Co-Authored by John D. Idoine III, D.O. and Yousef Shishani, MD
Shoulder pain from an injury to the long head of the biceps tendon (LHBT) is a common condition that affects many competitive athletes each season. Athletes who engage in sports with repetitive overhead motion—like swimming, volleyball, tennis and baseball—are at a high risk, because the overhead motion places a significant amount of stress on the shoulder. Although overhead athletes are at an elevated risk, all competitive athletes are susceptible to biceps injuries.
Biceps tendon injuries often result from physical contact, repetitive drills during training and overuse during weightlifting. When left untreated, chronic biceps tendonitis can lead to degeneration and tearing, which may require surgery to restore function and alleviate pain.
The anatomy of the LHBT is complex, as illustrated in Figures 1 and 2. The tendon originates from a tubercle on the superior glenoid and meets with the superior labrum. The labrum is a rim of strong fibrous tissue that surrounds the bony glenoid, which increases the depth of the socket and provides stability to the joint.
Injury to the biceps tendon at its origin results in a very specific type of labral tear known as a SLAP (Superior Labrum from Anterior to Posterior) tear. Figure 3 illustrates a SLAP tear, which often affects competitive athletes, especially pitchers.
As we move distally from the origin of the LHBT, a portion of the tendon is found within the shoulder joint. The tendon passes obliquely over the humeral head before turning sharply to exit the joint beneath the transverse ligament. In order to have pain-free range of motion, the intra-articular portion of the tendon must be able to slide freely back and forth within the bicipital groove. During certain ranges of motion, like forward flexion and internal rotation, tendon excursion within the bicipital groove is nearly two centimeters. This piston-like motion beneath the transverse ligament can irritate the tendon over time, causing a painful inflammatory condition called biceps tendonitis.
Athletes who try to "work through the pain" often exacerbate a simple case of biceps tendonitis, because repetitive athletic motion—especially overhead—can lead to further tendon irritation and more severe injury. Chronic tendonitis causes the tendon to swell and lose its uniform cylindrical shape, which prevents it from sliding smoothly within the bicipital groove, further increasing irritation. Repetitive arm rotation can twist the tendon like a wet dishrag, which may cause the tendon to fray, tear and rupture over time as shown in Figure 4.
In cases of severe biceps tendonitis, the transverse ligament—which retains the tendon within the bicipital groove—can become compromised, resulting in a painful condition known as biceps instability. Patients with biceps instability often report sharp pain and an audible snap with arm rotation, as the tendon dislocates from and then relocates within the bicipital groove.
Patients suffering from a biceps injury often complain of a dull, aching type of shoulder pain. Early symptoms include pain that radiates from the front of the shoulder to the side of the arm. Certain rotational movements, such as reaching into the back seat of a car, taking off a tight shirt or reaching behind the back may exacerbate the pain. Once triggered, the pain becomes sharp and biting.
Typically, weakness in the shoulder is only secondary to pain, but it does make lifting objects difficult, like placing a gallon of milk on the top shelf of your fridge. Another common complaint is difficulty sleeping, since any arm motion throughout the night can trigger the sharp pain and cause you to wake up.
The diagnosis of a biceps injury is usually based on a clinical exam. During the physical exam, range of motion is normally full, although testing may cause pain during internal and external rotation. If biceps instability is present, there is often an audible snap during range-of-motion testing. If tendonitis exists, there is often associated tenderness when pressing along the bicipital groove.
Many tests have been developed to isolate biceps tendonitis from other possible diagnoses like impingement, bursitis and rotator cuff tendonitis.
- The Yergason Testis performed with the elbow flexed at 90 degrees, and the patient is asked to resist against a supinating force. The test is considered positive if pain is noted at the bicipital groove. When performing the Speed Test (Figure 5), the patient tries to flex her shoulder against resistance with the elbow extended and the forearm supinated. Again, a positive test produces pain at the bicipital groove.
- O'Brien's Test is useful to detect a possible SLAP tear of the labrum. The arm is fully extended at the elbow; positioned with 90 degrees of forward flexion at the shoulder; then adducted approximately 15 to 20 degrees across the body. The patient is instructed to internally rotate the arm with his thumb pointing down. A downward force is applied to the arm, and any pain is noted. The test is then repeated in the same position, except the arm is externally rotated with the palm pointing up. A positive finding for a SLAP tear occurs if pain is produced with the thumb pointing down, but decreases or is eliminated when the palm is pointed up.
Biceps injuries are initially treated in a conservative fashion. Non-surgical treatment typically begins with a period of rest and activity reduction, which is often difficult for eager athletes who want to return quickly to their sports. However, athlete must understand that any premature return to activity—even light workouts—can jeopardize their long-term recovery. If symptoms are mild, a change of position (e.g., a pitcher moving to first base) may be sufficient to eliminate the repetitive stress that is producing the pain. An acutely inflamed shoulder can also benefit from intermittent ice therapy to reduce swelling.
Anti-inflammatory medications, such as ibuprofen and naproxen, are also helpful as an initial treatment option. Our recommendation is a two-week trial of anti-inflammatory medication taken in conjunction with activity reduction and rest. The patient is directed to take the full two-week course of anti-inflammatory medication regardless of pain; otherwise inflammation may become painful when he returns to sport.
Standard rehabilitation of an athlete's shoulder involves three phases: 1) rest; 2) stretching exercises; 3) strengthening. In throwing athletes, a fourth phase is added, which includes a progressive throwing program.
- Phase 1: Patients who are asymptomatic (pain free) following a two- to four-week period of rest and activity modification may slowly return to activity.
- Phase 2: The goal of stretching is to regain a balanced range of motion throughout the shoulder, with no stiffness or pain in any position.
- Phase 3: All athletes can greatly benefit from six practical exercises that we refer to as the Fabulous Six (see below). These exercises keep the elbow close to the body, which helps avoid further injury to the tendon. As a group, the Fab 6 effectively work all 17 muscles that contribute to shoulder strength and stability.
- Phase 4: For overhead athletes, a throwing program may be started once the rotator cuff, scapular rotators and humeral movers (i.e., pectoralis major, latissimus dorsi, and deltoid) are strong and conditioned.
If conservative treatment fails to provide pain relief after a period of rest, medication and a trial of physical therapy, further medicinal action may be required, such as cortisone injections. If this fails, surgery may be required.
In recent years more attention has been focused on injury prevention for all athletes. Strict guidelines on pitch counts have been introduced to protect developing pitchers, and trainers now use position-specific conditioning, which emphasizes proper mechanics and extends well into the off-season. Preventative measures, in conjunction with a better understanding of biceps tendonitis and its causes, will hopefully result in fewer injuries next season.
The Fabulous Six
The following six exercises are typically used as a form of rehab, but can also be incorporated into a regular training program to prevent injury.
- Seated Row
- Close-Grip Cable Pull-Down
- Seated Chest Press
- Biceps Curls
- Triceps Push-Downs or Kickbacks
- Dumbbell Shrugs