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Types of injury
What is biceps tendinitis?
Biceps tendinitis is a painful shoulder condition that typically causes pain at the front and side of the shoulder. It effects people of all the ages, but is common in those that lift weights in the gym and play overhead sports such as tennis. At your first appointment your clinician will carry out an ultrasound scan to assess if your tendon is torn and/or inflamed. Biceps tendinitis often responds well to a course of physiotherapy. If the pain is not improving or waking you at night, an ultrasound guided steroid injection as an adjunct to physiotherapy is an effective treatment package, providing pain relief to allow you to return to full function as quickly as possible.
What are the symptoms of biceps tendinitis?
The symptoms of a biceps tendinitis are:
- Pain at the front of the shoulder
- Pain with moving your arm forwards (flexion) and overhead movements
- Tenderness on the front of the shoulder
If this sounds like your pain, read on…
What other conditions can mimic biceps tendinitis?
If this does not sound like your pain there are other conditions that can mimic the pain of biceps tendinitis such as:
- frozen shoulder
- sub-acromial bursitis
- calcific tendinopathy
- shoulder impingement
- rotator cuff pain.
Biceps tendinitis vs rotator cuff pain
Biceps tendinitis causes significant pain and tenderness at the front of the shoulder whereas rotator cuff pain often causes a more diffuse, widespread pain around the shoulder and travels down the side of the arm. Rotator cuff pain is often associated with more weakness.
The bicep muscle is the large muscle group at the front of the upper arm that many bodybuilders religiously exercise in the gym.
When you contract your bicep muscle your elbow flexes (bends) and supinates (palm of hand turns upwards). The bicep also helps your shoulder muscles to lift your arm forwards.
The bicep muscle consists of 2 heads (the long head and the short head – see image below). Both bicep heads originate as tendons and attach in and around the shoulder joint. The short head of bicep tendon attaches to a bony prominence called the coracoid process. This part of the bicep muscle is very rarely injured and is, therefore, not discussed in this article.
The long head of bicep tendon attaches to a small bony prominence deep inside the shoulder joint called the supraglenoid tubercle and is pivotal in stabilising the shoulder joint. It is commonly injured and is a recognised source of symptoms for people suffering from shoulder pain.
What is the most common symptom of a long head of biceps issue?
The symptoms do vary but essentially a bicep tendon injury can cause pain at the front and the outside of the shoulder or both. The pain can also be referred away from the actual tendon location, down into the arm, the chest and the elbow.
Certain movements of the shoulder will exacerbate the pain, especially movements above shoulder level. Moving the arm forward, out to the side and even reaching behind your back will cause increased pain.
In the gym, a bench press and an overhead press will often aggravate the symptoms. Interestingly a bicep curl is normally pain-free because this exercise works the tendon at the elbow, not the shoulder. If you are getting pain at the elbow when you carry out a biceps curl, you may have injured the distal biceps tendon.
Pain is often worse at night and can even wake you up especially if you lie on it or stretch your arm out. If you do lie on the painful side the symptoms can often be worse with initial movement in the morning.
How does the long head of biceps become injured?
There are many causes of long head of bicep injuries. They vary from lifting too many heavy weights in the gym, to carrying shopping bags home from the supermarket. A bicep injury can also occur if you fall whilst skiing or cycling. It is not uncommon that there is no specific event that precedes the pain and the symptoms arise for no apparent reason.
The onset of pain will also depend on the specific type of long head of bicep problem you have sustained. The different types will be discussed below.
What are the different types of long head of biceps problems?
Long head of bicep tendon pain commonly occurs concurrently with other shoulder issues such as rotator cuff issues such as a tear or tendinopathy. The rotator cuff is a set of deep muscles of the shoulder responsible for stability and rotational movements (Atsushi et al, 2016).
The long head of bicep tendon sits within a groove in the upper arm and is encapsulated within a tendon sheath. A tendon sheath is a layer of tissue around the tendon.
Injuries occur either to the tendon itself or the tendon sheath.
