Biceps Tendinitis: A Tale of Two Heads

The biceps is the large muscle of the upper arm, connected to the shoulder and the forearm. At the shoulder, the muscle splits into two tendons called the short and long heads. Shoulder pain from the biceps presents dilemmas for the treating doctor and often long periods of pain for the patient. Here are some of the controversies.

Emily Salmons: Triathlete & Stone Clinic Patient

BioKnee patient Emily Salmons flexing those biceps after her 9th post-op Ironman triathlon  

The biceps muscle bends the arm and turns the forearm up and down. The top of the muscle inserts in two places on the shoulder: one through a long head running over the top of the humerus and one at the front to a protuberance on the scapula. When the shoulder becomes painful from injuries (often to the rotator cuff, consisting of four tendons connecting muscles to the upper arm), the biceps tendon is implicated as a contributor to the pain…but is it? And if so, what to do about it?

Biceps Tendinitis

On examination, the biceps tendon is easily felt at the front of the shoulder. Pushing on it often reproduces the pain. Yet, sometimes, the pain radiates to the back of the shoulder or to the deltoid muscle on the side. X-rays don’t show the tendon. An MRI often shows some excess fluid but is usually not definitive for inflammation.

Physical therapy for the biceps involves exercises that cause the tendon to contract isometrically and range of motion exercises to limit stiffness. It can be helpful but is not enough.

Injection of steroids frequently leads to biceps rupture and weakening of the rotator cuff. The steroids work by shutting down cell metabolism, which also shuts off the natural healing potential of the injured tissue. Steroids are so potent that many surgeons will no longer operate on a joint that has recently received a steroid injection, as the rate of infection is increased by this suppression of the body’s healing ability.

Some studies have shown that injections of PRP, often with hyaluronic acid, have been as effective as steroids. However, the data on this is not consistent, as the preparations vary widely. Still, since this strategy often works and causes no harm, it is our first-line therapy (in combination with physical therapy).

Surgery for the biceps presents a dilemma. The surgical world is divided between cutting the tendon and letting it fly (tenotomy), versus cutting it and anchoring it to a spot further down the arm (tenodesis). The results are the same in multiple studies—and both interventions can lead to a Popeye-like muscle bulge. Some surgeons won’t repair a torn rotator cuff without cutting the tendon for fear that the patient will still have pain despite a treated rotator cuff. Yet destroying an important tendon that has many functions in the shoulder seems barbaric in this age of tissue preservation and regeneration. 

The sad truth is that the science around stimulating the tendon to heal inflammation and resolve pain has simply lagged far behind the progress made in many other areas of the body.

So, hear ye hear ye, young scientists and surgeons alike! An obvious and widespread problem causing pain for so many is awaiting a good solution—and it sits within arm’s reach. 

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Medically authored by
Kevin R. Stone, MD
Orthopaedic surgeon, clinician, scientist, inventor, and founder of multiple companies. Dr. Stone was trained at Harvard University in internal medicine and orthopaedic surgery and at Stanford University in general surgery.