Bicipital tendinopathy is a common shoulder complaint and is easy to confuse with several other shoulder pathologies. Bicipital tendinopathy is an overuse pathology of the biceps brachii tendon and is a common cause of anterior shoulder pain. It is most common in active populations where there are repetitive overhead motions of the shoulder, such as those in swimming, tennis, or throwing activities. Repetitive shoulder motions performed at work may also be at fault. The pain from bicipital tendinopathy is easy to confuse with other problems around the shoulder, so orthopedic assessment helps differentiate this disorder from other shoulder pathologies.

Anatomical Background

Biceps means “two heads,” so this muscle has two locations of origin and one shared insertion. The short head arises from the coracoid process and the long head from the supraglenoid tubercle just above the glenoid fossa of the scapula. The two heads blend in the mid-arm region, and then insert on the tuberosity of the radius just distal to the elbow. Although tendinosis could affect either of the two origin tendons or the insertion tendon, the term bicipital tendinosis usually refers to the long head. It is more vulnerable to chronic degeneration due to friction in the bicipital groove (Image 1).
As the tendon of the long head of the biceps leaves its origin site on the supraglenoid tubercle, it courses under the acromion process on its way out of the shoulder joint capsule. As it leaves the capsule, it makes a sharp turn to head down the arm between the greater and lesser tubercles of the humerus. The groove between the two tubercles is called the bicipital or intertubercular groove. The long head tendon is exposed to significant friction as it makes the sharp turn over the top of the humerus to pass between the tuberosities. A synovial sheath envelops the tendon to reduce damaging friction on the tendon (Image 2). Most tendons surrounded by synovial sheaths are in the distal extremities where they have to bend across the foot and hand bones. The long head of the biceps is one of the few tendons in the body encased within a synovial sheath that is not in the distal extremities.

Description of Pathology

There are two main conditions that could both be considered bicipital tendinopathy: tendinosis and tenosynovitis. Tendinosis involves collagen degeneration within the tendon, and tenosynovitis involves an inflammatory irritation and potential adhesion between the tendon and its surrounding synovial sheath.
Tendinosis is now the preferred term for most chronic overuse tendon pathologies (as opposed to tendinitis). Histological examination has shown that there is minimal inflammatory activity with these conditions, so it is inappropriate to call the condition tendinitis. Tendinosis indicates some form of pathology in the tendon, although we are still learning more about what causes pain in this condition and how best to treat it.
The tendon must be somewhat mobile within its synovial sheath so it can glide back and forth during elongation and contraction of the muscle and movements of the joint. Excess friction over the top of the humerus or in the groove can lead to irritation of the tendon within its sheath. This is a condition called tenosynovitis. Friction and pressure on the tendon fibers in this region can also produce the collagen degeneration of tendinosis. Having tendinosis and tenosynovitis present at the same time is possible. The symptoms of tenosynovitis are virtually the same as those of tendinosis, but luckily the two conditions are treated with the same approach, so making a specific distinction between them isn’t crucial.
Compression of soft tissues against the underside of the acromion process or under the coracoacromial ligament during shoulder motions is known as shoulder impingement. Subacromial impingement may be responsible for tendon degeneration in bicipital tendinosis as well. The biceps’ long head tendon is especially susceptible to impingement at the end of shoulder flexion movements where the tendon is compressed against the coracoacromial arch (Image 3). Bicipital tendinosis is often secondary to impingement of other structures in the subacromial region of the shoulder.
 The biceps brachii is also the primary supinator of the forearm. Therefore, excessive supination, especially against resistance, may lead to the development of this condition. Excessive elbow flexion against resistance may do the same thing. These repetitive upper extremity motions occur in occupational, as well as recreational, settings with increasing frequency.
Another possible cause of bicipital tendon dysfunction involves the movement of the tendon in the bicipital groove. The transverse humeral ligament spans between the greater and lesser tuberosities of the humerus and acts as a restraint to the tendon. Although the transverse humeral ligament holds the tendon in the groove, this ligament may be somewhat loose through individual genetic differences or from a previous injury. If this ligament is loose, the tendon may partially dislocate out of the bicipital groove during certain shoulder motions. Repeated subluxation of the tendon out of the groove may also lead to the fiber degeneration of bicipital tendinopathy.

