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Bicep Tendonitis: Shoulder Pain and Treatment

By Last updated on September 29th, 2022September 29th, 2022No Comments

The soft tissues in our bodies allow us to have a full range of motion. The term “soft tissue” encompasses most of the muscle, tendon, and cartilage in our bodies – the tissues which are not bone.

The interaction between bone and soft tissue help to facilitate our range of motion but this interaction is fragile as our soft tissues can become damaged or injured over time. Specifically, tendons are responsible for this interaction as they attach muscle to bone thereby enabling motion.

With overuse or repetitive use, they can wear down and upset the delicate nature of the relationship between bone and muscle. When tendons break down, pain in the form of tendonitis (sometimes spelled as tendinitis) occurs. The causes of this pain may vary from patient to patient but generally, the treatment is similar.

The symptoms of tendonitis can be spotted easily but must be treated quickly depending on the severity of the injury. Once diagnosed, there are several treatment options available to patients that are worth considering.

Tendons of the Bicep

Tendons of the Bicep

Tendons are the tissue that connects muscle to bone throughout the body. They appear all over the body and play an active role in most of our movements. Their main function is to allow the muscles to have an anchor to the bone. 

This anchor creates a tether that converts the contractions in the muscles to movement by tightening and elongating the tendons which connect to neighboring bone structures. Tendons are not to be confused with ligaments; whose purpose is to connect bone to bone rather than muscle to bone.

In the bicep muscle, two tendons connect to the bone and are largely responsible for most of the movement of the shoulder – the long head and the short head. The short head tendon reaches up from the bicep at an angle and attaches it to the front of the shoulder blade. The long head tendon wraps around the outside edge of the upper arm and attaches to a point in the shoulder directly behind the end of the short head tendon. 

Tendonitis usually occurs in the long head tendon where it wraps around the edge of the shoulder but may happen at any point in either tendon due to injury, overextension, or tearing. It is not uncommon for a patient suffering from bicep tendonitis to feel pain in either the shoulder, upper arm, or elbow area. Depending on the person’s career or daily activity level, this can cause a great disturbance to their way of life.

What Is Bicep Tendonitis?

As the long head of the tendon detaches from the bone, a patient may feel pain in that area as well as weakness or soreness in the shoulder or elbow. Bicep tendonitis typically develops simultaneously with other issues involving the shoulder. 

These issues can include arthritis, complications from a dislocation, chronic pain/inflammation, issues with the rotator cuff, and general degeneration. If the muscle is being used often, such as in an athlete who plays a sport that requires overhead motions, the repetition can play a role in the injury as well. Similar to tennis elbow, bicep tendonitis can occur when the muscle is overworked.

Signs and Symptoms

One of the first signs of bicep tendonitis is pain in the shoulder area or elbow. This pain is more likely to occur during activity, especially involving overhead motion. Sometimes a patient will experience numbness or tingling as if these areas are falling asleep due to their nerves being pinched

In some cases, the patient will experience what is called “Popeye Arm”, which is characterized by a swelling of the bicep muscle.

Diagnosing Bicep Tendonitis

The aforementioned symptoms can help a doctor pinpoint the location of an injury but to truly diagnose bicep tendonitis, it is often necessary to use multiple diagnostic tools. Doctors can use ultrasound technology or MRIs to assess the condition of the tendon and its attachment to the bone. 

MRIs can also be used to determine the health of the tissue surrounding the injury and this helps influence the doctor’s treatment recommendation. MRI technologies allow doctors to locate the exact source of the pain and clearly understand its underlying cause so that it may be treated effectively.

Some doctors will also use X-ray technology. X-rays display the bones surrounding the bicep clearly which can help indicate a deeper structural issue that may be causing or contributing to the tendonitis. Because tendonitis occurs at the same time as other injuries or issues, X-rays are used to ensure that the chosen treatment will alleviate all of the underlying causes of pain.

How is Bicep Tendonitis Treated?

Doctors will initially recommend non-invasive treatments for the patient such as over-the-counter anti-inflammatory medications, as well as an application of ice and compression, and rest. Many bicep tendonitis flare-ups can be treated with these 3 practices alone. The body has an amazing way of healing itself. If the patient’s lifestyle allows them to take a break to allow for healing, then they can let the tendon recover on its own.

Some patients go through physical therapy to strengthen the bicep and its surrounding muscles. By boosting the performance of the surrounding muscle tissues, the biceps, and their associated tendons have less load befall on them, limiting the casual factors of pain. Another conventional treatment option for bicep tendonitis is cortisone steroids. 

These come in the form of injections and are relatively effective in managing pain levels and inflammation. Unfortunately, studies have shown that while cortisone steroids are an effective pain management tool, over time these injections can further degenerate tissue and inflame the injuries which they are meant to treat.

Though conventional treatment options may be enough for minor cases of bicep tendonitis, severe cases will require more drastic treatment methods. To assess the severity of the bicep tendonitis, doctors take into account how detached the tendon is from the bone, how worn the tissues are, the degree of inflammation caused by the injury, and the amount of pain that the patient is in. 

