Biceps Tendon Injuries and Tendonitis

The biceps muscle goes from the shoulder to the elbow on the front of the upper arm. The muscle has two tendons that attach it to the bones of the shoulder and one tendon that attaches to the bone at the elbow. Bicep tendons can be torn or overused, causing tendonitis.

Biceps Tendon Tears

Biceps tendon tears can happen at either the shoulder or the elbow. Tears can also be partial or complete.

• Partial tears mean that the tendon has not completely been severed.
• Complete tears, also called biceps rupture, means that the tendon has torn away from the bone.

The long head tendon, which attaches to the top of the shoulder socket (glenoid), is more likely to be injured. Because it travels through the shoulder joint to its attachment point in the socket, it is the most vulnerable to tearing. The short head tendon, on the other hand, which attaches to a bump on the shoulder blade called the coracoid process, rarely tears. Because of where the short head tendon is located, many people are still able to use their biceps even after the long head has suffered a complete tear.

Causes of biceps tendon tears

The two main causes of biceps tendon tears are sudden injury or overuse. Injury-related biceps tendon tears can happen to anyone. These types of tears typically occur after falling hard on an outstretched arm or lifting something too heavy. Most cases of biceps tendon tears, however, occur in middle-aged people (usually age 40 to 60) as a result of years of wear and tear on the shoulder (degeneration).

As we age, everyday wear and tear begins to fray the biceps tendon. Eventually, the long head of the biceps weakens and becomes prone to tears. Examination of the tissues within most torn or ruptured biceps tendons commonly show signs of degeneration. Degeneration in a tendon causes a loss of the normal arrangement of the collagen fibers that join together to form the tendon. Some of the individual strands of the tendon become jumbled due to the degeneration, other fibers break, and the tendon loses strength. This is what allows it to tear.

Symptoms of biceps tendon tears

Symptoms of a biceps tendon tear may include:

• Hearing and/or feeling a “snap” in the top of the shoulder at the time of injury
• Immediate, sharp pain in the shoulder or elbow when a tear occurs
• Bruising in the middle of the upper arm down to the elbow
• Difficulty or inability to bend the elbow, lift the shoulder, or turn the arm
• Obvious bulging in the biceps area above the elbow

If you experience any of the above symptoms, you should see your doctor right away so a proper diagnosis can be made with a physical exam. Imaging procedures such as X-ray or MRI may also be needed to determine if the tear is partial or complete. These tests can also show if there are any additional problems that need to be treated.

Treatment & Rehabilitation for Your Biceps

Non-Surgical Treatments

Doctors usually treat a biceps tendon injury without surgery. This is especially true for older, less active individuals who can tolerate the loss of arm strength in their dominant arm, or for those whose injury occurs in the non-dominant arm.

Non-surgical biceps tendon treatments may include a combination of some of the following:

• Icing to control swelling
• Electrical stimulation to ease the pain
• Taking nonsteroidal anti-inflammatory medications (NSAIDs), such as ibuprofen, to reduce pain and swelling.
• Resting, with limited lifting. Some patients may need to wear a sling to help them protect the arm and avoid overuse.  
• Working with a physical or occupational therapist to gain strength and flexibility.

Not having surgery usually only results in a moderate loss of strength. The short head of the biceps is still attached and continues to supply strength to raise the arm up. Flexion of the elbow may be affected, but supination (the motion of twisting the forearm such as when you use a screwdriver) is usually affected more. Not repairing a ruptured biceps reduces supination strength by about 20 percent.

Patients usually need to avoid heavy arm activity and wear a protective sling for three to four weeks. As symptoms ease, a physical or occupational therapist will create a rehabilitation program that will slowly work your arm up to more strength and improved movement. This often involves four to six weeks of therapy.

Surgical Options for Biceps Tendon Injuries

Surgery is reserved for patients who need arm strength, are concerned with cosmetics of the balled up biceps, or who have pain that won't go away.

The goal of surgery is to re-anchor the torn tendon back to the bone. Biceps tenodesis, as well as acromioplasty and direct tenodesis, are two common procedures that allow surgeons to repair the tendon with minimal incisions.

Biceps Tenodesis

Biceps tenodesis is a method of re-attaching the top end of the biceps tendon to a new location. While this is not the most common method of surgery for this condition, tenodesis may be needed when the biceps tendon has severely degenerated or when shoulder reconstruction for other problems is needed.

A common way to do this surgery is called the keyhole technique. The keyhole describes the shape of a small hole made by the surgeon in the humerus. The end of the tendon is slid into the top of the keyhole and pulled down to anchor it in place.

This surgery can be performed using the open method or arthroscopically.

Acromioplasty and Direct Tenodesis

This procedure involves removing the front portion of the acromion, the bony ledge formed where the scapula meets the top of the shoulder joint. By removing a small portion of the acromion, more space is created between the acromion and the humeral head. This takes pressure off the soft tissues in between, including the biceps tendon.

