Biceps Tendinopathy - Another Cause of Shoulder Pain

Bicipital tendinopathy, often called biceps tendinitis or biceps tendinosis, is a common cause of pain on the front of the shoulder. This blog post will discuss what causes biceps tendinopathy, movements that can aggravate the tendon, and treatment options that can help with biceps tendon pain. 


The biceps muscle is located on the front of the arm and has a long head and a short head (hence why it’s called the biceps). The long head originates on the top of the glenoid while the short head originates on the coracoid process. The long and short head of the biceps muscle then attach onto the radius bone in the forearm. When the biceps muscle contracts it causes the elbow to flex and to a lesser extend the shoulder to flex. 


A biceps tendinopathy can either be the result of a primary or secondary cause. A primary cause of biceps tendinopathy would be a result of overloading the tendon, such as performing too many bicep curls while at the gym. While a secondary cause of biceps tendinopathy occurs when the biceps tendon is compressed against the humeral head. This compressed can be caused by a spasmed rotator cuff that is pressing the humeral head into the biceps tendon, leading to tendon irritation. Of both causes of bicipital tendinopathy, the secondary cause appears to be the more common reason. 

With either cause of biceps tendinopathy, the tendon goes through several changes in response to the increased load and compression on the tendon. The changes in the tendon are divided into two stages: (1) reactive tendinopathy and (2) degenerative tendinopathy. 

A reactive tendinopathy occurs with a sudden increase in load. The increase in load causes the tendon to an increase in cell production which leads to fluid accumulation in the tendon. Normally this fluid accumulation decreases with adequate rest; however, this fluid in the tendon can remain with insufficient resting time leading to tendon fiber disorganization and therefore a weaker tendon structure. 

With prolonged loading, the tendon transitions from a reactive tendinopathy to a degenerative tendinopathy. The chronic fluid accumulation of the reactive tendinopathy leads to extensive tendon fiber disorganization as well as causing the tendon cells to degenerate. These changes are typically irreversible but the tendon can generate new tendon fibers around it. 

The tendon can become painful in either stage of tendinopathy, and the pain severity does not correlate well to the structure of the tendon. This means that the pain can be severe with a reactive tendinopathy and mild in a degenerative tendinopathy, or vice versa. 

Movements to avoid

Temporarily limiting shoulder extension movements can help decrease the load and irritation of the bicipital tendon. The exercises that commonly irritate the biceps tendon include dips, flies, and push ups. 

There is nothing wrong with any of these exercises, however, they can cause compression of the biceps tendon which can increase the pain with a bicipital tendinopathy. Once the pain in thebiceps tendon has reduced, these exercises can slowly be reintroduced into a training program. 

Conservative pain management 

Since pain can occur in both reactive and degenerative tendinopathies, pain management is an important part of the rehabilitation process because pain can alter movement patterns. Conservative treatment options for the pain of a tendinopathy can include joint mobilizations and manual therapy. As mentioned above, if the humeral head is compressing the bicipital tendon, it can cause irritation and pain of the tendon. Mobilizations to the shoulder joint (the glenohumeral joint) and the shoulder blade (the scapulothoracic joint) can decrease the compression on the biceps tendon on the humerus. Manual therapies such as myofascial release and Graston therapy to the tissues around the biceps muscle can also help reduce the irritation of the bicipital tendon. 


For the reactive stage of tendinopathy, the first step is to reduce the amount of load on the biceps tendon. The load on the bicipital tendon doesn’t need to be completely removed, but the load should be reduced enough so that the symptoms are either no provoked at all or at least kept to a minimum. The exact amount of load reduction will vary between individuals because the tolerance of the tendon to load depends on many different factors (age, genetics, exercise history, etc). Once the tendon pain has subsided, a progressive loading program for the biceps tendon should begin to strengthen the tendon and to prevent a sudden spike in loading. 

In the degenerative stage of tendinopathy, the goal of the rehabilitation program is to strengthen the bicipital tendon through load. By gradually loading the bicipital tendon, the tendon will be stimulated to create new tendon cells which will increase their ability to tolerate more load. 

The loading program should begin by performing isometric shoulder flexion, which means contracting the biceps muscle without moving the shoulder or elbow. Generally this position is held for 30-45 seconds for 3-5 repetitions. 

The next progression would be to begin moving the shoulder with load. A bowler curl can be used that will load the upper biceps tendon as opposed to a biceps curl which will load the lower biceps tendon. 

The final progression includes plyometric exercises, which increases both the force and speed of contraction on the biceps. An example of an exercise that can be used is a plyometric push up. 

Besides loading the biceps tendon, the muscles around the shoulder can also be strengthened. The muscles that can be involved include the supraspinatus, infraspinatus, and teres minor of the rotator cuff along with the trapezius, rhomboids, and serratus anterior of the shoulder blade. 


  • The bicipital tendon is a common cause of pain on the front of the shoulder. 
  • It can either be the result of overloading of the biceps tendon or compression of the biceps tendon against the humeral head. 
  • Biceps tendinopathy is categorized into either reactive tendinopathy or degenerative tendinopathy. For reactive tendinopathy, a short period of load reduction on the biceps tendon is necessary. Loading of the biceps tendon is the primary focus of a degenerative tendinopathy to strengthen the tendon. 
  • Joint mobilizations and manual therapy to the tissues around the shoulder can help reduce the discomfort in both reactive and degenerative tendinopathy.