Biceps tendonitis pain is one of the more common types of shoulder pain. This article explains what causes biceps tendonitis, what biceps tendonitis feels like, and how to rehab it, including exercises to do and activities and exercises to avoid. It also discusses recovery times for biceps tendonitis. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.
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In this article:
We’ve also made a video about this:
This article is about proximal biceps tendonitis, at the upper or shoulder end of the biceps muscle. We also have an article on distal biceps tendonitis, at the lower or elbow end of the muscle.
Anatomy and function of the biceps muscle and tendons
The bicep muscles are your “guns” that run from the font of your shoulder down to the crook of your elbow.
The shoulder end of the muscle has two heads – the long head and the short head. The long head is attached directly to your shoulder joint via a tendon, and the short head is similarly attached to the coracoid process, which is a bit of bone sticking out from the top of your shoulder blade.
Biceps tendonitis most commonly affects the long head's tendon but it can affect either or both of these tendons.
The biceps muscle has three main functions
1. It bends the elbow
When you stand with the palm of your hand facing forwards or up (forearm in supination) and bend your elbow (do a bicep curl), it’s the biceps doing most of the work; it doesn’t do much work when you do this movement with your palm facing inwards or down.
2. It helps to flex the shoulder
Its second function is to help your other shoulder muscles to lift your arm upwards (shoulder flexion), like when you’re lifting something above your head.
3. It turns the forearm out (supination)
The third function is to help rotate the forearm outwards (supination)
What causes biceps tendonitis?
There are three types of causes of biceps tendonitis: overload, overstretch (especially if it’s combined with added weight), and poor biomechanics.
Overload
The most common cause of proximal biceps tendonitis is that the tendon has been worked too hard to an extent that it isn’t used to or not allowing enough recovery time between workouts. So, we’re talking about something like a pull-up challenge, massively ramping up the weight on your bicep curls, or a marathon session in front of a one-armed bandit. Even a sudden increase in household activities that requires you to either lift your arms above your head or carry heavy things can cause trouble, e.g. redecorating the house.
Overstretching or excessive compression
A second cause is overstretching, where the tendon is stretched too tight over the bones. This can cause excessive compression between the shoulder bone and tendon which then causes it to get injured.
An example is when you go too far with certain yoga positions. And during the lockdowns of the COVID-19 pandemic, I had quite a few patients who got biceps tendonitis from doing triceps dips with their arms behind them – typically off the edge of a chair or coffee table. In that position, your upper bicep tendons are really stretched and compressed over the bone and can get irritated if you don’t have good strength and control in your shoulder girdle.
Poor biomechanics
Lastly – and this is especially the case with swimmers and people who do racket sports – biceps tendonitis can be caused when the muscles that stabilise the shoulder blade aren’t strong enough to do their job properly towards the end of a long session. When these muscles are tired, the shoulder blade tilts further forward than it should, and this leads to more compression and friction than the biceps tendons are used to. This is also the reason why you should avoid rounding your shoulder girdle while lifting weights.
What does biceps tendonitis feel like?
Tendons are sneaky things. Often, they won’t complain at the time when you’re overworking them, only to pipe up hours later or even the next day. So, it could be difficult to trace the cause of the pain.
When the pain caused by proximal biceps tendonitis does arrive, it is over the front of the shoulder, and it is painful when you press directly on the biceps tendon in that area. If the tendon is very irritated, you may even feel the pain down your arm, in the biceps muscle itself. The muscle can also feel tight, and if your nerves are affected (they run close to the tendon), you can get a tingling feeling.
There are other conditions that may cause similar symptoms. A tingling feeling might be due to nerve issues in the neck, and your pectoral and rotator cuff muscles are attached to your skeleton in the same area. In fact, upper biceps tendonitis is often misdiagnosed as a rotator cuff injury.
An indication that it might indeed be your biceps tendon causing the trouble is if it hurts when, with the palm of your hand facing up, you curl up your forearm or lift your arm up towards the ceiling against resistance.
However, other muscles also contract during these movements, so it’s not a 100% accurate test. Seeing a physio would be useful, because they will ask you some specific questions and make you do some movements to piece the puzzle together.
Treatment for biceps tendonitis
The treatment for biceps tendonitis comprises two aspects:
Treatments that help the pain to calm down. These include using ice, relative rest, avoiding certain exercises and activities, and performing gentle exercises. See the sections below for more details on each of these.
Exercises that restore the strength and endurance in your injured tendon.
Here is the clip from our main video about the treatment of upper biceps tendonitis. At some of the exercises discussed below, we have provided a time stamp of where in the video you can see a demo.
Treatments that reduce pain
The early stage of rehab refers to when the tendon is still really painful, and any type of exercise or activity easily makes it worse. The right treatment here is to give it a bit of breathing space and to get the pain levels down to where you can start doing some strengthening exercises.
Ice
Ice is really useful for calming the irritation down. We have an article with more information on using ice for sports injuries.
