Updated: Jan 17, 2021
Got shoulder pain? An often overlooked cause of anterior shoulder pain could be a biceps tendon issue. This condition goes by many names, manifests in many ways, and is thought to occur for a few reasons.
First: An Anatomy Review
The biceps brachii has two proximal attachments, both on the scapula. The long head attaches to the supraglenoid tubercle and has ties to the superior glenoid labrum. It is often investigated by MRI in the case of labral tears to make sure that the long head biceps anchor is intact. The long head of the biceps travels within the bicipital groove on the humerus and is kept in place by the transverse humeral ligament. The short head attaches to the coracoid process; an attachment site it shares with pectoralis minor and coracobrachialis. Distally, the two heads join as one and attach to the radial tuberosity. The biceps brachii has a few functions. Primarily it acts as an elbow flexor but due to the attachments at the shoulder, it aids in shoulder flexion, and due to its distal attachment on the radius produces supination (palm turning face up). Finally, it is worth noting that functionally the bicep can aid as a shoulder stabilizer by compressing the head of the humerus in the glenoid cavity.
Brief tangent on the word tendonitis... The suffix 'itis' is used to indicate inflammation of the tissue. Appendicitis, cholecystitis, rheumatoid arthritis, etc. It is important to note the difference between the two terms: tendinitis and tendinopathy. Acute biceps tendinitis indicates actual inflammation and swelling within the bicipital groove from acute overload, trauma, or injury. The more long-standing, nagging shoulder pain is more likely biceps tendinopathy where inflammatory markers are no longer found but there may be degenerative changes noted within the tendon. For more information on this, check out, tendinopathy & tendinosis definition and long head biceps tendinitis/tendinopathy.
People can experience symptoms of biceps tendinopathy at any of the attachment sites. Long head biceps tendinopathy symptoms are experienced as anterior shoulder pain and pain in the bicipital groove. Short head biceps tendinopathy can be felt as pain and tenderness at the coracoid process in the anterior shoulder. And finally, elbow pain can be felt at the attachment of the biceps on the radius distally in biceps insertional tendinopathy. The discussion following will be about issues experienced at the shoulder joint and regarding longer standing tendinopathy versus acute tendinitis.
Regardless of where the tendinopathy is being experienced, this is what is likely happening at the tissue itself.
There is an interruption in the normal 3 stage remodeling of tendons
Like muscles, with training and use tendons must undergo a repair process to become stronger and accommodate progressive loading
Also like muscles, tendons require adequate rest in order to repair fully
With chronic use, there can be constant overloading that interrupts the above-mentioned process
Micro-trauma that is normally repaired is stuck in the third stage of healing; halting progress due to repetitive use
Patients experience pain with certain movements that stress the tendon and weakness; both attributed to pain with muscle contraction
If this seems like a real simplification of the process, it is. Check out the histopathology section of this resource for more details if you want them.
Pain is a very complex experience. Pain does not always equal damage. Pain does not always equal inflammation. This resource covers several pain theories related to biceps tendinopathy (can be extrapolated to most painful experiences) if you're in for some more deep reading on the topic.
Why Does This Happen?
This portion is based mostly on clinical and training experience, having talked with, evaluated, trained, and treated many patients and clients with shoulder pain, and thinking about the biomechanics and functional anatomy.
The inappropriately named rotator cuff has a much more important function than to just externally and internally rotate the arm. The actual function of the rotator cuff is to stabilize the head of the humerus in the glenoid cavity. This is a crucial job as the shoulder is a highly mobile joint. All of the rotator cuff muscles pull the head of the humerus back into the glenoid cavity, causing compression and stability as we use our limb and lift things overhead. The supraspinatus has an additional important job to depress the head of the humerus as the arm moves into abduction.
If the rotator cuff muscles are weak, torn, inhibited, dysfunctional, whatever fancy guru word you want to use*, then the biceps could be recruited as a stabilizer of the glenohumeral joint. In addition to its normal job, the biceps has to do a job it is poorly trained for. How do you feel when someone asks you to pick up the slack for your lazy coworkers? Annoyed? Partially torn? Unhealed? Painful? There we go.
