Are you struggling with pain in the front of your shoulder, often referred to as biceps tenidinitis or tendinopathy? Check out this blog to learn what to do!
Be sure to also check out our Shoulder Resilience Program!
Biceps Anatomy & Function
The biceps brachii consists of two heads – a short head and a long head. The short head (green) originates at the coracoid process of the scapula, or shoulder blade, while the long head (red) originates at the supraglenoid tubercle of the shoulder blade. These two heads come together to attach to the radial tuberosity of the forearm.
Since the biceps brachii crosses the elbow and the shoulder, it is expected to have actions at both joints. At the elbow and forearm, the biceps brachii contributes to flexion (bending the elbow) and supination (turning the palm up toward the ceiling).
Surprisingly, even in 2024, the exact function of the biceps brachii at the shoulder remains controversial. It likely plays a small role in shoulder flexion, but only when the shoulder is extended and up to about 30 degrees of shoulder flexion.
It may also act as a secondary stabilizer of the shoulder due to the path and attachment of the long head of the biceps tendon. Elser 2011, Giphart 2012, Cools 2014, Borms 2017, Diplock 2023
Biceps Tendinopathy
Pain in the front of the shoulder is often attributed to the long head of the biceps tendon based on its location. This biceps tendon pain is typically called biceps tendonitis, but inflammation is likely not the primary driver of symptoms.
For example, a paper by Streit et al in 2015 states the following: “Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases.” Therefore, biceps tendinopathy is the preferred terminology, which just refers to pain and impaired function secondary to gradual overload of the tendon.
Despite this information, it is difficult to isolate the long head of the biceps tendon as the sole culprit of anterior shoulder pain for 2 main reasons:
- Research demonstrates that clinical examination procedures, such as palpation and special tests, are not reliable for accurately diagnosing the condition. Gill 2007, Gazzillo 2011, Hegedus 2012
- Research using imaging, such as MRIs, overwhelmingly demonstrates that biceps tendon issues rarely happen in isolation. For instance, simultaneous rotator cuff pathology is common. Murthi 2000, Beall 2003, Kim 2003, Gill 2007, Lafosse 2007, Chen 2012, Redondo-Alonso 2014, Choi 2015, Godenèche 2017
So who is this blog for?
As long as symptoms aren’t related to frozen shoulder, osteoarthritis, or another condition that may require specific medical management, this blog is for individuals with non-traumatic pain in the front of their shoulder that is worsened with loading of the long head of the biceps tendon.
Examples usually include activities and exercises that stretch and load the tendon, such as reaching behind your back, the bottom of a bench press, triceps dips, pec flies, and even barbell back squats.
Load Management and Activity Modifications (Recommended)
The management of biceps tendinopathy is a simple, 2-step process. Simple, but not necessarily easy.
Step 1 involves modifying aggravating exercises and activities to calm symptoms down, especially early on when things may be more irritable or severe.
When it comes to tendon rehab, there are 4 main variables you want to adjust:
- Volume, which is the total amount of work you’re doing in a given day, week, or month.
- Range of Motion, to minimize or avoid provocative positions, such as end range shoulder extension.
- Speed, as quicker movements tend to load tendons more. Plus, slower movements allow for better control and feedback.
- Intensity, which is alluding to how heavy or hard something is.
When it comes to gym exercises, pressing movements are generally the most problematic.
For a barbell bench press or a flat dumbbell press, you can consciously reduce the range of motion, use a physical block to reduce the range of motion, or do something like a floor press.
Alternatively, you might swap the movement out for a push-up and modify that range of motion as needed.
Triceps dips and regular dips can be aggravating, especially for new trainees, because they require more shoulder extension range of motion than we typically use in our day-to-day lives.
Dumbbell flyes, cable flyes, and pec machines may also need to be modified.
If overhead pressing with a barbell is an issue, you probably don’t want to bring the bar all the way down to your shoulders.