1. Tendon injuries – these occur due to prolonged overuse of the tendon or due to a fall or injury, causing pain and swelling of the tendon. This is known as tendinopathy. More severe cases of tendinopathy can result in a tear of the tendon.
One cause of tendinopathy is when the tendon itself slips out of the bony groove it is designed to sit in. This groove is known as the bicipital groove. This slipping occurs due to an insufficiency in the overlying ligament which is designed to keep the tendon situated in the bony groove. This condition is called long head of biceps subluxation/dislocation.
2. Tenosynovitis – This is inflammation of the tendon sheath (the layer of tissue around the tendon) and can be a very painful condition.
3. Rupture – these injuries are rare in the young sporting population, however, as age increases the likelihood of a long head of bicep tendon rupture increases.
A rupture is when the tendon is torn into two (see image below). Incidents rates are dramatically increased after the age of 50. 96% of all long head of bicep injuries in this population is due to tendon rupture (Carter et al, 1999).
Most clients who have sustained a long head of biceps rupture display a ‘Popeye Sign ‘ in the arm (see below). This makes the diagnosis relatively straight forward.
Surgery is not routinely conducted on long head of bicep ruptures in this population due to poor clinical outcomes. Long head of bicep tendon ruptures is most commonly treated conservatively using physiotherapy and exercise prescription.
How do you diagnose a long head of biceps tendon problem?
Long head of biceps tendon pain is diagnosed through clinical examination and diagnostic ultrasound. A series of clinical tests are used to help diagnose this condition; however, research has shown that many of the clinical tests used to diagnose long head of bicep pathology are not very accurate (Chen et al, 2011).
In simple terms, if you think you may have a biceps issue a doctor, physiotherapist or any other health professional cannot confirm this diagnosis without a diagnostic ultrasound scan or MRI scan
Diagnostic musculoskeletal ultrasound imaging is well documented within the evidence to be as effective as MRI in diagnosing shoulder tendon pathology including long head of biceps issues (Joseph, 2009). Due to the lack of specific clinical tests, the use of diagnostic musculoskeletal ultrasound is critical for gaining a definitive diagnosis.
On your first session we will carry out a clinical assessment and a diagnostic ultrasound scan to make a diagnosis and if appropriate an ultrasound-guided injection. There is no extra charge for the scan. Diagnostic ultrasound can differentiate all types of long head of biceps issues including tendinopathy, a tear, tenosynovitis, subluxation/dislocation and rupture.
How is long head of biceps tendon pain treated?
Most bicep tendon issues can be successfully treated using a progressive strengthening program designed to restore normal movement and increase strength around the shoulder joint. This will incorporate exercises to strengthen the biceps itself, the rotator cuff tendons and the scapula muscles. It will also include advise regards activity modification what to avoid.
If your bicep tendon pain does not subside there are a few further options available to you to help reduce your pain and get you back to full function.
Ultrasound-guided corticosteroid injection
If you have been diagnosed with a long head of biceps issue and the pain is not improving, then you should consider an ultrasound-guided steroid injection. Steroid (also known as corticosteroid)is a strong anti-inflammatory medication, commonly used in sports medicine. The role of a steroid injection is to reduce your pain to allow you to engage in a rehabilitation programme which strengthens the shoulder muscles and enables you to achieve full function. The injection provides a ‘window of opportunity’ to carry out your physiotherapy exercises with less /no pain.
It is involved in shoulder impingement disorders and can be a target for a steroid injection, particularly when asub-acromial bursa injectionhas not provided significant enough pain relief. The long head of biceps tendon is sometimes referred to as the ‘fifth’ rotator cuff and can be involved in rotator cuff type pain. It has been demonstrated to exist in combination with other shoulder pathologies such as rotator cuff disorders and capsulitis (Redondo-Alonso et al, 2014).
The injection reduces the swelling in and/or around the tendon as is appropriate for tendinopathy, tenosynovitis and some partial tears. It is not appropriate for the treatment of a long head of biceps rupture.