Relative rest
Relative rest means that you don’t have to rest your tendon completely. Instead, you adapt your daily activities and training so that you cut out all the things that aggravate your pain but continue with the activities that don’t affect it. When done correctly, relative rest can help to preserve your strength and speed up your recovery.
Remember to check the 24-hour pain response. Tendons will often feel absolutely fine during an activity only to flare up and hurt a lot more several hours later or even the next day.
The guideline for relative rest to be effective is: You can do any activity as long as it doesn't cause an increase in pain during and within the 24 hours after completing the activity.
Stretches for biceps tendonitis
Avoid stretching your shoulder backwards - this includes doing pec and bicep stretches as well as movements that take the biceps into a stretch position.
One of the symptoms of biceps tendonitis is a stiff feeling in the biceps muscles, so many people are naturally inclined to want to stretch. However, the stiffness is due to the irritation caused by the injured tendon and will only permanently go away once your tendon starts to recover.
Injured tendons don’t like being stretched. When you stretch the biceps muscle, you also stretch the tendon and, whilst that can feel really good and satisfying in the moment, it often causes it to hurt more later, or it’s the reason why the pain does not want to settle down.
A better solution to help relieve that tight feeling is to massage the muscle. Just be careful not to massage too hard over the biceps tendon itself, because that can further irritate it and also cause it to hurt a lot more several hours later.
And if someone tells you that your tendonitis is due to a tight biceps muscle that needs to be stretched, don’t listen to them. Biceps tendonitis is not caused by overly tight muscles.
Everyday activities to avoid
When you lift your arm towards the ceiling, the space in the front of your shoulder joint reduces as the bones move closer together, and they press on your biceps tendon. This is normal, and for a healthy tendon this isn’t a problem; but when the tendon is injured and sensitive, this can really irritate it. This is why, during the early stages of recovery, it is best to avoid positions that lift your arm above 90 degrees shoulder flexion or where you have to keep it at that level for a prolonged period of time.
You’ll be surprised how often we move our arms into that position. Be careful with seemingly innocuous activities that can cause compression or friction on the tendon.
Obvious movements to avoid are things like washing windows and hanging the washing out to dry. But there are several less obvious activities that can cause trouble. For example, when you’re driving, it would be better to grip the steering wheel towards the bottom than at the top. If you sleep on your front with your arm up next to your head, try and change that position so your arm is next to your body.
If your job involves sitting at a desk and working on a computer, make sure that your chair is high enough and you sit close to the keyboard, so that your shoulders are not as flexed and your biceps muscles and tendons don’t have to work too hard to keep your arms stretched out.
Keeping things moving – exercises that can reduce pain
You have to rest your tendon, but not moving enough can also make an injured tendon ache more. (This is why relative rest is better than total rest.)
Pendulum exercise
A nice, gentle way to get some movement going is to lean slightly forwards while supporting yourself with the uninjured arm on a desk or table and to let your injured arm swing gently back and forth and from side-to-side – nothing more vigorous than the pendulum of a grandfather clock.
See video for demo: 00:12:32
Place your uninjured side's hand on a table and bend over so your injured arm is hanging down relaxed.
Gently swing your arm forwards and backwards, or side to side.
You may find that it hurts if you swing to vigorously or into a specific direction, so keep the movements gentle and choose the direction that feels most comfortable.
Avoid doing circles, because that can often irritate the tendon - stick to straight lines.
Do this for 30 seconds.
Come upright and rest for 30 seconds.
Do 3 sets.
Do this 2 to 3 times a day.
Shoulder blade positioning
A movement that will create some more space for your tendon is opening up the space in the front of your shoulder by gently rolling your shoulder blades back from time to time. This reduces the pressure over the tendon and can make it feel a lot more comfortable.
See video for demo: 00:13:48
Grow tall – by lengthening your spine up towards the ceiling, you will find that your shoulders naturally move into a more open position.
Your natural inclination might be to pull your shoulder blades down and back as much as you can, but this isn’t that useful for the biceps tendon because it can often make the bones press down on it more.
The better way is to pull your shoulders up slightly and then roll them back gently. It's a very small movement.
Hold the position for 10 seconds.
Rest for 10 seconds.
Do 6 repetitions.
Do this 2 to 3 times a day, and correct your position every time you become aware that your shoulders have hunched forward.
Biceps tendonitis exercises that strengthen the tendon
Once the pain has calmed down, you can gradually start to build the tendon’s strength back up.
The key word here is “gradually”. If you were doing weights, forget about what you used to be able to do, and try out every exercise with super light weights first. It’s easier to increase the weight when you feel it's too easy and doesn't flare it up than to start out too heavy, irritate your tendon, and then having to go back to square one and wait for it to calm down again.
Also, in the first few weeks, don't do strength training that involves lifting your upper arms higher than 90 degrees, because we still want to avoid compression of the tendon at this stage.
