Biceps Tendinopathy: Overview and Evidence Summary

Condition Overview

Biceps tendinopathy refers to irritation, overload, or degenerative change of the long head of the biceps tendon (LHBT) as it travels through the bicipital groove and into the shoulder joint. This tendon plays an important role in shoulder stability, assisting the rotator cuff in controlling humeral head movement during elevation and rotation. Because of the tendon’s close relationship with surrounding structures—including the rotator cuff, labrum, and subacromial space—biceps tendinopathy often coexists with other shoulder conditions.

Symptoms typically develop gradually rather than from a single incident. Patients commonly report pain at the front of the shoulder, tenderness over the bicipital groove, and discomfort with lifting, reaching overhead, or supination-based activities such as turning a screwdriver. Rotational movements that tension the LHBT may also provoke symptoms. Night pain when lying on the affected side is not unusual.

Modern understanding of biceps tendinopathy emphasizes tendon overload and capacity mismatch rather than simple inflammation. Microstructural changes within the tendon—such as collagen disorganization and altered cell turnover—reduce its ability to tolerate load, leading to persistent pain with activity. Successful rehabilitation focuses on gradually rebuilding tendon capacity while improving shoulder mechanics and reducing excessive strain on the biceps.

Summary of Current Evidence for Biceps Tendinopathy

Evidence-Based Management Discussion

Understanding the Condition

The long head of the biceps tendon is exposed to significant mechanical stress as it crosses the shoulder joint. It acts not only as a shoulder flexor and forearm supinator but also as a dynamic stabilizer. When the surrounding rotator cuff and scapular muscles fail to control humeral head movement effectively, the LHBT may be forced to absorb excessive strain. Over time, this can lead to tendinopathy.

Contrary to the old model of “tendon inflammation,” most symptomatic cases reflect degenerative adaptation. The tendon becomes less efficient at tolerating load, making ordinary movements painful. Rehabilitation, therefore, focuses on gradually restoring tendon capacity rather than attempting to eliminate inflammation alone.

Exercise Therapy

Tendon-specific loading is the central component of treatment. Effective rehabilitation programs typically include:

• Isometric exercise to reduce pain and maintain muscle activation early on

• Eccentric loading to stimulate tendon remodeling

• Heavy–slow resistance (HSR) for strengthening and long-term adaptation

• Scapular stabilizer and rotator cuff strengthening to optimize shoulder mechanics

Exercises involving resisted supination, flexion, and shoulder elevation should be progressed carefully to avoid excessive early strain on the tendon.

Training the kinetic chain—thoracic spine, trunk, and hips—is especially important for athletes and active individuals. When movement efficiency improves globally, the biceps tendon experiences less overload locally.

Manual Therapy

Manual therapy can support rehabilitation by reducing pain, improving soft tissue flexibility, and addressing associated movement restrictions. Techniques may include soft tissue work around the anterior shoulder, mobilization of the glenohumeral joint, and thoracic spine mobilization. These interventions help create a more favorable environment for active strengthening.

Medications and Injections

NSAIDs may help with early symptom management but should not be relied upon for long-term improvement. Corticosteroid injections can reduce pain briefly but come with risk—tendons exposed to repeated steroids may weaken. As such, injections should be used sparingly and only when pain significantly limits rehabilitation.

Surgical Considerations

Surgery is rarely necessary for isolated biceps tendinopathy. When pursued, it is typically in the context of additional shoulder pathology such as rotator cuff tears or superior labral lesions. Procedures may include tenodesis or tenotomy, depending on the patient’s age, function, and activity demands.

References

American Academy of Orthopaedic Surgeons. Management of Rotator Cuff Injuries: Clinical Practice Guideline. 2025.

Severud, E., et al. “The Biceps Tendon: Function, Pathology, and Management.” Journal of Shoulder and Elbow Surgery, 2005 and updates.

Cools, A., et al. “Rehabilitation of the Shoulder Complex: Integrating Kinetic Chain Principles.” Sports Medicine, 2015.

Lewis, J. “Rotator Cuff Related Shoulder Pain: Contemporary Concepts and Rehabilitation Approaches.” British Journal of Sports Medicine, 2018.

Littlewood, C., et al. “Exercise-Based Management of Shoulder Tendinopathies.” Journal of Orthopaedic & Sports Physical Therapy, 2015.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.