A recent systematic review (Eldra et al. 2018) revealed that ultrasound-guided steroid injection for the treatment of long head of bicep tenosynovitis was significantly more accurate, with (90%) of injections successfully targeting the tendon sheath in comparison to “blind’ landmark guided injections (30%). This significant increase in accuracy was shown to be more efficacious with a significant improvement in pain reduction post-injection.
Steroid injectionsfor long head of biceps should be carried out using ultrasound guidance. If you have been diagnosed with a long head of biceps problem and have received an unguided steroid injection which was unsuccessful, it is likely the injections did not reach the target tissue/area. In these cases, a repeat injection underultrasound guidancecan often achieve the required outcome.
Non-operative treatments including corticosteroid injections are effective for the treatment of biceps tendon issues. Zhang et al, 2011, showed that 80% of patients had significant pain relief following injection into biceps tendon sheath using ultrasound guidance. Patients who had an ultrasound-guided injection had a significantly improved result when compared to ‘unguided’ or landmark guided injections.
All clinicians at Complete arehighly specialised physiotherapists, independent prescribers, injection therapists and musculoskeletal sonographers. On your initial assessment, your therapist will be able to formally diagnose your condition using a combination of clinical testing and a diagnostic ultrasound scan. If deemed safe and appropriate your clinician will discuss the provision of an ultrasound-guided injection. There is no need for a GP referral.
If you think you may have a long head of biceps issue or you would like more information regarding this diagnosis or our ultrasound-guided injection service please do not hesitate to contact us. To make an appointment please contact us on0207 4823875or firstname.lastname@example.org.
Other shoulder conditions:
- Acromioclavicular Joint Pain
- Calcific Tendinopathy
- Osteoarthritis GHJ
- Frozen Shoulder
- Rotator Cuff Pain
- SA Bursitis
- Shoulder impingement
- Injection therapy for shoulder pain
- Amy’s story – 51-year-old living in Essex
- Hydrodistension Injection for Frozen Shoulder
- Steroid injections for shoulder pain
ELSER, F., M.D., BRAUN, S., M.D., DEWING, C.B., M.D., GIPHART, J.E., Ph.D. and MILLETT, PETER J.,M.D., M.SC, 2011. Anatomy, Function, Injuries, and Treatment of the Long Head of the Biceps Brachii Tendon.Arthroscopy: The Journal of Arthroscopic and Related Surgery,27(4), pp. 581-592.
MALANIN, D.A., NORKIN, A.I., TREGUBOV, A.S., DEMESHCHENKO, M.V. and CHEREZOV, L.L., 2019. PRP-Therapy for Tendinopathies of Rotator Cuff and Long Head of Biceps.Traumatology and Orthopedics of Russia,25(3), pp. 57-66.
URITA, ATSUSHI,MD, PHD, FUNAKOSHI, TADANAO,MD, PHD, AMANO, TORAJI,MD, PHD, MATSUI, YUICHIRO,MD, PHD, KAWAMURA, DAISUKE,MD, PHD, KAMEDA, YUSUKE,MD, PHD and IWASAKI, NORIMASA,MD, PHD, 2016. Predictive factors of long head of the biceps tendon disorders—the bicipital groove morphology and subscapularis tendon tear.Journal of Shoulder and Elbow Surgery,25(3), pp. 384-389.
