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Your Shoulder Pain May Be Bicep Tendonitis E-mail
Written by Jeff Behar, MS, MBA   

Bicep Tendonitis

Biceps tendonitis, more properly termed tendinosis, refers to the inflammation, pain, or tenderness in the region of the biceps tendon in the front part of the shoulder or upper arm.

How can bicep tendonitis occur?

Bicep tendonitis results from acute or chronic stress of the rotator cuff tendons. The injury typically occurs from repetitive overhead reaching multidirectional instability, calcifications into the tendon, repetitive weight training and in some cases direct trauma.

Years of shoulder wear and tear can cause the biceps tendon to become inflamed. Examination of the tissues in these cases commonly shows 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. When this occurs individual strands of the tendon become frayed, some break, causing the tendon loses strength; which could also cause the tendon to eventually rupture.

Because the bicep tendon attaches inside the shoulder through a small hole in the rotator cuff bicep tendonitis is usually associated with rotator cuff pathology.

What are the symptoms?

You feel pain when you touch the front of your shoulder or during certain activities, such as throwing.

You feel pain when you move your arm and shoulder, especially when you move your arm forward over shoulder height.

How is it diagnosed?

Rotator cuff/bicep tendinosis is diagnosed by eliciting pain or weakness with stress testing of the rotator cuff muscles.

There are two common tests used for diagnosis of impingement: The Neer’s Test and the Hawkins’ Test.  The Neer's test elicits pain with passive abduction of the shoulder to 180 degrees. The Hawkins' test elicits pain with the shoulder passively flexed to 90 degrees and internally rotated.

How is it treated?

Treatment may include:

  • Rest/Ice to control inflammation.
  • Ice application 20 to 30 minutes every 3 to 4 hours for 2 or 3 days or until the pain goes away
  • Anti-inflammatory medications
  • Cortisone injections
  • Physical therapy/rehabilitation exercises
  • Surgery

Most people if they pay attention to the signs and symptoms of tendonitis and address the problem early will respond to non-surgical therapy.  Surgery may be recommended if the problem doesn't go away after such treatments, chronic conditions or when there are other shoulder problems present. The most common surgery for bicipital tendonitis is acromioplasty, especially when the underlying problem is shoulder impingement (see discussion above). 

Acromioplasty involves removing the front portion of the acromion, the bony ledge formed where the scapula meets the top of the shoulder joint. The purpose behind removing a small portion of the acromion is to create more space between the acromion and the humeral head so that there is less pressure on the soft tissues and the bicep tendon located in between the acromion and humeral head.

Acromioplasty is a relatively simple procedure for a skilled orthopedic surgeon.  It is usually done using an arthroscope. The surgeon will make a small incision in the skin over the shoulder joint; use the arthroscope to locate the deltoid muscle on the outer part of the shoulder. The surgeon will then split the front section of the deltoid so that the acromion is visible. Depending upon condition and style of the surgeon, the surgeon may also detach the deltoid muscle where it connects on the front of the acromion. The surgeon then will remove the bursa sac that lies just under the acromion. Following the removal of the bursa sac the surgeon will use a surgical tool is used to cut a small portion off the front of the acromion to create the required space between the acromion and the humeral head (note the ligament arcing from the acromion to the corocoid process, called the coracoacromial ligament may also be removed).

The surgeon will then use a surgical file to shave the undersurface of the acromion to remove any bone spurs. Then a series of small holes are drilled into the remaining acromion so that the surgeon can reattach the deltoid muscle to the acromion. At this stage the surgeon will also inspect the rotator cuff muscle to see if any tears are present, since a large number of these injuries tend to go hand in hand. If there are no rotator cuff tears the surgeon will attach the free end of the deltoid muscle to the ridge of the acromion using the drill holes made earlier. If upon inspection the biceps tendon is severely degenerated, as was in my case, the surgeon may perform biceps tenodesis. Biceps tenodesis is a method of reattaching the top end of the biceps tendon to a new location when the biceps tendon is severely degenerated or when shoulder reconstruction for other problems is needed.

