Long biceps tendonitis
Image showing inflammation of the biceps tendon


Bicipital or biceps tendonitis refers to the inflammation of the tendon that connects the upper biceps with the shoulder.

Anatomy of a healthy shoulder showing the biceps tendon relative to the glenoid, rotator cuff and bursa (purple)


Anatomical considerations: The biceps muscle is used to bend (flex) the elbow, rotate the arm (supination) and is important to stabilise the shoulder joint. The proximal end of the biceps muscle is connected to the shoulder by the short head inserting to the coracoid process and the long head, which attaches the biceps to the supraglenoid tubercle and the glenoid labrum. The distal tendon at the elbow is attached to the proximal end of the radius. Tendonitis of the long biceps tendon is caused by a prolonged inflammation of the collagenous tissue forming the tendon. As a result of the inflammation the tendon degenerates and becomes reddish, swollen, weak and more prone to a tear. With its complete rupture, the biceps muscle is deformed and on contraction it produces a bulging swelling above the elbow joint, which is often referred to as “Popeye arm”. This pathology is often found in concomitance with other conditions of the shoulder such as arthritis, instability and impingement, tear of the glenoid labrum and other inflammatory conditions of the joint.

Arm abduction is restricted by the inflamed bursa and tendons, reducing the joint space
Cross section of the shoulder depicting the compression of the bursa (red) above the rotator cuff (white) and below the deltoid muscle


There are various classification systems for a shoulder impingement syndrome.

Stages of subacromial impingement in athletes - Jobe’s Classification

Pure impingement with no instability

Primary instability, with capsular and labral injury with secondary impingement, which can be internal or subacromial impingement

Primary instability due to intrinsic ligament laxity with secondary impingement

Pure instability with no impingement.

Grading of impingement changes - Milgrom’s Ultrasound Classification:

Stage 1 Bursal thickness from 1.5 to 2.0 mm

Stage 2 Bursal thickness over 2.0 mm

Stage 3 Partial or full thickness tear of the rotator cuff.

Impingement lesions - Copeland Levy Classification:

This is based on the location of the impingement, either on the acromial or the bursal side.

Acromial side

A0 normal - smooth surface

A1 minor deterioration, haemorrhage or local inflammation

A2 marked scuffing/damage of the undersurface of the acromion and coraco-acromial ligament

A3 exposed bone areas.

Bursal side

B0 normal - smooth surface

B1 minor deterioration, haemorrhage, inflammation

B2 major deterioration of the cuff, partial thickness tear

B3 full thickness tear of the rotator cuff

B4 massive cuff tear.

Two-part proximal humerus fracture

According to the Habermeyer Classification the fractures to the proximal humerus are divided into:

Type 0 one fractured part without dislocation

Type A two-part fracture of the great tuberosity and lesser tuberosity avulsion

Type B involves the humerus “surgical” neck below the femoral head as two-part, three-part and four-part with one or both tuberosities

Type C involves the humerus anatomical neck (between the head and greater tuberosity) as two-part, three-part and four-part with one or both the greater and lesser tuberosities.

These are defined further as:

One-part fractures are non-displaced fractures or fractures with minimal displacement

Two-part fractures only involve a single segment

Three-part fractures involve two segments

Four-part fractures occur when all humeral segments are involved (see image in pathology section)

The injury severity is proportional to the increasing number of fractures.

Three-part proximal humerus fractures

Heavy weight lifting can cause biceps tendonitis


Inflammation of the long biceps tendon is mostly due to prolonged overuse by repetitive overhead activities. It can also result from a sudden injury caused by an excessive force applied to the biceps tendons whilst lifting or carrying a heavy weight with the upper extremity. Additional factors can contribute to long biceps tendonitis:

Tear of the rotator cuff

Shoulder instability

Joint stiffness especially of the elbow

Lack of, or excessive training

Inadequate warm up

Weakness of the muscles

Tightness of the biceps

Repetitive challenging sport is a risk factor for biceps tendonitis

Risk factors

Men between 20 and 40 years are more often affected by this pathology. Those individuals regularly active in golfing, swimming, tennis, baseball, basketball as well as those involved in heavy weight lifting are at greater risk to develop long biceps tendonitis.

Pain is the common symptom of a biceps tendonitis


The main symptom of long biceps tendonitis is pain in the front of the shoulder and upper arm, which is exacerbated during overhead activity and weight lifting. Frequent is a sensation of pain whilst extending the arm. Occasionally snapping or catching noises can be heard during moving the shoulder.

Palpation of the shoulder area and arm is part of the medical examination


A detailed medical history is recorded to assess past injuries of the shoulder, pre-existing chronic inflammatory conditions, predisposing physical activities and a description of ongoing symptoms. Medical examination includes:

Palpation of the shoulder

Identification of movement restriction

Testing for reduced muscular strength of the biceps

Shoulder instability

X-rays are only performed to exclude other pathologies of the shoulder joint. Ultrasound and MRI are not routinely recommended but are also employed to better visualise the integrity of the biceps tendon


Oral therapy with NSAIDs (non-steroidal antiinflammatory drugs) is recommended to reduce inflammation, pain and swelling of biceps tendonitis

Nonoperative treatment

Conservative treatment is the most common approach to long biceps tendonitis. Rest from those activities causing stress to the tendon and daily applications of ice pads are recommended. Administration of NSAIDs is efficacious to reduce inflammation, swelling and pain. Injection of steroids within the tendon can be done but presents the risk of further weakening the tendon, possibly leading to its rupture.

Normal (L) and frying (R) biceps tendon seen during arthroscopic surgery

Surgical treatment

Different surgical methods are available to treat long biceps tendonitis. The outcome of surgery is usually satisfactory, however in some cases those athletes involved in high demanding sports may need to reduce their activities.

Arthroscopic surgery This surgical approach is performed to determine the status of the tendon and of other components of the shoulder. A debridement can be performed to smoothen the tendon by removing the irregular fibres that have been damaged.

Biceps tenodesis

Biceps Tenodesis Arthroscopic scissors are inserted via a small incision to severe the long head biceps tendon. Once exposed, the tendon is cut and then fixed to the humerus head using a screw.

Biceps tenotomy

Biceps Tenotomy Arthroscopic scissors are inserted via a small incision to the shoulder to cut the long head biceps tendon without reconnection to the bone. Despite being detached the functional impairment of the shoulder is minimal. Following tenotomy, the function of the biceps muscle is maintained by the short head biceps tendon.

Physiotherapy can begin once the inflammation has subsided


Most patients with long biceps tendonitis recover well following a rehabilitation program and are able to return to normal activities after a few weeks or, in more severe cases, after a few months. After surgery, the use of a sling is recommended for up to three weeks to allow for the repair of the tendon. The sling is always kept on during the night and while walking but it can be removed for restricted daily activities (showering, changing of clothes). Following this period of immobilisation, an intensive rehabilitative therapy can begin under the guidance of a physiotherapist. This focuses on reacquiring flexibility of the shoulder and elbow as well as strengthening the biceps muscle. Therapy includes massage, stretching exercises and preparing the patient to a gradual return to strenuous physical work.

Stretching prior to workout is advised to prevent biceps tendonitis


A guided education on physical activities is crucial to prevent the recurrence of long biceps tendonitis. Regular stretching exercise, warm up and avoidance of heavy weights are key elements for maintaining a strong biceps tendon and muscle. Particular care should be taken in the transition from rehabilitation therapy to sport activity.