Bicep curls
Check the position of your elbow. If your elbow is going to be at your side or further behind your trunk, it will stretch the tendon more than when you have it out in front of you (supported). So, seated bicep curls with your upper arm resting on or over something in front of you are better. Start with a very light weight and only do a few repetitions to test what your tendon can tolerate.
Seated rows
These are useful for strengthening the muscles around your shoulder blades, which will lessen the compression and friction on your biceps tendon. Only pull your elbows back as far as your torso; pulling them back further during the early stages may irritate the tendon.
Overhead press
It is usually best to do these only to shoulder height or even a bit lower (about 80 degrees shoulder flexion) initially to avoid compressing the tendon while it is still irritable. You may also find that it is more comfortable to have your elbows slightly forward rather than straight out to the side.
Once the tendon has calmed down significantly and my patients are able to lift weights without discomfort to 90 degrees shoulder flexion, it is usually time to start going higher. For the first few sessions, I then start my patients with just the weight of their arm. Only when their shoulders are happy to do three sets of 15 through full range do we start adding some weights.
I don't recommend exercise bands for these; the resistance of the band increases as your arm goes higher, but your shoulder is normally not as strong in the fully extended position. So, as you get to the weaker range, the band is now tighter. It's a much better option to use light weights, so that the load stays constant throughout the movement.
Here's a selection of weights in different price and weight ranges:
If you don't have weights, remember that one litre of water equals 1 kg or 2.2 lbs. So, you can use bottles or other containers filled with water. If you want to increase the weight eventually and you don’t have bottles that are big enough, put a number of smaller bottles in a bag.
The endgame
As you carefully progress your exercises to become more difficult without flaring your biceps tendon up again, you should eventually aim to replicate the movements of your arm that your sport will require you to do, whether it’s doing weights, swimming, or tennis.
Exercises to avoid (during the early stages)
Turning your arm in and out
An exercise that often aggravates the biceps tendon when it is injured is where you have your elbow tucked into your side, forearm parallel to the floor, and you move your forearm in and out against resistance (lateral rotation). The exercise is typically prescribed for rotator cuff injury rehab, and I think clinicians sometimes just assume it should be good for the biceps tendon as well.
The reason it can often cause trouble when you have biceps tendonitis is that the rotation movement causes increased rubbing or friction on your injured biceps tendon, and that can make it hurt more.
A better way to train your shoulder rotators is to start with isometric holds, but even these may aggravate the biceps tendon if it is still very sensitive.
See video for demo: 00:16:04
Stand with your elbow tucked in your side and bent to 90 degrees, forearm pointing forwards.
Hold an exercise band in your hand so it is pulling straight out to the side.
Now gently step away (very small step) from the band so it pulls on your hand, but resist the movement so that your arm continues to point straight forward.
It should be a very light pull, just requiring a gentle activation of your muscles. If you're too aggressive, it will likely make your pain worse.
Hold the contraction for 10 seconds.
Rest for 10 seconds.
Do up to 10 repetitions.
Train it into both directions to work the internal and external rotators.
Push-ups
Avoid these until you have progressed quite a bit with the other strength training exercises, because they create a huge compression force on the bicep tendon.
Start with low-load positions and then gradually progress from there. For example, start off by doing push-ups against a wall, then gradually progress to doing them with your hands on the edge of a table, then on the floor but on your knees, and then finally in the classic hands-and-feet position.
Test different hand placements to find the most comfortable one for your shoulder.
Alternative treatments
Medication
I’m not a doctor who can prescribe medicine, so check with your GP before you follow any of the following advice.
Anti-inflammatories are not usually prescribed for tendon injuries, because inflammation is not a big component of this type of injury.
However, if your pain just doesn’t want to go away, it could be that you also have an inflamed bursa in your shoulder. A bursa is a fluid-filled sac that is meant to reduce the friction between various body parts, e.g. between tendons and bones. But if a bursa experiences excessive compression or friction, it can become inflamed and painful. In that case, it could be useful to speak to your doctor to ask whether it's okay to take a short course of anti-inflammatories to see whether it makes a difference.
Only consider using a corticosteroid injection as the very last resort. It works well to calm down pain, but it will do nothing to heal your tendon. In fact, steroids are harmful to tendons, and may have detrimental effects on long-term healing.
Shockwave
Shockwave can be useful, but it has to be introduced at the right time. If your biceps tendon is still very irritated and painful, shockwave is not the way to go.
Biceps tendonitis recovery time
If you follow the advice in the pain management section of this article, resting the tendon from all activities (exercise and daily life) that make the pain worse, your pain should calm down within a few weeks.
However, the rehab period that follows this can be quite long. Tendon injuries generally take longer to heal than muscle injuries.
If you have flared it up very badly or ignored it for a long time and continued to train with it, expect anything from four to six months of doing rehab exercises before it’s back to its former strength.
Biceps tendonitis recovery time also depends on what you want to be doing. If you just want to get on with life, you could be looking at three months. However, if you’re seriously into stretchy or strength things like yoga or weightlifting, it could take up to six months or even more.
How we can help
Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.