joint for inspection (Fig 2). We often find a tendon split or tenosynovitis that was not visible before performing this maneuver, which may change our treatment algorithm. After Inspection is complete, the clamp is simply derotated in the opposite direction, which allows the biceps tendon to retract. The clamp can then be opened, releasing the tendon, and then closed again before removing it from the joint. The LHBT immediately returns to its normal tension and encounters no damage. At this point, the remainder of the planned procedure can be completed, including any tenotomy or tenodesis of the LHBT. The benefit of the Allis Clamp for this purpose is that its jaws are smooth with the exception of the ridges that close at the end, which allows it to avoid causing any iatrogenic damage to the tendon. It can also be locked closed to allow easy entrance into and removal from the joint. It's blunt tip while locked also makes it ideal to insert into the joint without a cannula because it does not entrapany soft tissue during insertion.In the same shoulder as in Fig 1, through the same portals, (A) the Allis clamp is rotated, (B)pulling more of the distal LHBT into the joint for evaluation. The humeral head is marked with an asterisk.[8]

Outcome Measures

Main Outcome Measure(s) of biceps tendinopathy are disabilities of the Arm, Shoulder and Hand (DASH) scoring, range of motion, and clinical and radiographic complications.Of 18 patients in a tertiary practice who underwent distal biceps repair, 12 and 6 underwent acute or chronic repair, respectively. The average durations from injury to surgery were 15.3 (range, 9 to 25) and 50.1 (range, 29 to 75) days for the acute and chronic groups, respectively.

A total of 18 patients met our criteria and were included in the study. All biceps tendon ruptures were diagnosed on physical examination and confirmed on MRI. Twelve patients (67%) were treated acutely (at 4 weeks or less) and 6 (33%) were treated chronically (more than 4 weeks after injury). No differences were noted between groups in age or dominant versus nondominant-side injury. As expected, time from injury to surgery was different between groups. All patients were high-functioning, active males. Acute repair was proposed for all patients; however, the timing of surgery was prolonged in the chronic group due to late presentation in 3 patients and work or personal reasons in 3 patients.

In terms of outcomes, no differences were noted for DASH score or ROM in all planes. No complications occurred in either group. All patients returned to their previous level of activity and employment in similar time frames. No differences were observed in dominant- versus nondominant-side injury[9].

Medical Management

In low-functioning or medically complicated patients, nonoperative measures may be pursued; however, ultimate strength and function will be compromised. Freeman et al reported overall satisfactory outcomes in 18 patients who underwent nonoperative treatment for distal biceps ruptures at 38 months of follow-up. A decrease in elbow flexion (88%) and supination (74%) strength was found when compared to the contralateral side. The decrease in supination strength was significant when compared with historical controls, but the difference in elbow flexion strength was not.Surgical repair of distal biceps ruptures results in improved strength and function. Frazier et al reported a case series of 17 patients with unilateral partial biceps tendon ruptures. The average isometric and dynamic elbow flexion was comparable to the contralateral side. There was minimal decrease of isometric (6%) and dynamic (10%) supination with 1 partial rupture at 4 years. Patients with acute distal biceps tendon ruptures should undergo surgical repair within 1 month of injury. Delay increases the technical difficulty of the repair secondary to scar formation and tendon retraction. Partial biceps tendon ruptures can be initially treated with activity modification and physical therapy for 3 to 6 months. If conservative measures fail, surgical repair should be considered.Surgical options include both single-incision and 2-incision techniques. Several methods of fixation have been used to anchor the distal biceps tendon to the radial tuberosity, including transosseous bone tunnels, suture anchors, interference screws, and the EndoButton. Chavanet al compared surgical techniques as well as methods of fixation in their systematic review of the literature. They reported that biomechanical data suggest superiority of EndoButton fixation and better results with use of a single-incision technique. The 2-incision technique was associated with significant loss of forearm motion and high rates of patient dissatisfaction(31%).[10] Surgery should be considered if conservative measures fail after three months. Structures causing primary and secondary impingement may be removed, and the biceps tendon may be repaired if necessary. [2] (level of evidence 2A)

