Physical Therapist's Guide to
Biceps tendinitis is a common cause of shoulder pain and impingement (compression of tissue with movement), often developing in people who perform repetitive, overhead movements. Biceps tendinitis develops over time, with pain located at the front of the shoulder, and usually worsens with continued aggravating activity. When treating biceps tendinitis, physical therapists work to determine the exact source of the pain by assessing the entire shoulder, and typically prescribe a program of activity modification, stretching, and strengthening to resolve pain and return individuals to their desired activities.
What is Biceps Tendinitis?
Tendinitis is a condition in which inflammation accumulates at a tendon, causing pain. The biceps tendon, the tendon associated with the biceps muscle, is made up of 2 parts: the long head and the short head. The long head of the biceps is most commonly affected by tendinitis, as the tendon from the muscle runs up the length of the arm and attaches to the labrum (a rim of cartilage) and the shoulder blade in the shoulder joint.
Biceps tendinitis results when excessive, abnormal forces are applied across the tendon, including tension (a pulling of the muscle and tendon), compression (pushing or pinching), or shearing (rubbing). When the tendon is subjected to repetitive stresses, it can become irritated, swollen, and painful.
There are many factors that may lead to biceps tendinitis, including:
- Activities requiring repetitive overhead movement of the arms, such as placing dishes in a high cupboard or lifting boxes above the head.
- Rotator cuff tears
- Weakness in the rotator cuff and muscles of the upper back
- Shoulder joint hypermobility (looseness)
- Shoulder joint and/or muscle tightness
- Poor body mechanics (how a person controls their body when moving)
- An abrupt increase in an exercise routine
- Age-related body changes
- Other pathology within the shoulder joint
How Does it Feel?
If you are experiencing biceps tendinitis, you may feel:
- Sharp pain in the front of your shoulder when you reach overhead, behind your back, or across your body
- Tenderness to touch at the front of your shoulder
- Pain that may radiate toward the neck or down the front of the arm
- Dull, achy pain at the front of the shoulder, especially following activity
- Weakness felt around the shoulder joint, usually experienced when lifting or carrying objects or reaching overhead
- A sensation of "catching" or "clicking" in the front of the shoulder with movement
- Pain when throwing a ball
- Difficulty with daily activities, such as reaching behind your back to tuck in your shirt, or putting dishes away in an overhead cabinet
- Pain when resting that may become worse at night
How Is It Diagnosed?
When you first go to see your physical therapist, the therapist will review your medical history, ask you to describe your shoulder condition, and perform a comprehensive physical exam of your shoulder and upper trunk. Your physical therapist will assess different measures, such as sensation, motion, strength, and flexibility, and may ask you to briefly perform the activities that cause your pain.
Your physical therapist will likely touch various areas on your shoulder to see which seem to be most consistently painful. Other nearby areas, such as your neck and upper back, also will be examined to determine whether they might be contributing to your shoulder pain.
Imaging techniques, such as an X-ray or MRI, are typically not needed to diagnose biceps tendinitis. However, in the event that your physical therapist suspects there are other conditions present in your shoulder, you may be referred to an orthopedist for further investigation.
How Can a Physical Therapist Help?
Once biceps tendinitis has been diagnosed, your physical therapist will work with you to develop an individualized plan tailored to your specific shoulder condition and your goals. There are many physical therapy treatments that have been shown to be very effective in treating this condition. Your treatment may include:
Range-of-motion exercises. Often, abnormal motion of the shoulder joint may contribute to biceps tendinitis. Your physical therapist will assess your shoulder motion compared to the expected normal motion and to the motion of your other shoulder. Your physical therapist will guide you through exercises to improve your shoulder’s range of motion.
Muscle strengthening exercises. The muscles of the shoulder and upper back work together to allow for normal, coordinated upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, balanced strength of all the upper-body muscles is crucial to make sure the shoulder joint is protected and is moving efficiently. Your physical therapist will choose exercises to safely strengthen the muscles around your shoulder without causing more pain.
Manual therapy. Physical therapists are trained in manual (hands-on) therapy. Your physical therapist will gently move and mobilize your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
Pain management. Your physical therapist may recommend therapeutic modalities, such as ice and heat, to aid in pain management, and reduce the need for medication, including opioids.
Functional training. Improper movements can, over time, cause pain in the body. Physical therapists are experts in assessing movement quality and in training people to function at their best. Your physical therapist will point out and correct any movements that could be causing you trouble, so you can maintain a pain-free shoulder throughout your daily activities. Often, the strategies learned through specific education from your physical therapist will allow you to avoid reversing the positive effects of your physical therapy, and help make sure that your improvements last.
Can this Injury or Condition be Prevented?