Acromioplasty is usually performed arthroscopically. Arthroscopy is a minimally-invasive procedure allows your doctor to assess the condition of the biceps tendon as well as other structures in the shoulder. Because the arthroscope and surgical instruments are thin, your surgeon can use very small incisions (cuts). If necessary, the acromioplasty can also be performed using the older, open method. The open method requires a larger incision in the skin over the shoulder joint.

Immediately after surgery, you will need to wear a shoulder sling approximately four weeks. Therapy often starts slowly, with gentle range-of-motion exercises along with ice or electrical stimulation to control pain and swelling.

Exercises will increase gradually, with heavier exercises being introduced no earlier than 4 to 6 weeks after surgery. It is still important to avoid doing too much too quickly.

In all, physical therapy may be required for 6 to 8 weeks. Before your sessions end, your physical therapist will teach you a number of ways to avoid future problems.

An SROSM orthopedic specialist will discuss what options are available – both surgical and non-surgical – and which they recommend for your specific situation.

You can learn more about biceps tendon tears by downloading our educational document A Patient’s Guide to Biceps Rupture.

Shoulder Biceps Tendonitis

Biceps tendonitis, also called bicipital tendonitis, is inflammation in the long head (main) tendon that attaches the top of the biceps muscle to the shoulder.

Causes of tendonitis in the biceps

The most common cause of bicep tendonitis is overuse from certain types of work or sports activities. Continuous or repetitive shoulder actions can cause overuse of the biceps tendon. Damaged cells within the tendon don't have time to recuperate. The cells are unable to repair themselves, leading to tendonitis. This is common in sport or work activities that require frequent and repeated use of the arm, especially when the arm motions are performed overhead.

Biceps tendonitis can also happen suddenly from a direct injury, such as a fall onto the top of the shoulder. A torn transverse humeral ligament, the ligament that holds the biceps tendon within the bicipital groove near the top of the humerus, can also lead to biceps tendonitis. If this ligament is torn, the biceps tendon is free to jump or slip out of the groove, eventually causing inflammation and irritation.

Biceps tendonitis sometimes occurs in response to other shoulder problems, including:

• rotator cuff tears
• shoulder impingement
• shoulder instability

Symptoms of Tendonitis in the Biceps

Patients generally report the feeling of a deep ache directly in the front and top of the shoulder. The ache may spread down into the main part of the biceps muscle. Pain is usually made worse with overhead activities. Resting the shoulder generally eases the pain.

The arm may feel weak with attempts to bend the elbow or when twisting the forearm into supination (palm up). A catching or slipping sensation felt near the top of the biceps muscle may suggest a tear of the transverse humeral ligament.

Patients who experience symptoms such as these should schedule an appointment with an orthopedic specialist.  A physical exam is often most helpful in diagnosing biceps tendonitis.

Treatment & Rehabilitation

Non-Surgical Treatment Options for Biceps Tendonitis

Whenever possible, doctors treat biceps tendonitis without surgery. Treatment usually begins by resting the sore shoulder. The sport or activity that led to the problem is avoided. Resting the shoulder relieves pain and calms inflammation.

In addition to rest, your doctor may recommend:

• Over-the-counter, anti-inflammatory medication such as ibuprofen
• Physical or occupational therapy
• Platelet Rich Plasma (PRP) Therapy
• Cortisone steroid injection (this is rare)

With non-surgical treatment, you will need to avoid heavy arm activity for three to four weeks. As the pain goes away, you should be safe to begin doing more normal activities.

You may also need to undergo a rehabilitation program under the supervision of one of our physical therapists. This could involve four to six weeks of therapy.

Surgery for Tendonitis of the Biceps

Patients who are improving with conservative treatments do not typically require surgery. Surgery may be recommended if the problem doesn't go away or when there are other shoulder problems present, such as a torn transverse humeral ligament.

The most common surgery for bicipital tendonitis is acromioplasty, especially when the underlying problem is shoulder impingement. Biceps tenodesis may also be performed in combination with acromioplasty if the biceps tendon has severely degenerated or when shoulder reconstruction for other problems is needed.

Post-Surgery Recovery

After surgery, you will meet with an SROSM physical therapist who will design a rehabilitation plan for you. Exercises start slow and gradually get more challenging over time, focusing on improving movement in the forearm, elbow, and shoulder.

Heavier exercises for the biceps muscle are avoided for two to four weeks after surgery. Your therapist may begin with light isometric strengthening exercises. These exercises work the biceps muscle without straining the healing tendon.

You may require therapy for six to eight weeks. It generally takes three to four months, however, to safely begin doing forceful biceps activity after surgery.

You can learn more about biceps tendonitis by downloading our educational document A Patient’s Guide to Biceps Tendonitis.