Patient education: Biceps tendinitis or tendinopathy (Beyond the Basics)

OVERVIEW — Tendons are tough bands of tissue that connect muscles to bones. Repetitive activities and overuse can injure tendons, leading to pain and impaired function. This is called tendinopathy. Some people call this condition biceps tendinitis, although the more correct term is tendinopathy because most people do not have inflammation ("-pathy" means pain, "-itis" means inflammation).

Although the most common cause of tendinopathy is wear and tear over time, overuse can cause sudden swelling and tendinitis. It can also be caused by other conditions, including rheumatic diseases.

Tendinopathy is a common problem. The risk of developing tendinopathy increases with age and is higher in people who routinely perform activities that require repetitive overhead activities in work or sport. Treatment focuses on resting the injured tendon to allow healing, using techniques to decrease pain, and exercising to improve muscle strength and tendon stability. In most patients, biceps tendinopathy resolves with treatment.

Tendinitis can affect many different tendons in the body. Other forms of tendinitis are discussed separately. (See "Patient education: Rotator cuff tendinitis and tear (Beyond the Basics)" and "Patient education: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)".)

WHAT IS BICEPS TENDINOPATHY? — The biceps muscle is located in the front of the upper arm, and is used when lifting, bending the elbow, and reaching up over the head. The upper portion of the biceps muscle attaches to the front of the shoulder in two places, and the lower portion attaches to a bone in the forearm (figure 1). Lifting, pulling, reaching, or throwing repeatedly can lead to biceps tendinopathy or even tears of the upper biceps tendon.

BICEPS TENDINOPATHY SYMPTOMS — Patients with biceps tendinopathy typically have pain in the front of the shoulder that worsens at night. Pain may increase with lifting, pulling, or repetitive overhead reaching. Symptoms usually develop slowly over time with tendinopathy, although they may begin all of a sudden in people with tendinitis or biceps rupture.

If a proximal biceps tendon ruptures, the person will feel sudden pain, a pop, bruising, and swelling. It may be possible to feel or see a lump in the lower biceps muscle. Shoulder pain is sometimes completely relieved after the rupture occurs. Surprisingly, a proximal biceps tendon rupture causes only about a 25 percent decrease in muscle strength.

BICEPS TENDINOPATHY DIAGNOSIS — Biceps tendinopathy is usually diagnosed based upon a person's history and a physical examination.

During the physical examination, the clinician assesses the person's pain while moving the affected arm through a series of movements. X-rays are not usually helpful in confirming biceps tendinopathy or rupture, but may be recommended to help evaluate factors that led to the condition or rule out other problems.

An ultrasound examination can help to confirm the diagnosis of biceps tendon injury. MRI (magnetic resonance imaging) can provide detailed images of the biceps tendon, although it is expensive and not usually necessary.

BICEPS TENDINOPATHY TREATMENT — Treatment of biceps tendinitis focuses on reducing inflammation and swelling, strengthening, and preventing tendon rupture. Surgery is not usually necessary.

Initial treatment — Initial treatment of biceps tendinitis includes:

●A nonsteroidal antiinflammatory drug (NSAID), such as ibuprofen (eg, Advil, Motrin) or naproxen (eg, Aleve) is often recommended for five to seven days. (See "Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)".)

●Limit lifting and reaching until symptoms improve. It is safest to use the following strategies:

•Keep the arm down in front of and close to the body.

•Lift objects close to the body.

•Only lift light weights below shoulder level.

•Do sidestroke or breaststroke when swimming.

•Throw balls underhand or sidearm.

•Do not overhand serve in tennis.

•Avoid rapid, ballistic movements such as shoveling.

●An NSAID gel or patch may be recommended for pain. These are applied to the skin.

●Apply ice for 15 to 20 minutes each hour as needed to reduce pain and swelling.

Physical therapy — If symptoms do not improve, a course of physical therapy may be recommended. This usually includes stretching and strengthening exercises, and may include massage or ultrasound treatments. The exercises are intended to help keep the muscles, joints, and tendons mobile and flexible.