The most common method of bicep tenodesis used today is called the keyhole technique. It is called this because a small hole, the size of a keyhole is made by the surgeon using a burr in the humerus, which the surgeon used to slide the end the tendon into. The tendon is then pulled down to anchor it in place. Before performing the reattachment, the tendon is prepared by cutting away frayed and degenerated tissue. Once prepared the surgeon rolls the top end of the bicep tendon into a ball, uses sutures to ensure that the ball shape stays that way and after bending the elbow to remove tension from the tendon, pushes the tendon ball into the top part of the keyhole. The surgeon gradually straightens the elbow, and as this is done the tendon ball is pulled into the narrow slot in the lower end of the keyhole, and is set in place. The surgeon completes the procedure by closing the incision with sutures.


Everyone recovers from an injury at a different rate. Like other overuse injuries the length of recovery depends on many factors such as your age, health, severity of the injury, and if you have had a previous injury.

Recovery typically involves controlling pain and inflammation with Ice, rest and anti-inflammatory medicines.

Some surgeons prefer to have their patients start a gentle range-of-motion program soon after surgery; others prefer to start a few days after surgery. Once cleared by the surgeon they should be done every day for the first week post-op, to maintain blood flow and help prevent blood clots. Note: rehabilitation protocol and restrictions may vary based on extent of repair, and other factors, therefore rehabilitation protocol should be discussed with your surgeon.

Physical Therapy

Physical therapy will typically begin 3-4 days after surgery under the direction of the surgeon. It is very important for you to start therapy when recommended and follow the recommended rehabilitative protocols in order to maximize recovery. Graduated physical therapy is vital to proper recovery and to increase muscle strength and range of motion during the recovery process. Physical therapy combined with assigned home exercising/strengthening may be required for approximately six to eight weeks. The first few therapy sessions may involve nothing more than passive range of motion exercises followed by ice and electrical stimulation treatments to help control pain and swelling from the surgery. If you are experiencing muscle spasm and significant pain your therapist may also use massage and other types of hands-on treatments to ease these symptoms.

Once pain and swelling subsides physical therapy will involve gradually increasing the range of motion (ROM) and starting exercises to improve movement in the forearm, elbow, and shoulder. Care should be employed while performing ROM and strengthening exercises and avoid doing too much, too quickly. ROM exercises will most likely include:

  • Passive ROM for elbow flexion and supination (with elbow at 90 degrees)
  • Assisted ROM for elbow extension and pronation (with elbow at 90 degrees)
  • Shoulder ROM as needed based on evaluation, avoiding excessive extension.

During the first few weeks the strengthening program will most likely be limited to:

  • Sub-maximal pain free isometrics for triceps and shoulder musculature
  • Sub-maximal pain free biceps isometrics with forearm in neutral.

After four weeks, rehabilitation protocol typically includes: 

  • Active-assisted ROM elbow flexion
  • Gradual active strengthening exercises to strengthen and stabilize the muscles and joints of the elbow and shoulder. Note: It generally takes three to four months, however, to safely begin doing forceful biceps activity after surgery. 
  • Single plane active ROM elbow flexion, extension, supination, and pronation
  • Progressive resisted exercise program is initiated for elbow flexion, extension, supination, and pronation.

Return to normal activities will be determined by how soon your tendon recovers, not by how many days or weeks it has been since the injury has occurred. You need to stop doing the activities that cause pain until the tendon has healed. If you continue doing activities that cause the tendon pain, your symptoms will return and it will take longer to recover. In general, the longer you have symptoms before you start treatment, the longer it will take to get better. A mild injury may recover within a few weeks, whereas a severe injury may take 6 weeks or longer to recover. Typically, patients may initiate light upper extremity weight training after 12-14 weeks.

Persistent pain and weakness may be a sign of a serious strain of the biceps that may also involve tearing of the attachment of the tendon inside the shoulder joint. Such serious injury may require surgery. If persistent pain and weakness is experienced the injury should be re-evaluated by a surgeon.


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