Biceps Tendinopathy

Updated: Feb 26, 2021
  • Author: Peter G Gonzalez, MD; Chief Editor: Robert H Meier, III, MD  more...
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Practice Essentials

Biceps tendinopathy describes pain and tenderness in the region of the biceps tendon. [1] The biceps musculotendinous junction is particularly susceptible to overuse injuries, especially in individuals performing repetitive lifting activities. [2] This condition is often diagnosed incorrectly and confused with rotator cuff tendinopathy. Biceps tendinopathy is rarely seen in isolation. It coexists with other pathologies of the shoulder, including rotator cuff tears, shoulder instability, and imbalances of the dynamic stabilizers of the shoulder. Among patients with biceps tendinopathy, 95% have "impingement syndrome" as their primary diagnosis. [3]  Plain radiography, ultrasonography, and magnetic resonance imaging (MRI) can aid in injury assessment, while treatment can include rest, ice, compression, and elevation (RICE), as well as, in the subacute stage, soft-tissue therapy.

Symptoms of biceps tendinopathy

The diagnosis of biceps tendinopathy is primarily clinical. [4, 5] Patient history suggests the diagnosis. Characteristics of the condition are as follows:

  • Pain is reported in the region of the anterior shoulder located over the bicipital groove, occasionally radiating down to the elbow
  • The pain is aggravated by activities that require shoulder flexion, forearm supination, and/or elbow flexion
  • Pain is usually exacerbated by the initiation of activity
  • Some patients describe fatigue with shoulder movements
  • The symptoms are alleviated by rest, ice, massage, stretching, and sometimes heat
  • Night pain is not uncommon

Workup in biceps tendinopathy

In patients with biceps tendinopathy, plain radiography may show calcifications in the biceps tendon or demonstrate associated degeneration in the glenohumeral or acromioclavicular joint.

Ultrasonography can be used to assess the dynamic function of the biceps tendon. It is also useful for diagnosing biceps ruptures or instability. [6, 7, 8]

Magnetic resonance imaging (MRI) is performed to rule out shoulder pathology (eg, rotator cuff tear, labral tears, biceps rupture).

Diagnostic local anesthetic infiltration of the region of the bicipital groove may help to clarify the source of nociception, while electromyography (EMG) or nerve conduction studies (NCSs) can be performed to rule out mononeuropathy, brachial plexopathy, and cervical radiculopathy.

Management of biceps tendinopathy

Physical therapy can include rest, ice, compression, and elevation (RICE), while biceps tendinopathy in the subacute stage can be treated with soft-tissue therapy, electrical stimulation and/or ultrasound, application of moist heat, resistive exercises, kinetic chain exercises, and proprioceptive shoulder exercises. Surgery (often, decompression of the musculotendinous structure through tenolysis) is rarely necessary but may be required in refractory cases. [9, 10, 11, 12, 13]

Related Medscape Drugs & Diseases topics:

Bicipital Tendon Injuries

Bicipital Tendonitis

Elbow and Forearm Overuse Injuries

Shoulder Impingement Syndrome



Historically, all disorders of the biceps tendon have been termed biceps tendinitis. Evidence suggests that degenerative changes in the tendon occur without inflammation. [14]  A study by Streit et al supports the idea that inflammation is lacking in biceps tendinopathy. The study involved 26 patients who underwent surgery for anterior shoulder pain localized to the bicipital groove; histologic analysis of the extra-articular portion of the long head of the biceps tendon and synovial sheath showed chronic inflammation in just two of the patients and acute inflammation in none. Evaluation of the tendon and synovial sheath, however, suggested that a chronic degenerative process might be taking place in the subjects. [15]

In acute cases of biceps tendinopathy, an inflammatory pathology may still be a valid explanation of biceps tendon pain. [14]

Tendinitis describes inflammation of the tendon and the paratendon. This is usually caused by chronic overload, which leads to microscopic tears in the tendon, triggering an inflammatory response. Peritendinitis is the inflammation of the paratendon or tendon sheath. This usually occurs as a result of a direct injury or irritation in which the tendon rubs over a bony prominence; this is referred to as a tenosynovitis. Tendinosis is a histological definition describing degenerative changes in the tendon.

Macroscopic evaluation of a degenerative tendon reveals disorganized tissue that is soft and yellow or brown (mucoid degeneration). [16] The microscopic appearance reveals degenerative changes to collagen with fibrosis. Inflammatory mediators are not usually present in tendinosis. Most injuries of more than 3 months involve only a minimal amount of persistent inflammation, with tendinosis being a greater component of the injury.

A study by Nuelle et al of patients with chronic tendinopathy of the long head of the biceps found that the tendon exhibited no significant structural abnormalities. However, histopathology was significant, being greatest in the tendon’s proximal and middle sections, as measured from the labral insertion and assessed using Bonar scores. [17]

A study by Zabrzyński et al of patients who underwent an arthroscopically assisted biceps tenodesis or tenotomy indicated, based on samples taken from the long head of the biceps tendon, that the degenerative process predominates over the inflammatory process in the pathology of biceps tendinopathy. This does not apply, however, to the early phases of the disease. [18]

Another study by Zabrzyński et al indicated that in patients with chronic tendinopathy of the long head of the biceps, smoking inhibits neovascularization of the tissue. The investigators found that in nonsmokers, former smokers, and current smokers, the neovessel density scores were 2.23/3, 1.60/3, and 1.31/3, respectively. Former smokers in the study smoked for a mean period of 15.50 years, averaging 24 cigarettes/day, while the figures for current smokers were 21.69 years and 15 cigarettes/day. [19]

The term tendinopathy refers to the clinical presentation of a symptomatic tendon. The underlying pathology, degenerative or inflammatory, is not considered in this definition.

Three etiologies of tendinopathy have been described, as follows [16] :

  • Mechanical theory - This theory states that repetitive loading of the tendon results in microscopic degeneration. Fibroplasia occurs within the tendon, resulting in scar tissue.

  • Vascular theory - According to this theory, tendon degeneration occurs as a result of focal areas of vascular compromise.

  • Neural modulation - The newest of the 3 theories, this focuses on the assumption that tendinopathy results from neurally mediated mast cell degranulation and the release of substance P.

More studies are needed to more clearly understand the relationship between the peripheral nervous system and tendinopathies.

Knowing the anatomy of the biceps brachii muscle is important in understanding biceps tendinopathy. The biceps brachii has 2 heads. The short head arises from the tip of the coracoid process of the scapula. The long head arises from the supraglenoid tubercle of the scapula, and the superior labrum runs through the intertubercular groove between the greater and lesser tubercles of the humerus. Proximally, the long head of the biceps acts as a shoulder stabilizer through depression of the humeral head. [20, 21]

The 2 heads join together in the distal arm to form 1 strong tendon, which inserts on the radial tuberosity on the upper end of the radius. Distally, the tendon gives off the bicipital aponeurosis (an expansion that blends with the flexor forearm muscles, extending to the ulna). The biceps brachii is innervated by the musculocutaneous nerve (C5, C6). [22, 23]

The actions of the biceps brachii muscle are flexion of the elbow, supination of the forearm, humeral head depression, and shoulder flexion (short head primarily).

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Biceps tendinopathy is a common condition, but the exact frequency is unknown.