Assessment

The first clue in identifying bicipital tendinopathy is a history of repetitive shoulder motion or other movements (forearm supination) that significantly use the biceps muscle. Repetitive shoulder motion is common but not required to develop bicipital tendinopathy. Other factors, such as using antibiotics in the fluoroquinolone family, can cause tendinopathy without any repetitive shoulder motion at all.
The pain from bicipital tendinopathy is usually felt on the anterior aspect of the shoulder, although it can also radiate down the arm. The client may complain of pain being worse at night because certain sleeping positions compress the subacromial region and irritate the tendon. Night pain is also characteristic of rotator cuff pathology.
Palpation is an important part of the evaluation strategy for bicipital tendinopathy. The tendon feels like a long pencil-sized structure on the anterior aspect of the shoulder, usually near the medial edge of the anterior deltoid. It is sometimes easier to feel its location with a moderate pressure, back and forth (medial to lateral) palpation of the anterior shoulder.
Pain and tenderness with palpation are likely over the anterior shoulder region. If the tendon is palpated and the shoulder is then slowly internally or externally rotated underneath the palpating finger, pain is likely if bicipital tendinopathy is present. Excessive pressure isn’t required when examining for tendon irritation.
Active motion that uses the involved tendon may also be painful, especially if there is a load on the muscle (such as lifting a weight overhead). Pain is most likely in flexion (shoulder or elbow) or forearm supination. In most cases of tendinopathy, passive movements that shorten the involved muscle-tendon unit (flexion and supination in this case) are not painful because they take the load off the affected tissues.
Pain is not common with passive motion that shortens the muscle-tendon unit because the tensile load is removed from the tendon. However, with bicipital tendinopathy, pain during passive shoulder flexion or abduction may occur because the tendon gets pinched under the coracoacromial arch, even if there is no load on it.
Passive motion in shoulder extension with the elbow extended may be painful as well. This position will stretch the biceps brachii and, therefore, put tensile stress on the tendon and potentially reproduce the pain. Shoulder extension with elbow extension also pulls the tendon more firmly against the upper humeral head during that motion, which may also reproduce the client’s pain. In some cases, pain is felt at the far end of medial or lateral rotation as the tendon is pulled against the sides of the bicipital groove.
Resisted isometric contractions of shoulder flexion, elbow flexion, or supination may also cause pain. Speed’s test is a special orthopedic test that is a modification of a simple manual resistive test. For this procedure, the shoulder is flexed to about 90 degrees, and the elbow is fully extended while the forearm is held in supination. The therapist exerts downward pressure on the client’s distal forearm while the client attempts to maintain this position. Bicipital tendinopathy is likely if this procedure causes pain in the anterior shoulder region and there are other supporting indicators of tendinopathy.
A variation on this test that may be a little more sensitive at picking up tendon pathology involves movement during the test. From the initial starting position of resisted shoulder flexion, the therapist slowly overcomes the client’s resistance to shoulder flexion, causing the shoulder to slowly extend (eccentric contraction across the shoulder joint). With this variation, there is some movement of the tendon within the bicipital groove and the slight movement may give a more specific indication of tendon pathology.
Several other conditions may present signs and symptoms similar to bicipital tendinopathy and should be considered when formulating a treatment plan. Rotator cuff pathology will often have pain in the same region. Tears or tendinosis of the supraspinatus or subscapularis muscles may refer pain into the same region as that of bicipital tendinopathy. Degenerative arthritis or sprains of the acromioclavicular (AC) joint may also cause chronic pain in the anterior shoulder region near the bicipital tendon. However, pain with the AC joint pathology tends to be more proximal and would likely increase with palpation of the joint itself.