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Conservative management of biceps tendinitis consists of rest, ice, oral analgesics, physical therapy, or corticosteroid injections into the biceps tendon sheath. Surgery should be considered if conservative measures fail after three months, or if there is severe damage to the biceps tendon.What are the 2 special tests we use to exam for biceps tendonitis? ›
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).What is long head biceps tenodesis? ›
What is the biceps tenodesis procedure? The biceps tenodesis procedure treats shoulder and biceps muscle pain and weakness that happens when you tear your long head biceps tendon. This tendon is located at the top of your bicep muscle. It's connected to your labrum, which is cartilage that lines your shoulder socket.What does a long head tendon injury feel like? ›
Most cases of a torn long head of biceps tendon present with sudden pain, swelling, and bruising in the upper part of the biceps muscle. Sometimes, the biceps muscle bunches up and looks like a 'popeye' muscle. We avoid operating on these common ruptures because pain and function are not significantly changed.Will my bicep tendonitis ever go away? ›
Proximal biceps tendonitis usually heals well in 6 weeks to a few months and doesn't cause any long-term problems. It's important to rest, stretch, and rehabilitate the arm and shoulder long enough to let it heal fully.Why won't my bicep tendonitis go away? ›
Because it's probably tendinosis. Often, chronic tendonitis (also spelled tendinitis), which lasts more than 6 weeks is really tendinosis (also spelled tendonosis).What exercises should I avoid with bicep tendonitis? ›
If any exercise increases your pain, stop doing it. Avoid overhead lifting while your tendon is healing.What is the bicep squeeze test? ›
As the biceps is squeezed, the muscle belly is drawn away from the underlying humerus, eliciting an anterior bow of the muscle. Lack of forearm supination with this maneuver is considered a positive test, indicating rupture of the biceps brachii tendon or muscle belly.Will a shoulder MRI show bicep tendonitis? ›
There are distinct symptoms of biceps tendinopathy and a few provocative maneuvers can help make the diagnosis. Imaging studies (eg, MRI) can show changes in signal sequence or tears. However, MRI has a low sensitivity and frequently results in missed or misdiagnosed biceps pathology.When is surgery needed for bicep tendonitis? ›
Do I need to have this surgery? Biceps Tendonitis will usually resolve within one year. If the pain persists and is generally not relieved with time or cortisone injections, then a patient may consider surgery since it's likely there are more problems in the shoulder. There is usually no rush on surgery.
You may be able to do easier daily activities in 2 to 3 weeks, as long as you don't use your affected arm. Most people who work at desk jobs can go back to work in 1 to 2 weeks. If you lift, push, or pull at work, you may be able to return in 3 to 4 months.What is the best exercise for the long head of the bicep? ›
Incline Dumbbell Curls
Your long head bicep will be targeted very well with incline bench curls. This position will have your elbows down at your side's behind you, which means your long head will be working from a stretched position. Also, you will be rotating the forearm from a neutral to supinated position.
For people suffering from tendonitis, it can help with pain relief and speed up the recovery process. Since tendonitis can take weeks to heal, using a massage therapy program to both relax and strengthen the inflamed tendon can give the sufferer a better chance of a full and speedy recovery.Can a long head tendon be repaired? ›
Repair. Rarely, the biceps tendon can be repaired where it attaches to the shoulder socket (glenoid). Biceps tenodesis. In some cases, the damaged section of the biceps is removed, and the remaining tendon is reattached to the upper arm bone (humerus).How do I know if my bicep Tenodesis failed? ›
Failed biceps tenodesis is usually recognized with persistent pain in the area of the bicipital groove, often caused by either the mechanical failure of the tenodesis or associated shoulder pathology that is not addressed at the time of the primary surgery.Why is my tendonitis not healing? ›
Tendons require a long time to heal because of their poor blood supply. Continued and repetitive activity puts stress on the tendon and slows down the healing process.Should you stretch bicep tendonitis? ›
With palms down, raise the arm on your injured side, and touch the thumb side of your hand to the wall. Keep your arm straight and turn your body away from your raised arm until your experience a stretching sensation in your bicep. Hold the stretch for 15 seconds, rest, and then complete 2 more repetitions.Is tendonitis a permanent condition? ›
When properly treated, most tendinitis conditions don't result in permanent joint damage or disability.Can you make bicep tendonitis worse? ›
Distal biceps tendonitis is inflammation in the biceps tendon near the elbow. It's usually caused by normal wear and tear but repetitive motion can make it worse.Can stretching make tendonitis worse? ›
The more severe the tendinopathy, the less likely stretching would help. In fact, stretching results in further compression of the tendon at the irritation point, which actually worsens the pain.