Pendulum stretch — The pendulum stretch may be performed for five to ten minutes a day during the first few weeks of recovery.

Range of motion/flexibility exercises should not cause more than a mild level of pain; patients who feel sharp or tearing pain while stretching should stop exercising immediately and consult with their healthcare provider.

This exercise should be performed after heating the shoulder with a warm pack or in the shower for five minutes, once or twice per day.

The exercise is performed as follows (picture 1):

●Relax your shoulder muscles.

●While standing or sitting, keep your arm vertical and close to your body (bending over too far may pinch the rotator cuff tendons).

●Allow your arm to swing forward to back, then side to side, then in small circles in each direction (no greater than one foot in any direction). Only minimal pain should be felt.

●Stretch the arm only initially. Gradually increasing the diameter of the movements until you feel discomfort (not to exceed 18 to 24 inches or 45 to 60 cm).

●After a few weeks this exercise should be supplemented or replaced by other exercises to target specific areas of tightness/restriction. The pendulum stretch may be recommended as a warm up for more localized flexibility exercises and/or strengthening exercises.

When performed correctly, the pendulum exercise should not cause more than mild discomfort. If more pain is felt, consult a healthcare provider.

Strengthening — Strengthening exercises are introduced once pain is minimal or absent. Exercises such as the "Thrower's 10 Program" simultaneously strengthens the biceps tendon and supporting musculature, thereby reducing stress on the tendon.

Wall walks — Face a wall, standing close enough that you can touch the wall with your fingertips. Starting with the arms outstretched, parallel to the floor, walk the fingers up and down the wall. Keep your shoulders level (do not shrug the shoulders). You should walk your fingers high enough that you begin to feel mild discomfort or aching, but not sharp or severe pain. Continue for up to five minutes. Perform several times per day.

To increase the difficulty, try to walk the fingers higher. Again, you may feel mild discomfort but you should not feel sharp or severe pain.

Injection — If symptoms are severe or persist despite using the above treatments, the clinician may recommend an injection of a steroid into the affected area to reduce inflammation and pain. Following injection, patients are generally prescribed a regimen of rest, ice, acetaminophen (Tylenol) for soreness, and stretching/strengthening exercises.

Other non-surgical treatments — Regenerative injection therapy using platelet-rich plasma or other biologic agents may be considered, although further research of these treatments is needed. Other treatment modalities may include laser therapy, iontophoresis, and dry needling, although these interventions too require further research.

Surgery — Biceps tendinopathy or rupture rarely requires surgery, although it may be considered if a person is young and very active, has severe pain after trying the above treatments, or if there is a cosmetic concern (eg, due to the appearance of a lump in the biceps).

RETURN TO ACTIVITY — When it is possible to move the arm in all directions without pain, it is safe to begin slowly returning to normal activities or sports. If symptoms recur, reduce activities that require repetitive lifting and overhead activity.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Biceps tendinopathy (The Basics)
Patient education: Rotator cuff injury (The Basics)
Patient education: Elbow tendinopathy (tennis and golf elbow) (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Rotator cuff tendinitis and tear (Beyond the Basics)
Patient education: Elbow tendinopathy (tennis and golf elbow) (Beyond the Basics)
Patient education: Nonsteroidal antiinflammatory drugs (NSAIDs) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Biceps tendinopathy and tendon rupture
Evaluation of the adult with shoulder complaints
Musculoskeletal ultrasonography: Clinical applications

The following organizations also provide reliable health information.

●National Library of Medicine

     (https://medlineplus.gov/healthtopics.html)

●American Academy of Orthopaedic Surgeons

     (http://orthoinfo.aaos.org/)

●National Institute of Arthritis and Musculoskeletal and Skin Disease

     (www.niams.nih.gov)

●American College of Rheumatology

     (www.rheumatology.org)

●Arthritis Foundation

     (www.arthritis.org)

[1-4]