Biceps Tendonitis (Bicipital Tendinitis)

**Biceps tendonitis** refers to inflammation, irritation, or degeneration of the **long head of the biceps tendon (LHBT)**. The biceps muscle has two tendons originating at the shoulder: - **Long head**: Originates from the supraglenoid tubercle (top of the shoulder socket) and runs through the bicipital groove — vulnerable to irritation - **Short head**: Originates from the coracoid process — rarely affected **Three Main Types:** **1. Primary Biceps Tendonitis (10% of cases):** - Isolated inflammation of the LHBT - No associated rotator cuff or shoulder pathology - Typically from overuse (overhead sports, repetitive activities) - Younger, active patients **2. Secondary Biceps Tendonitis (90% of cases):** - Associated with [shoulder impingement](/condition/shoulder-impingement-syndrome) or [rotator cuff](/condition/rotator-cuff-tear) pathology - The biceps tendon is irritated by the same processes affecting the rotator cuff - More common in older adults **3. Biceps Tenosynovitis:** - Inflammation of the tendon sheath itself - Often associated with subluxation (slipping) of the tendon out of the bicipital groove **Severity Spectrum:** - **Tendinitis** — acute inflammation - **Tendinosis** — chronic degenerative changes (more common in chronic cases) - **Subluxation/dislocation** — tendon slips out of the bicipital groove - **Partial tear** — fraying or partial disruption - **Complete rupture** — full tear, producing "Popeye deformity"

## Root Causes **Mechanical/Activity-Related:** - **Repetitive overhead activities** — baseball pitching, swimming, tennis serves - **Heavy lifting** — particularly with elbow flexed and forearm supinated - **Sudden increase in shoulder activity** — weekend warriors - **Direct trauma** — falls, collisions **Associated Pathology:** - **[Shoulder impingement](/condition/shoulder-impingement-syndrome)** — most common cause; the same compression that affects rotator cuff also irritates biceps tendon - **[Rotator cuff tears](/condition/rotator-cuff-tear)** — destabilize the biceps tendon, particularly subscapularis tears - **SLAP lesions** — superior labrum tears affect biceps anchor at the top of the glenoid - **Biceps subluxation** — tendon slips out of the bicipital groove (often associated with subscapularis tears) **Anatomic Factors:** - **Shallow bicipital groove** — predisposes to subluxation - **Coracohumeral ligament damage** — disrupts the "pulley" that keeps the biceps in place - **Subscapularis tear** — the subscapularis forms part of the biceps pulley **Risk Factors:** - Overhead athletes (baseball pitchers, swimmers, volleyball players, tennis players) - Manual laborers (painters, electricians, construction workers) - Age 40-60 (peak for degenerative changes) - Smoking — accelerates tendon degeneration - Diabetes — increases tendon vulnerability - Prior shoulder injury or surgery

## Conservative Treatment (First-Line — 70-85% Success) **1. Activity Modification:** - Avoid the specific movements that aggravate symptoms (especially overhead activities and palm-up lifting) for 4-6 weeks - Modify exercise routine — substitute pull movements for pressing temporarily - Sleep position adjustments — avoid arm overhead **2. Physical Therapy:** *Phase 1 (Weeks 1-2): Pain Reduction* - Ice 15-20 minutes after activity - Pain-free range of motion exercises - Pendulum swings - Posterior capsule stretching *Phase 2 (Weeks 3-6): Mobility and Activation* - Rotator cuff strengthening (essential — addresses associated impingement) - Scapular stabilization (rows, scapular squeezes) - Biceps eccentric strengthening — slow lowering with weight - Light isometric biceps activation *Phase 3 (Weeks 6-12): Progressive Loading* - Progressive resistance training - Sport-specific or activity-specific training - Gradual return to overhead activities - Address postural issues (forward head, rounded shoulders) **3. Medications:** - NSAIDs (ibuprofen, naproxen) for 2-4 weeks during acute flares - Topical NSAIDs for localized application - Acetaminophen as adjunct for pain **4. Corticosteroid Injection:** - **Peritendinous injection** (around the tendon, NOT into it) — direct injection into the tendon increases rupture risk - Ultrasound-guided for accuracy - Provides 60-75% short-term relief - Best when combined with physical therapy - Limit to 2-3 injections per year **5. Address Underlying Causes:** - Treat associated [shoulder impingement](/condition/shoulder-impingement-syndrome) - Strengthen rotator cuff - Correct postural and biomechanical issues - Address SLAP lesions if present ## Surgical Treatment (<10% of Cases) **Indications:** - Failed 3-6 months of structured conservative treatment - Persistent severe pain limiting function - Biceps subluxation or instability - Complete or near-complete tendon rupture - Associated SLAP lesion or rotator cuff tear requiring repair **Procedures:** - **Biceps tenotomy**: Cuts the long head of the biceps; tendon retracts but pain resolves; may cause "Popeye deformity" (cosmetic concern) - **Biceps tenodesis**: Cuts the tendon and reattaches it to the humerus, preserving cosmetic appearance and avoiding cramping - **Tenodesis preferred** for younger active patients; tenotomy acceptable for older sedentary patients **Outcomes:** - 80-90% pain relief - Recovery: 4-6 weeks for daily activities, 3-4 months for full return to sport - Tenotomy: 5-15% develop "Popeye deformity"; some develop biceps cramping with use