When the tendon has detached completely from the bone, it is often necessary to jump to the most drastic treatment option – surgery.

Bicep tenodesis is the formal name for bicep tendonitis surgery. Doctors have several options for surgical treatment. If the tendon has detached completely or is nearing complete detachment, a screw-like medical device can be used to reattach the tendon to the bone.

In other cases, surgeons perform what is called arthroscopy. This technique involves the use of an instrument called an arthroscope, which is simply a very small camera that surgeons use to examine the tissue surface as they perform the surgery. By using the arthroscope, surgeons can reduce the invasiveness of their procedures and help guide their surgical instruments to the correct location.

If it becomes evident that the pain is caused by more than one underlying issue, surgery is often the method used to treat pain as it can help treat the other causes of pain as well. In these instances, doctors elect for highly invasive open surgery so that allows them to reach various portions of the bicep at once.

Complications of Bicep Surgery

Any surgery will come with a risk of complications. Though the risk is generally small, it is necessary to be aware of what could go wrong. If bicep tenodesis is being performed alongside other shoulder operations, which is often the case, the risk for complications increases. These operations are typically performed under anesthesia which comes with risks. 

Patients with weakened immune systems from diabetes, kidney or liver disease, or autoimmune diseases are at a greater risk of these complications. Rarely, anesthesia can come with the risk of stroke, heart attack, blood clots, pneumonia, and even death – these risks are more likely in elderly patients. Chondrolysis is also a condition often associated with arthroscopy. Chondrolysis refers to a deterioration of cartilage that can be catalyzed by forms of anesthesia.

Surgery can also come with non-anesthesia-related complications such as infection, bleeding, nerve damage, and stiffness. Nerve damage can come in several forms and can often be repaired over time with physical therapy and the body’s natural healing processes. It may become necessary for further medical intervention if nerve damage begins to interfere with daily activities. Stiffness after shoulder surgery is fairly common and almost always goes away within the first 3 months following surgery.

Additionally, depending on the post-operative symptoms, doctors may elect to perform a second surgery. This is called “revision surgery” and is known to have a low success rate. Revision surgeries are typically performed to relieve pain in the shoulder area post-surgery. The success of revision surgery is influenced by several factors, including the number of previous surgeries, muscle strength, and tissue health. 

This is often viewed as a last resort and should be discussed only if physical therapy and conventional methods of healing are not effective after the initial operation.

Though it is sometimes deemed necessary to undergo surgery, they are not often covered by insurance which makes cost another determining factor in treatment. In addition to the high cost, recovery time can take months leaving a person unable to work or perform other daily activities. 

Some patients have begun to consider other treatments because of these reasons.

Alternative Methods for Treating Bicep Tendonitis

In recent years, some patients have been turning to alternative methods to treat the shoulder or elbow pain caused by bicep tendonitis. Two of the most effective alternative procedures are cell-based therapies and platelet-rich plasma (PRP) therapy.

These are less invasive and painful methods than conventional treatments and are outpatient procedures, which means you can go home right after the process. Both cell-based therapies and PRP therapy have a short recovery time.

Cell-Based Therapies

Stem cell or cell-based therapies take the patient’s own cells or “autologous” tissues, concentrate them, and reinject them into the pain site. Depending on your shoulder condition, your doctor may opt for one of the two types of cell-based therapies:

  • Minimally Manipulated Adipose Tissue (MMAT) Transplant. It involves replacing damaged cells in the shoulder with healthy adipose (fat) tissue to promote healing. One benefit of MMAT is that your doctor can perform it in multiple locations in the same procedure. 
  • Bone Marrow Concentrate (BMAC). This procedure replaces the damaged cells in your shoulders with highly concentrated cells from your bone marrow. 

Both cell-based procedures are performed within 1.5 to 2 hours. The doctor will put you under anesthesia for comfort and use a live X-ray (fluoroscopy) or ultrasound to ensure the exact transplant location. 

PRP Therapy 

PRP therapy involves isolating platelets from the patient’s blood plasma, concentrating them, and then reinjecting them into the injury site. Platelets contain 10 Growth Factors that are used to help the body heal. They also attract healthy cells in the blood and produce fibrin, a sticky web that supports the development of new tissues. 

Once injected, the number of growth factors surrounding the injury site increases and, in turn, speeds up the healing process. PRP therapies have been scientifically proven to reduce pain in patients experiencing it in their muscles, tendons, and cartilage. The procedure takes about 45 minutes to complete. 

Cell-based therapies and PRP can help patients with pain associated with bicep tendonitis when the tendon is ripped, damaged, or inflamed. Inflammation typically goes away in a matter of days, and pain should be significantly reduced in only several weeks. 

Dr. Matthew HC Otten

Director of Regenerative Orthopedic and Sports Medicine
Fellowship-trained & Board Certified in Sports medicine
Director Angiography at Harvard Clinical Research Institute
Michigan State University Alumni

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