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The biceps muscle is a flexor of the elbow and supinator of the forearm, making it important for lifting and carrying tasks. Tendons are strong connective tissue that join muscle to bone.

The biceps has 3 tendons, 1 of which originates within the shoulder joint and forms the long head of biceps (LHB), another begins at the coracoid process of the scapula and forms the short head of biceps (SHB) and finally a third distal tendon connects onto the radius just below the elbow.


Biceps tendinopathies can occur in all 3 tendons, but are most commonly seen in the LHB or distal biceps tendons. You may hear this referred to as a proximal biceps tendinopathy (LHB), or a distal biceps tendinopathy.

What is a Tendinopathy?

Tendinopathy comes under the umbrella term of “overuse injuries”, and often occurs when load is increased too quickly for a tendon to handle. A healthy tendon is stiff, and responds to increases in load by becoming more stiff. However when increases in load occur too fast, the tendon attempts to deal with this by thickening. 

Early on, load can be adjusted and the tendon will return to its normal state. However, if continually overloaded, the tendon will become weak and subject to potential tears in the long-term.

Biceps tendinopathies often occur when there has been an increase in carrying, lifting or throwing related activities, as this places increased load on the biceps tendons.

Tendinopathies can also occur from general long term use and may be referred to as “wear and tear” injuries. These are normal changes that occur as the collagen fibres in our tendons break down over time, resulting in an increase susceptibility to tendon injury and tears.

Often these injuries occur towards the end of someones career due to extensive use of the biceps throughout their working or sporting life.

Contributing Factors

Increase in Load:

As previously mentioned, increase in load is the primary cause of tendinopathy in the majority of cases. The biceps is most active in tasks that involve rotation of the forearm, bending of the elbow and lifting of the shoulder. Rapidly increasing your participation in tasks that involve these movements can put you at risk of developing a biceps tendinopathy.

Some common situations where someone may increase the use of their biceps include:

  • Beginning a new job that involves heavier and more frequent lifting than previously.
  • Taking up a new sport, specifically throwing sports such as baseball or cricket.

History of Biceps Overuse:

The other main contributing factor to developing a biceps tendinopathy is a history of activities that involve heavy use of the biceps muscle. This might include an occupation that involves lots of heavy, consistent lifting or activities over shoulder height.

It is common for people who work these kind of jobs to develop a biceps tendinopathy towards the end of their career, as the tendon collagen fibres have gradually weakened over an extended period of time.

Past Shoulder Injuries:

A history of shoulder injuries and shoulder pain may increase the chance of developing a biceps tendinopathy. Examples of conditions associated with biceps tendinopathies are:

  • Osteoarthritis of the shoulder.
  • Shoulder dislocation.
  • Subacromial Impingement.
  • Rotator cuff tears.
  • SLAP tears.

Common Symptoms

  • Pain in the front of the shoulder (proximal biceps tendinopathy) OR pain in the front of the elbow (distal biceps tendinopathy).
  • Gradual onset of pain with no obvious acute mechanism.
  • Pain mostly at the beginning of activity and/or after activity.
  • Pain associated with an increase in carrying, lifting or throwing activities.
  • Pain in the morning or at night-time.
  • Pain when completing overhead activities.

Treatment Options

Load Management:

Load management is the cornerstone of tendinopathy treatment. This does not mean that you have to stop doing everything, but reducing the frequency of tasks that cause pain is important in the initial management of biceps tendinopathy.

This might mean having some time off sport, or avoiding lifting and overhead activities for a short period of time. This allows time for the tendon to settle down and heal, as well as providing an opportunity to begin rehabilitation exercises, in order to gradually strengthen the tendon.

Strengthening the Tendon:

Your Physiotherapist will develop a suitable strengthening program in order to improve the capacity of the biceps tendon so that it has the ability to handle more load.

This might initially involve isometric exercises. Isometric exercises have been shown to have pain relieving effects, as well as improving tendon strength. Once pain is not the primary limiting factor, exercises can be progressed.

A combination of isometric, heavy and slow concentric, as well as eccentric exercises has been shown to have the best effect when treating tendinopathy. These exercises encourage the realignment of tendon collagen fibres.

From here, task-specific exercises can be introduced in order to prepare the tendon for the load it may experience during day to day tasks. This can include plyometric activities once other exercises are pain-free.

Treating the Chain:

Treatment may not necessarily be limited to the direct source of the pain. Areas such as the neck, upper back and shoulder blades can often influence pain in the shoulder and biceps. Therefore, treating these areas that are “further up the chain” can provide relief in the affected area.

Heat and Ice:

Ice might be used initially, as it can relieve some pain. However ice should only be used in the acute stages of treatment, whilst inflammation is a primary factor.

It is generally more beneficial to use heat, especially when returning to activity. Applying a heat pack or heat cream to the muscle belly of the affected tendon can help to active the muscle and prepare it for activity.


Massage directly over the tendon is not recommended, and is likely to increase pain. However, massage of the surrounding muscles, and the muscle belly of the affected tendon can be helpful.

Dry Needling:

Similar to massage, it may not be effective to dry needle the tendon. Dry needling of the surrounding muscles and affected muscle belly is useful to offload the tendon and provide symptom relief.


Ultrasound may be helpful when pain levels are too high to complete any strengthening exercises or other treatment options. Once able to complete other treatment options, the use of ultrasound is not as beneficial.


Shockwave might be trialed in more chronic cases of biceps tendinopathy, once more conservative measures have not yielded the expected results.

Shockwave can kick start the healing process and promote collagen fibre realignment, however should be done in conjunction with treatments such as load-management and strengthening and not as a primary treatment.

Returning to Activity

Getting your return to normal activities right is a crucial part of preventing recurrence in biceps tendinopathy. This needs to be done as a graduated return, with pain during activity and the pain following morning being an indication of the level of loading.

The Traffic Light System

During return to activity, it is okay to experience some pain. Using the traffic light system is a good approach to ensuring pain is within manageable limits, and that we are not damaging the tendon further. The traffic light system uses that VAS scale, which is a score of pain on a scale of 0-10, where 0 is no pain at all, and 10 is the worst pain you can imagine.

Pain should be scored using this scale during activity, as well as the following morning.

The traffic light system for tendinopathy works as follows:

  • GREEN LIGHT: Pain scored at less than 3/10
    • Pain less than 3/10 is okay, and activities can be continued at the current load and potentially increased.
  • YELLOW LIGHT: Pain scored from 4/10 to 6/10.
    • Pain in this range means we should take some caution, and load should not be increased any more.
    • As long as pain levels settle back down to less than 3/10 following activity, and the next morning, then it is okay to continue activity at the current level.
    • If pain stays above 4/10 after activity and the following morning, load should be reduced and an appointment with your Physiotherapist to review your symptoms is indicated.
  • RED LIGHT: Pain scored at 7/10 or higher.
    • Pain scored this highly means the load on the tendon is too much.
    • Stop what you are doing and deload the tendon until pain is below 3/10.
    • An appointment with your Physiotherapist is indicated to assess the tendon.

You can use the below pain diary to keep track of this.