You can also swap out the exercise for a dumbbell overhead press with your arms further out in front of you, so you don’t have to use as much shoulder range of motion.
For any pressing exercises, you should obviously decrease the weight as needed.
I also mentioned that slowing exercises down can be helpful. You can try a slow tempo, particularly during the eccentric portion of an exercise, or use pauses at the bottom of a movement.
Changes to your technique can be useful for pulling movements as well. If you’re doing a dumbbell row, focus on engaging your back and shoulder blade and stopping the movement when your arm is in line with your trunk.
If pull-ups are an issue, try chin-ups or use a neutral grip.
Barbell back squats may also need to be modified. You can use a wider grip, a thumbless grip where your thumbs aren’t wrapped around the bar, or choose a different leg exercise altogether.
Once again, the idea is that you’re minimizing the time spent in these aggravating positions and modifying your volume and intensity, so that you can recover and adapt from your training appropriately.
All of this information applies to throwing, reaching behind your back, daily chores, and any other movements that may be irritating your shoulder.
In some cases, you will have to temporarily stop performing an activity altogether in order to move forward in your rehab.
Once you’ve managed to calm your symptoms down to a reasonable level, step 2 is pretty basic – it requires gradually progressing back to your normal function over time. If you had to modify any of the variables that I mentioned above, you just slowly reintroduce them into your routine and make adjustments if you have any flare-ups along the way.
Regain your range of motion first and then add intensity, volume, and speed as needed.
That’s it.
It’s not a perfect science and ups and downs will happen, but many people could end the blog right here and be okay if they just apply these principles.
Shoulder Exercises (Optional)
Since biceps tendinopathy rarely happens in isolation and the long head of the biceps tendon may act as a secondary stabilizer of the shoulder, you can try to strengthen the surrounding muscles for additional support.
One category of exercises that can be performed involves shoulder external rotation strengthening, which is often associated with the rotator cuff. Examples include side lying external rotation, standing external rotation with a cable or band, and external rotation with your elbow on your knee.
Pick one option to perform slowly within tolerable symptoms for 2-3 sets of 10-15 repetitions, 2-3 times per week.
External rotation strengthening can also be done isometrically by just pulling a band apart and holding this position for 30-45 seconds. Your arms can be at your side, at shoulder height, or you can move back and forth between the two.
The second category is posterior shoulder strengthening in the form of As, Ts, and Ys, with or without resistance. These can be done isometrically on the floor or through a full range of motion on an elevated surface.
Once again, pick one for 2-3 sets of 10-15 repetitions or 30-45 second holds, 2-3 times per week.
Since most of these exercises shouldn’t load the biceps tendon much, they can likely be performed at the same time that you’re modifying aggravating activities.
Biceps Exercises (Optional)
On the other hand, exercises that purposely load the biceps tendon should only be performed when symptoms are at a much more reasonable level, and only if they are necessary for your goals.
For elbow flexion, you’ll want to start with your shoulder in a flexed position, preferably supported. Two examples are preacher curls and one arm dumbbell curls over an incline bench.
Spider curls are another option, but they are unsupported.
From there, you’d progress to curls with your arms down by your side.
The last options would involve curls with your shoulders extended, such as dumbbell curls while seated on an incline bench or cable curls.
For shoulder flexion, the emphasis should be on the stretched position of the long head of the biceps tendon, starting with a light load. These front raises can also be done while seated on an incline bench with dumbbells or while standing with cables.
For any of these movements, 2-3 sets of 8-15 repetitions, 2-3 times per week is a safe starting point.
Keep them slow and controlled, tolerable, and work on very gradual progressions over several months.
Proper rehab and long-term changes take time and consistency.
Do you want a structured plan that’s going to provide you with the knowledge and tools to feel more confident, capable, and resilient than ever before?
Check out our Shoulder Resilience Program!
Want to learn more? Check out some of our other similar blogs:
SLAP Tear Rehab, The TRUTH About Shoulder Impingement, How To Improve Your Shoulder Range of Motion
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