*There are many, many reasons why the rotator cuff muscles may be damaged or inhibited and are beyond the scope of this article*
What To Do About It
Of course, I am going to say go see your friendly neighborhood sports chiropractor or physical therapist and get an appropriate diagnosis and treatment plan. While I cannot make blanket recommendations to diagnose or treat any condition, I wrote out a step by step guide to how I manage these cases conservatively while continuing to train and to bulletproof the shoulder joint.
1. Relative Rest & Load Management
Now the first thing I would recommend to anyone experiencing some shoulder discomfort is to relatively rest for a bit and see if it resolves on its own. Most musculoskeletal problems will resolve spontaneously. Does your shoulder hurt? Great... but I'm sure your legs are fine! And I'm sure there are a bunch of other exercises you can do that don't cause pain. Train those while relatively resting the painful thing for a bit.
Next, evaluate your training program. Direct bicep work with the forearm supinated and a lot of overhead work stress the biceps tendon a lot. If you're experiencing symptoms, cut the volume on some of this work while emphasizing other parts of training. Even deadlifting with a supinated hand can place extra stress on the biceps (a lot of bicep tears are from deadlifting with an alternated grip on the supinated hand).
2. Graded Loading of the Tendon Directly
One of the rehab techniques often used in any tendinopathy is eccentric loading. This helps to provide "prevailing tension" to aid in that 3rd stage of healing: remodeling without causing further pain and discomfort. For the biceps, this could look be eccentric focused reps of a supinated dumbbell bicep curl. Lower the weight under control, and then perform either the full concentric or an assisted concentric. The eccentric component should be between 3 and 6 seconds long. The concentric portion is fine to do, just make sure you are progressively loading in a safe, and slow way.
3. Self-Symptom Management
Some self-care can be helpful to make it more tolerable to go about your day while experiencing pain. If done in the peri-training window this can allow you to train or rehab the biceps tendon with less discomfort or in better positions. Just know that this stuff offers temporary relief. Doesn't mean it's useless, just means that this alone will likely not do much for the problem outside of transient pain relief and transient increases in ROM. Some options include:
Ice or heat (pain modulation)
Topical pain modulation (BioFreeze, TigerBalm, etc.)
SMR of biceps and biceps tendon directly and surrounding muscles that have nearby attachment points (SITS, pec major, lat)
4. Targeted Strengthening
To me, this is the key and most important step. Sometimes I avoid the word "rehab" because people assume it means grabbing a little yellow band and doing small little movements. Going off of the theory that the biceps tendinopathy developed in the presence of a slacking cuff, while relatively resting by taking a break from provocative movements you can strengthen the rotator cuff in its function (not muscle action). Here's how I would approach it.
Stabilize the glenohumeral joint in a variety of activities. We are not training the action of the rotator cuff muscles, but using our limbs while those muscles do their job.
Bear Crawls - forward, backward, side to side, weighted, etc
Plank Taps with a strong serratus pushup the whole set
Strengthen the pressing movement in a pain-free way. Some options I have used with clients successfully are:
5. Get Your Back Really Strong
Finally, oftentimes when I talk with a client or patient about their shoulder complaint it seems that they are doing a lot of volume in pressing either overhead or horizontally in a much larger quantity than they are doing any kind of pulling. You hear a lot of people talk about this ratio of pulling twice as much as you press... I don't know exactly where that came from and it is not a hard fact at all. But... if you just do a quick anatomy review you will see that there is WAY more muscle mass dedicated to pulling than there is pressing so to me this does make sense.
PUSHING MUSCLES: PECS, ANTERIOR DELT, TRICEPS
PULLING MUSCLES: TRAPS, LATS, RHOMBOIDS, TERES MAJOR, POSTERIOR DELT, BICEPS
So, typically if you focus on rowing exercises and upper back exercises during this relative rest period it will bode well for your training overall and for getting over this injury. Make sure the exercise choices do not cause additional pain, of course. Getting your back really, really strong never hurt anyone.
Disclaimer again, if you are in pain and it is hindering activity and function do not solely use some article on some guy's blog as medical advice and seek out some professional help!
If you want to try some of this stuff, awesome! Let me know how it goes. Again, this is a strategy I developed working with a lot of people and studying anatomy, movement, and biomechanics. I don't know of any RCTs using farmer's walks and landmine presses to treat biceps tendinopathy.
Make sure you are always warming up properly. Check out my Master Upper Body Warm-Up Template.
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Thanks for reading.