Shoulder Conditions

Biceps Tendon Problems

Biceps Tendon Problems: Causes, Symptoms and Treatment Options

Problems affecting the biceps tendon are a common source of pain at the front of the shoulder, particularly in people who perform repetitive lifting, overhead activity, or sports involving throwing. Biceps tendon conditions frequently occur alongside other shoulder problems, including rotator cuff disease, shoulder impingement, and labral injury.

Understanding the anatomy of the biceps tendon

The biceps muscle in the arm has two distinct connections at the shoulder, giving rise to the ‘long head’ and the ‘short head’ of biceps. It is the long head of biceps which is discussed here. The short head of biceps arises from the coracoid process, a bony prominence at the front of the shoulder, and lies outside the shoulder joint. This portion of the tendon is almost never a cause of shoulder pain.

The long head of biceps tendon, however, is one of the few tendons in the human body that travels inside a joint. It attaches to the top of the socket (at the upper glenoid labrum), passes through the shoulder joint and then runs down the front of the shoulder within a narrow channel known as the bicipital groove. This unique pathway makes the long head of biceps tendon particularly vulnerable to irritation, instability, and injury.

Why the biceps tendon (referring to the long head of biceps) is prone to problems

Several anatomical and biomechanical factors contribute to biceps tendon pathology:

Within the joint, the long head of the biceps lies directly beneath the supraspinatus tendon. Biceps problems are commonly associated with rotator cuff disease and they can both be prone to fraying and degeneration with overuse and time.
If the supraspinatus tendon is torn, the biceps tendon may be exposed to increased friction or impingement beneath the acromion
At the front of the shoulder, the biceps tendon passes through the bicipital tunnel, a tight space where inflammation can lead to swelling and entrapment
The biceps tendon relies on the subscapularis tendon for stability within its groove. When the subscapularis is torn, the biceps tendon may partially or fully dislocate
At its attachment to the superior labrum, repetitive stress can lead to SLAP (Superior Labrum: Anterior to Posterior) tears, particularly in overhead and throwing athletes

Because of these relationships, biceps tendon pathology is rarely an isolated problem and often forms part of a broader shoulder condition.

Common biceps tendon conditions

1 Biceps Tendinitis and Tendinopathy

Degeneration or inflammation of the biceps tendon may develop gradually over time. This is often associated with rotator cuff disease or shoulder impingement and typically causes pain at the front of the shoulder, particularly with lifting or overhead use.

2 Biceps Tendon Instability

When the stabilising structures of the shoulder are compromised, particularly the subscapularis tendon, the biceps tendon may slip out of its groove. This can cause pain, clicking, or snapping sensations at the front of the shoulder.

3 SLAP Tears

The long head of the biceps attaches to the superior labrum. Injury at this attachment point is known as a SLAP tear and is commonly seen in throwing athletes or following repetitive overhead activity. Symptoms may include deep shoulder pain, catching, or weakness.

4 Biceps Tendon Rupture

A rupture of the long head of the biceps tendon may occur suddenly or following long-standing weakness from degeneration. Patients may notice a sudden “pop,” bruising, and a visible change in arm shape, sometimes referred to as a Popeye deformity. Pain often improves, but fatigue or cramping in the bicep muscle may persist in some individuals.

Symptoms of biceps tendon problems

Patients with biceps tendon disease commonly report:

Pain at the front of the shoulder
Pain that may radiate down the upper arm
Tenderness over the biceps groove
Pain with lifting, pulling, or overhead activity
Clicking or snapping sensations
Sudden pain and a change in the shape of the biceps muscle in cases of full rupture

Specific clinical tests are used in the office during consultation to assess whether the biceps tendon is contributing to symptoms.

How is a pectoralis major rupture diagnosed?

Assessment involves:

Identifying whether the biceps tendon is the primary pain generator or part of a broader shoulder problem is essential when planning treatment.

A detailed clinical history and physical examination

Targeted testing to reproduce biceps-related pain

Imaging such as ultrasound or MRI to assess tendon integrity and associated pathology

X-rays where appropriate to assess contributing bony anatomy

Diagnosis and assessment

1 A detailed clinical history and physical examination

2 Targeted testing to reproduce biceps-related pain

3 Imaging such as ultrasound or MRI to assess tendon integrity and associated pathology

4 X-rays where appropriate to assess contributing bony anatomy

Non-operative treatment

Most biceps tendon problems are initially managed without surgery.

Treatment may include:

Even full ruptures of the tendon can be treated without surgery, accepting a change in shape of the bicep muscle (the ‘popeye’ or dropped biceps deformity). Often pre-existing pain from a frayed and inflamed bicep tendon will resolve after it ruptures. Discomfort and bruising around the shoulder and upper arm will persist for 3 to 4 weeks and can be managed with analgesics and a gentle movement exercise plan to ensure recovery of full movement range at the shoulder.

Full strength around the shoulder and the bicep muscle itself will return since the bicep muscle remains fully connected via the short head of bicep tendon which is always unaffected. It is only the long head component which ruptures.

If shoulder stiffness or pain persists for a more prolonged period, then further treatment may be required.

Surgical treatment options

Surgery may be considered if bicep symptoms persist despite appropriate non-operative management or if biceps pathology is contributing significantly to shoulder dysfunction. Given the close relationship between the biceps tendon and other shoulder structures, surgery often addresses multiple issues simultaneously.

Regarding surgical options specifically for the biceps tendon itself, there are two approaches:

Biceps tenotomy: Biceps tenotomy involves releasing the long head of the biceps tendon from its attachment. This option may be appropriate for some patients and is associated with a simpler recovery. A cosmetic Popeye deformity may occur, though this does not usually affect function.

Releasing the tendon does not reduce bicep muscle strength since the muscle remains fully connected through the more important short head of biceps.

Biceps tenodesis: Biceps tenodesis involves removing the diseased portion of the tendon from within the joint and reattaching it to the humerus. This approach maintains the contour of the biceps muscle and reduces the risk of cosmetic deformity. Because the tendon must heal to bone, rehabilitation is more structured and protective in the early phase.

Shoulder strength and function remain unchanged regardless of which surgical approach to the tendon is taken.

The biceps very commonly requires treatment at the time of rotator cuff repair surgery.

Individualised treatment planning

Management of biceps tendon problems depends on:

The specific tendon pathology

Associated shoulder injuries

Age, activity level,
and functional goals

Dr Richard Dallalana places particular emphasis on determining the role of the biceps tendon within the overall shoulder problem, ensuring treatment is appropriately targeted and individualised.

When to seek specialist assessment

If shoulder pain persists, worsens, or interferes with daily activities or sleep, specialist assessment can help identify the underlying cause and guide appropriate treatment.

Shoulder Conditions

Biceps Tendon Problems