Treatment

The first component in addressing tendinopathy is to rest from the offending activity. Usually, there is some activity performed with repetition that led to the tendon pathology. Reducing the constant irritating load on the tendon helps prevent it from getting worse and also gives the tissue a better opportunity to repair. However, the idea about rest from offending activity has been modified in recent years with recent research regarding tendon healing.1
It now seems most appropriate to talk about relative rest from offending activity as opposed to cessation of activity. It turns out that one of the most helpful factors for stimulating some of the key healing properties for various tendinopathies is putting a reasonable load on the tendon. Consequently, exercise and movement are good for addressing the condition. The trick is finding the right amount of exercise and load for the tendon that doesn’t put too much load on the tissue and perpetuate the problem.
One of the more common approaches used to treat tendinopathy in many regions of the body is deep transverse friction. For many years, transverse friction was advocated because it was theorized to help break up misaligned scar tissue associated with tendon repair in tendinitis. However, we now recognize that most tendinopathy does not involve tendon fiber tearing and inflammatory reactions, but friction treatment is still effective. Consequently, there must be some other key mechanism of benefit for this technique.
We have known for quite some time that friction massage is beneficial for tendinopathies. While very little research has confirmed the specific physiological effects of friction massage, there is some evidence that it encourages fibroblast proliferation that will help repair damaged collagen tissue within the tendon. It may also help reduce any fibrous adhesion that has developed between the tendon and the surrounding synovial sheath in tenosynovitis.
There is a significant caution with applying deep transverse friction to the bicipital tendon in this region. The tendon is held within the bicipital groove by the transverse humeral ligament, but if that ligament is somewhat loose or the friction is applied too vigorously, it is possible to dislodge the tendon out of the groove with the transverse movement. A way to avoid that is to perform the friction massage longitudinally (up and down on the tendon), so there are no transverse forces applied to the tendon that may potentially dislodge it from the grove.
When treating any tendinopathy, it is important to address the corresponding muscles that pull on the tendon. There are a wide variety of massage techniques that may help reduce bicipital tendinopathies. Of particular interest are some of the active engagement techniques that encourage active movement along with massage. Now that research has suggested that putting a load on these tendons can help in the rehabilitation process, there is a reason to explore the mechanical and neurological benefits of these approaches further.
One of the more effective methods for addressing these chronic overuse disorders involves active eccentric engagement of the muscle along with a longitudinal stripping technique. The client is in a supine position with the elbow flexed to about 90 degrees. Instruct the client to slowly extend the forearm to straighten their arm fully. As they straighten their arm, perform a longitudinal stripping technique along the length of the biceps brachii muscle. It is most effective to do this several times in a repeated fashion. Simply instruct the client to repeatedly flex and extend their forearm at a slow, moderate pace, and then each time the client extends the forearm the practitioner performs the stripping technique on the biceps muscle. The stripping technique can be performed with a broad contact surface like the backside of the fist or with a more specific and focused contact surface like a fingertip or thumb.
As treatment progresses, the intensity and effectiveness of this technique can be increased by incorporating active movement against resistance. For this variation, use the initial starting position with the elbow flexed at 90 degrees. Instruct the client to hold that position while you pull back against their resistance. Then, tell the client to slowly let go of the contraction so you can slowly pull the forearm into full extension. This process is repeated several times to encourage neurological facilitation and active load on the tendon while it is being worked.
Bicipital tendinopathy is a common shoulder complaint and, as noted earlier, is easy to confuse with several other shoulder pathologies. Based on what we now know about overuse tendon disorders, various massage approaches can be helpful in addressing this problem and alleviating the client’s complaint.

Note

1. Ebonie Rio et al., “Tendon Neuroplastic Training: Changing the Way We Think About Tendon Rehabilitation: A Narrative Review,” British Journal of Sports Medicine 50, no. 4 (September 2015): 209–15, https://doi.org/10.1136/bjsports-2015-095215.