Recovery from shoulder biceps tenodesis is a long process. While most patients experience some improvement within four to six months, complete recovery can take as long as a year. Generally, you will need to wear a sling for four to six weeks after surgery.Is it OK to lift weights with tendonitis? ›
If your healthcare provider gives you the OK, start exercising to strengthen the muscles around the sore joint within a day or two. Start with a long warm-up to reduce shock to the tissues. Then try lifting light weights or working with an elastic exercise band. Go easy at first.Why do I keep getting bicep tendonitis? ›
Many jobs and routine chores can cause overuse damage. Sports — particularly those that require repetitive overhead motion, such as swimming, tennis, and baseball — can also put people at risk for biceps tendinitis. Repetitive overhead motion may play a part in other shoulder problems that occur with biceps tendinitis.How do you calm bicep tendonitis? ›
- Rest. Rest is vital to healing tendon injuries. ...
- Nonsteroidal anti-inflammatory drugs (NSAIDs) ...
- Ice. ...
- Physical therapy. ...
- Pendulum stretches. ...
- Wall walks. ...
- Steroid injections. ...
- Non-surgical treatments.
To perform the squeeze test, place a heel of each hand just proximal to the midpoint of the calf, and compress the tibia and fibula by squeezing in an anteromedial to posterolateral direction. A positive test is marked by reproduction of pain in the distal syndesmosis, just above the ankle joint.What indicates a positive squeeze test? ›
The squeeze test compresses the proximal fibula against the tibia to assess the integrity of the bones, interosseus membrane, and syndesmotic ligaments. Pain occurs with fracture or diastasis and is considered positive.How do I know if I tore my bicep tendon? ›
The most common symptom of a bicep tear or strain is a sudden burst of pain in the upper arm near the shoulder. You could also hear a “popping” sound as the tendon tears. Other signs that you may have torn a bicep tendon can include: Weakness in the shoulder.Is bicep tendonitis related to rotator cuff? ›
Rotator cuff tendinitis is also called impingement, bursitis or biceps tendinitis. These are all different names for the same problem. They mean that there is pain and swelling of the cuff tendons and the surrounding bursa. The bursa is a soft sack that contains a small amount of fluid and cushions the joint.How serious is biceps tendonitis? ›
This is a serious injury that causes the muscle to separate from the bone and retract back toward the upper arm. While a person with a torn distal bicep tendon can still use their arm, there will be a loss of strength in motions that require palms-up rotations, like using a screwdriver or other tools.Who can diagnose bicep tendonitis? ›
A doctor will examine your arm and ask questions about the sports you play. Simply touching the bicep tendons can help your doctor diagnose bicep tendonitis. He or she will also observe which arm motions cause pain. If your doctor suspects a tear in any of the tendons, you will need an MRI.
Doctors usually perform surgical tendon repair under general anesthesia, so you are completely asleep during the procedure. The doctor makes small incisions in the skin over the tendon.How long is physical therapy for bicep tendonitis? ›
Biceps tendonitis can be a nagging problem, and it may take a few months to fully clear. Most cases can be treated successfully in about four to six weeks. Your condition may take a bit longer if it is severe, or it may be a distant memory in only a few weeks of treatment.How long can you wait to have bicep surgery? ›
How soon after injury do I need to have it fixed? Ideally you should have your distal biceps rupture repaired within two weeks. This is because a longer delay increases the muscle and tendon retraction and allows dense scarring to from around the ruptured tendon.What should you not do after biceps tenodesis? ›
The sling may be removed for exercises. *IMPORTANT*: Avoid any resistive twisting motions of your wrist and forearm. These include opening jars, using a screwdriver, opening doorknobs, wringing out towels, etc. These motions may put you at risk of injuring your biceps tenodesis.How often does bicep Tenodesis fail? ›
A recent systemic review and meta-analysis found the incidence of proximal failure resulting in Popeye deformity following arthroscopic suprapectoral tenodesis and open subpectoral biceps tenodesis to be as low as 1.7% versus 1.0%, respectively.What are the complications with a bicep Tenodesis? ›
