Biceps tendinopathy describes damage to the long head of the bicep tendon. This can be due to painful inflammation or degeneration. (1,2) The term “tendinopathy” just states that there is something wrong with the tendon and not the cause. It used to be that the diagnosis would be “tendinitis,” which refers to inflammation or “tendinosis” which refers to degeneration. Usually, inflammation is only present in the acute phase of the injury. Chronic overloading of the tendon can cause microscopic tearing which fails to heal and eventually leads to degenerative changes. (3) These degenerative changes include fibrosis after a few months. (4)
Most people are familiar with the bicep muscle. They don’t know that the biceps brachii attaches to the shoulder with two tendons. That is probably why it was named “bi” like a bicycle. That root word refers to two and, in this case, it is the two tendons of the bicep. The short head connects the medial biceps muscle to the coracoid process of the scapula. (5) The long head travels through the bicipital groove between the greater and lesser tubercles of the humerus. It is held in place by the transverse humeral ligament. Then the tendon goes across the head of the arm bone and between the supraspinatus above and subscapularis below. It then attaches on the supraglenoid tubercle of the scapula and the superior glenoid labrum deep within the shoulder socket. As you can imagine this makes the long head of the bicep more vulnerable to injury. (6) The degenerative changes are most often found just inside where the transverse humeral ligament holds the bicep in place. In 5% of cases the bicep tendon is aggravated within the intertubercular groove. (7)
Causes of bicep tendinopathy
Anyone who has ever shown off their arm muscles knows that the bicep flexes the elbow, what you may not know is that the bicep also supinates the forearm and brings the arm up in front of the body. The long head of the bicep also works to maintain shoulder stability by moving the head of the arm bone down so the rest of the arm can move overhead. (8)
Injury to the bicep tendon is most common in men between the ages of 18 and 35. (9) There is usually a stressful activity that they are engaged in such as throwing, swimming, gymnastics, martial arts, racquet sports, and contact sports. (10)
Often times bicep tendinopathy will be found in conjunction with impingement syndrome. (11) The research shows that 95% of individuals with biceps tendinopathy also have “shoulder impingement.” (12) It can also co-exist with rotator cuff tears, labral tears, and shoulder instability. (13) This can be a vicious cycle because damage to one of these tissue puts extra stress on the surrounding tissues which makes the whole area more vulnerable. (14)
Repetitive activities are a risk factor for the development of biceps tendinopathy. These include shoulder or elbow flexion and overhead activity. Other risk factors are improper lifting technique, shoulder muscle imbalances, poor posture, inflexibility, shoulder joint instability, trauma, and boney abnormalities that narrow the bicipital groove. (15)
Common symptoms of bicep tendinopathy
If you have bicep tendinopathy you will feel a deep throbbing ache over the front of the shoulder where the bicipital groove is located. (16) This pain can be felt midway down the upper arm and sometimes all the way down into the elbow or hand. (17) Repetitive overhead activity and movements that require forearm supination, shoulder flexion, or elbow flexion all will increase pain in the shoulder. (18) Usually, the pain is worse when initiating these movements. (18) Sleep may be difficult because of pain especially when sleeping on that shoulder. (18,19) Mild relief can be achieved with heat, ice, stretching, and massage. (18)
In extreme cases the bicep tendon will rupture. (19) If there is a history of a painful audible pop followed by relief then rupture is likely.
How to evaluate bicep tendinopathy
Since bicep tendinopathy happens in conjunction with other shoulder complaints it can be challenging to diagnose. There will be limited range of motion especially in the motions that are created with the bicep tendon such as forearm supination, elbow flexion, and shoulder flexion. If there is popping, catching, or locking movements during range of motion that indicates a concurrent labral injury. (20) There is tenderness to touch over the bicipital groove. (21,22) If the tendon has ruptured there will be bruising and swelling with a visible bulge (popeye deformity) where the muscle has retracted toward the elbow.
The most sensitive orthopedic tests for bicipital tendinopathy are the Bear Hug, Upper Cut, Belly Press, and Speed’s tests. In the Upper Cut Test you will perform an uppercut motion moving the arm from the waist to the chin level against resistance. If there is pain or popping that indicates an injured bicep tendon. When necessary, an injection of local anesthetic can differentiate between biceps and rotator cuff tendinopathy. (23)
Pain in the bicep tendon can be impacted by adjacent sites of dysfunction along the biomechanical chain. (24) Careful assessment of the neck, upper back, and shoulder blade are important. Look for scapular dyskinesis, upper crossed syndrome, scapular winging, and altered scapulohumeral rhythm. (25)
Diagnostic ultrasound can be a useful imaging technique for the biceps tendon. (26) MRI can be used to identify ruptures of the long head of the biceps tendon.
Upper cervical chiropractic for bicep tendinopathy
Beginning treatment of bicep tendinopathy starts with rest, ice, and activity modification in order to create pain relief. Limit activities that require repetitive overhead activity, elbow flexion, or forearm supination.
Myofascial release and gentle adjustments can be used over the biceps, neck, shoulder, and shoulder blade. These can be used to decrease shoulder pain while improving mobility and function. (27) As pain decreases and mobility improves then gentle stretching can be used. The next phase will encourage stabilization of the shoulder blade through activation of the trapezius and serratus anterior. A functional study of biceps activation by Borms provides a detailed continuum of advanced progressive biceps loading exercises.
If improvement is not noted then ultrasound-guided, local anesthetic injection into the biceps tendon sheath may provide relief. Surgery is not considered for biceps tendinopathy unless three months of other measures have failed. (66) Even then strength losses post-surgery is common.
Exercises to help heal bicep tendinopathy
If bicep tendon injury is a part of your life and you are looking for an answer then I can help. I can help figure out what the cause of the bicep tendon injury is. Use chiropractic adjustments and massage to get you out of pain and teach you the exercises you will need in order to build a resilient shoulder that is immune to pain. If you are ready to try this approach schedule with me today. Still looking for more information? Check out my eBook on Chronic Neck Pain.
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