Fortunately, there is much that can be done to lessen the likelihood of biceps tendinitis. Some general tips include the following:
- Avoid repetitive overhead activities that cause shoulder pain. If you must perform these activities for your job or sport, make sure you avoid overworking your shoulder, and set aside time to properly rest it.
- Check your posture. The shoulder, neck, and back are all at risk of injury when they are held in a poor posture over a long period of time. Ask your physical therapist to discuss your work environment; describe how you move (or don't move) throughout the day.
- Avoid lifting or carrying heavy objects held away from your body. Keep items close to the body and, when possible, use both hands and both arms to carry a heavy object.
- Perform rotator-cuff strengthening exercises regularly. Your physical therapist will teach you exercises to strengthen these muscles and any others that are weak.
- Consult with a physical therapist if your symptoms are worsening despite rest.
Real Life Experiences
Doug is a 45-year-old man who works as his town's lone electrician. He is also the father of 2 children, a 10-year-old son and a newborn daughter. With the addition of the new baby, Doug’s wife has decided to take extra time off from work, so Doug has been working extra hours. Over the past month, he has felt pain in his right shoulder when making certain movements, such as reaching behind his truck seat, lifting his toolbox, and replacing several ceiling light fixtures. He is still able to work, but not without a lot of discomfort, especially after working long days. He has also started waking up in the middle of the night after having rolled onto his right shoulder, causing pain. This is starting to disrupt his wife's sleep—the little that she gets. Doug doesn't remember ever hurting his shoulder; it just seems like the pain came out of nowhere.
One of Doug's friends mentions that he had a similar issue with his shoulder and went to see a physical therapist. At the encouragement of his tired wife, Doug decides to give it a try.
Doug’s physical therapist asks him questions about his activity, work, and prior shoulder conditions. Doug mentions that in addition to putting in extra hours at work, he has also just started coaching his son's Little League team and has been doing a lot of ball-throwing with the boys at practice.
Doug's physical therapist conducts a thorough assessment. She compares the motion and strength of each shoulder, and conducts tests to help determine the source of Doug's pain. She explains that his rapid increase in activity (work and baseball), specifically doing tasks that place his arm overhead for sustained or repetitive motions, has led to his developing biceps tendinitis.
Over the next 4 weeks, Doug works with his physical therapist 2 times a week to decrease his shoulder pain. She uses manual therapy techniques to improve the mobility of his shoulder joint, and prescribes a progressive exercise program to strengthen the muscles of his shoulder and upper back. She adapts the program to meet Doug’s crazy schedule. She even suggests that he make the exercises a fun father-son time!
Within 6 weeks, Doug is amazed by his progress. His shoulder pain has diminished, and he feels stronger than he has in a long time. He notes that he can work longer without developing aches and pains.
At his last physical therapy session, Doug reports that, best of all, he can rock his baby girl and toss a ball with his son in the backyard as much as he likes!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, injuries.
- A physical therapist who is a board-certified clinical specialist or who has completed a residency in orthopedic or sports physical therapy, as they will have advanced knowledge, experience, and skills that apply to an athletic population.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with shoulder pain.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of arthritis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Schickendantz M, King D. Nonoperative management (including ultrasound-guided injections) of proximal biceps disorders. Clin.Sports Med. 2016;35(1):57–73. Article Summary on PubMed.
Wilk KE, Hooks TR. The painful long head of the biceps brachii: nonoperative treatment approaches. Clin.Sports Med. 2016;35(1):75–92. Article Summary on PubMed.
Timmons MK, Thigpen CA, Seitz AL, et al. Scapular kinematics and subacromial-impingement syndrome: a meta-analysis. J Sport Rehabil. 2012;21(4):354–370. Article Summary on PubMed.
Longo UG, Loppini M, Marineo G, et al. Tendinopathy of the tendon of the long head of the biceps. Sports Med Arthrosc. 2011;19(4):321–322. Article Summary on PubMed.
Nho SJ, Strauss EJ, Lenart BA, et al. Long head of the biceps tendinopathy: diagnosis and management. J Am Acad Orthop Surg. 2010;18(11):645–656. Article Summary on PubMed.
Thigpen CA, Padua DA, Michener LA, et al. Head and shoulder posture affect scapular mechanics and muscle activity in overhead tasks. J Electromyogr Kinesiol. 2010;20(4):701–709. Article Summary on PubMed.
Senbursa G, Baltaci G, Atay A. Comparison of conservative treatment with and without manual physical therapy for patients with shoulder impingement syndrome: a prospective, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2007;15(7):915–921. Article Summary on PubMed.
* PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Wilfred Diaz, PT, DPT, board-certified orthopaedic clinical specialist. Authored by Laura Stanley, PT, DPT, board-certified sports clinical specialist. Reviewed by the editorial board.