While there are multiple fixation techniques for performing a biceps tenodesis, the complications for each procedure are similar. These include failure or rerupture of the tendon, hematoma, infection, persistent pain, reaction to a fixation device, nerve injury, cosmetic deformity, and fracture.Do you need the long head bicep? ›
One of the important functions of the long head of the biceps is to stabilize the humeral head in the glenoid during powerful elbow flexion and forearm supination by the main muscle. Sacrifice of the intraarticular segment of this tendon in surgical procedures of the shoulder may produce instability and dysfunction.Is short head or long head bicep better? ›
The short head is usually the part of your biceps which helps to make your arm look bigger and fuller. Therefore, if you are trying to put more size on your arms, train your short head. On the outside of your biceps is your long head. This part of your biceps is what helps to create your peak.Do hammer curls work the long head? ›
Hammer curls target the long head of the bicep as well as the brachialis (another muscle in the upper arm) and the brachioradialis (one of the key forearm muscles). The hammer curl is a relatively simple exercise that beginners can quickly master.Is Deep heat good for tendonitis? ›
Heat may be more helpful for chronic tendon pain, often called tendinopathy or tendinosis. Heat can increase blood flow, which may help promote healing of the tendon. Heat also relaxes muscles, which can relieve pain.
To treat tendinitis at home, use rest, ice, compression and elevation. This treatment can help speed recovery and help prevent more problems. Rest. Avoid doing things that increase the pain or swelling.Is compression good for bicep tendonitis? ›
For biceps tendonitis, tears or strains at the elbow, a an elbow brace like the Bionic Elbow can provide support whereas the Trizone Elbow can help provide compression.When is it too late to repair a torn bicep tendon? ›
Surgery to repair the tendon should be performed during the first 2 to 3 weeks after injury. After this time, the tendon and biceps muscle begin to scar and shorten, and it may not be possible to restore arm function with surgery.Do tendon injuries ever fully heal? ›
“Once a tendon is injured, it almost never fully recovers,” says Nelly Andarawis-Puri, Mechanical and Aerospace Engineering. “You're likely more prone to injury forever. Tendons are very soft tissues that regularly transmit very large forces to allow us to achieve basic motion.What does bicep Tenodesis feel like? ›
Bicep tendon tears may come with the following symptoms: Cramps in the bicep after repetitive use. Pain in the affected shoulder and elbow. Quick, sharp pain in the arm, with or without a popping sound.How much does a bicep Tenodesis cost? ›
Purchase an Arthroscopic Biceps Tenodesis today on MDsave. Costs range from $5,891 to $15,525. Those on high deductible health plans or without insurance can save when they buy their procedure upfront through MDsave.How long does it take for bicep tendon to reattach after surgery? ›
How long does it take to recover from biceps tendon surgery? The objective of torn biceps surgery is to reattach the tendon to the bone. Full recovery from biceps tendon surgery can be anywhere from six months to a year.How do you stretch a long head tendon? ›
Gently bend your wrist back so that your fingers point down toward the floor. You may also do this next to a wall and rest your fingers on the wall. For more of a stretch, bend your head to the opposite side of your affected arm. Hold for 15 to 30 seconds.How should I sleep with bicep tendonitis? ›
Bicep Tendonitis causes pain and tenderness at the top of your arm, so your shoulder pain will worsen if you try to sleep on your front or side. To get to sleep with bicep tendonitis, it's best to sleep either on your back, or on the non-affected side – using the sleeping positions above.Why does my long head bicep hurt? ›
Ruptured Long Head of Biceps
A degenerate tendon can rupture causing the muscle to retract down the arm. This can alter the contour of your biceps to give a 'Popeye Sign'. Patients typically describe a sudden tearing and pain, sometimes with bruising tracking down their arm.
Take care of your body: If you aren't sleeping enough, not giving yourself the proper nutrition, or damaging your body with alcohol and stress, there's no chance of growing those impressive bicep muscles. Lifting weights alone is not enough; a better overall health level will always lead to improved gains.