Physical Therapy Management

The treatment modalities have mainly been aimed at controlling this inflammation. The mainstays of treatment have included rest, nonsteroidal anti inflammatory medications (NSAIDs), and periodic local corticosteroid injections.Physical therapy has been commonly used for the treatment of tendinopathies, especially eccentric training. There is, however, mixed data to support its use. The type of therapy used can be quite variable from one therapist to the next, and orthopaedic surgeons are often not involved in choosing the type of therapy used. Stretching and strengthening programs are a common component of most therapy programs. Therapists also use other modalities, including ultrasound, iontophoresis, deep transverse friction massage, low-level laser therapy, and hyperthermia.[11] [11] level of evidence 2A

The physical therapist must consider both the patient's subjective response to injury and the physiological mechanisms of tissue healing; both are essential in relation to a patients return to optimal performance.As a preface to discussion of the goals of treatment during injury rehabilitation, two points must be made.First, healing tissue must not be overstressed. During tissue healing, controlled therapeutic stress is necessary to optimize collagen matrix formation, but too much stress can damage new structures and slow the patient’s rehabilitation.Second, the patient must meet specific objectives to progress from one phase of healing to the next. These objectives may depend on ROM, strength, or activity. It is the responsibility of the physical therapist to establish these guidelines.[12] level of evidence 5 (boek)

The Guide provides two main practice patterns that biceps tendinopathy may fall under:

  • Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
  • Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation

Patients should apply ice to the affected area for 10-15 minutes, 2-3 times per day for the first 48 hours. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are used for 3-4 weeks to treat inflammation and pain. The degree of immobilization depends upon the degree of the injury and the patient's discomfort. Most authors agree that prolonged immobilization tends to result in a stiff shoulder.[13] level of evidence 5

Physical therapy intervention should include restoring a pain free range of motion, trunk and core stability, as well as ensuring proper scapulothoracic rhythm.[12] Pain free range can be achieved with such activities as PROM, Active-Assisted Range of Motion (AAROM), and mobilization.[12] Painful activities such as abduction and overhead activities should be avoided in the early stages of recovery as it can exacerbate symptoms.[12] Once a pain free range of motion is achieve, a strengthening program should begin with emphasis on the scapular stabilizers, rotator cuff and biceps tendon[12]. For more chronic presentations, corticosteroid injections along the tendon sheath may be indicated.[4] Surgical management of biceps tendinitis includes removing the long head of the biceps tendon via arthroscopic tenodesis. Research has shown this to provide sufficient reductions in pain levels while maintaining normal biceps function.[6]

Key Evidence

Differential Diagnosis & Management/Interventions:

- Krupp JK, Kevern MA, Gaines MD, Kotara S, Singleton SB. Long head of the biceps tendon pain: differential diagnosis and treatment. J Orthop Sports Phys Ther. 2009;39:55-70.- Diagnosis and Treatment of Biceps Tendinitis and Tendinosis. CATHERINE A. CHURGAY, MD, St. Luke's Hospital/The University of Toledo, Family Medicine Residency Program, Toledo, Ohio. Am Fam Physician. 2009 Sep 1;80(5):470-476.- Quantitative Diagnostic Method for Biceps Long Head Tendinitis by Using Ultrasound; Shih-Wei Huang and Wei-Te Wang; ScientificWorldJournal. 2013; 2013: 948323.- The long head of biceps and associated tendinopathy; The journal of bone and joint surgery; P.M. Athrens et Al.; 2007;89-B:1001-9


Biceps rehab protocol

Clinical Bottom Line

Biceps tendinopathy is an inflammation that can be caused by a normal aging process as well by a degenerative process which usually occurs in overhead athletes. It is important to know, that this inflammation has many different causes and is frequent accompanied by many other shoulder pathologies such as: SLAP-lesions, rotator-cuff tears, instability, … The patient himself will primarily experience pain localized in the bicipital groove and may radiate toward the insertion of the deltoid muscle, or down to the hand in radial distribution. That’s why pull, push and overhand motions will be more difficult to carry out. The best way to diagnose biceps tendinopathy, is by comparative palpation of the biceps tendon along the intertubercular groove, or otherwise by doing a ultrasonography ( extra-articulair). The treatment consists of a conservative or surgical treatment. Surgery should be considered if conservative measures fail after three months. Structures causing primary and secondary impingement may be removed, and the biceps tendon may be repaired if necessary.

Recent Related Research (from Pubmed)

- Single injection of platelet-rich plasma (PRP) for the treatment of refractory distal biceps tendonitis: long-term results of a prospective multicenter cohort study.- A. Nuri et Al.; Superior labrum anterior to posterior lesions of the shoulder: Diagnosis and arthroscopic management; World J Orthop; 2014 July 18; 5(3): 344-350.(


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