Biceps tendonitis (LBS)

Quick overview

• Typical pain in the front of the shoulder, pressure pain in the groove of the biceps tendon, discomfort when lifting, carrying or rotating the forearm.
• Often the result of overload, incorrect loading or accompanying problems with the rotator cuff or the biceps pulley system.
• Diagnosis by history, clinical tests (e.g. Speed, Yergason test) and sonography; MRI if necessary.
• Therapy is initially conservative: load control, physiotherapy, anti-inflammatory measures, targeted training.
• Ultrasound-controlled infiltrations can be useful in individual cases; Surgical options only if symptoms persist or structural damage occurs.

Anatomy & Function of the Long Biceps Tendon (LBS)

The long biceps tendon arises from the upper edge of the socket (superior labrum) of the shoulder and runs through the shoulder joint into the bony biceps groove (intertubercular sulcus). There it slides in a tendon sheath and is guided and stabilized by connective tissue structures - the pulley system.

Functionally, the LBS supports the lifting and rotation of the forearm (supination) and contributes to fine stabilization of the shoulder joint, especially in overhead positions. It works closely with the rotator cuff. If there is irritation of the tendon or disruption of the gliding and guiding system, pain and loss of function occur.

Causes and risk factors

Biceps tendonitis is rarely just “an isolated tendon problem.” Often several factors increase the strain in the biceps groove or directly at the tendon origin.

• Overload/overhead sports: tennis, volleyball, throwing and climbing sports, CrossFit, swimming.
• Repeated one-sided or unusual activities at work or at home.
• Impingement and accompanying problems of the rotator cuff (e.g. tendon irritation or tears).
• Instability of the pulley system with subluxation of the LBS (tendon pops out of the groove).
• Degenerative changes with increasing age.
• Calcifications, bone spurs or narrowing of the biceps groove.
• Metabolic and lifestyle factors: diabetes, smoking, low tissue blood flow.
• Injuries or microtraumas (e.g. jerky load changes).

Typical symptoms

Those affected usually report front shoulder pain that increases with lifting and turning movements, while carrying or playing sports. The pain can radiate into the upper arm and be disturbing at night.

• Pressure pain in the biceps groove (front upper arm just below the shoulder head).
• Pain when supinating against resistance (turning the palm upwards) or when “holding” with a bent elbow.
• Painful, stabbing pull when lifting or throwing quickly.
• Occasional snapping/“clicking” due to tendon instability.
• Loss of performance, uncertainty in overhead positions.

Diagnostics: This is how we proceed

A careful clinical examination is crucial in order to differentiate LBS symptoms from other shoulder causes and to plan sensible treatment steps. Imaging complements diagnostics when it influences treatment.

In selected cases, ultrasound-guided diagnostic infiltration of the tendon sheath with local anesthetic can help to better isolate the source of the pain.

Differential diagnoses of the shoulder

• Rotator cuff tendinopathies (supraspinatus, infraspinatus, subscapularis, teres minor).
• Subacromial impingement, bursitis.
• Calcified shoulder (tendinous calcifications).
• SLAP lesions (top of the labrum) or other labral injuries.
• AC joint osteoarthritis.
• Adhesive capsulitis (frozen shoulder).
• Cervical causes (nerve root irritation) – radiating pain.

Conservative therapy – the standard

In the vast majority of cases, structured conservative treatment is successful. It combines stress control, education, physiotherapy-guided training and anti-inflammatory measures.

• Relative relief: First reduce provocations (heavy loads, rapid overhead lifting, jerky supination) - not complete immobilization.
• Medication: Short-term use of non-steroidal anti-inflammatory drugs (NSAIDs) can relieve pain and inflammation - only after individual consideration and if possible for a limited period of time.
• Cold/heat: In acute phases, local cooling (10–15 minutes), later heat to relax muscles.
• Physiotherapy: Mobi close to the joints, soft tissue techniques, coordination and neuromuscular training.
• Strength building in doses: Start with isometric exercises, transition to eccentric-concentric training of the biceps tendon, rotator cuff and scapular stabilizers.
• Posture and technique training: shoulder blade control, thoracic spine mobility, ergonomic adjustments in everyday life/job.
• Taping/Orthosis: Can provide temporary support to reduce irritation.
• Stress progression: Gradual return to sport/work with documentation of reaction and adaptation to the stress.

Typical treatment period: 6-12 weeks for noticeable improvement, sometimes longer for chronic cases. Close instructions ensure the appropriate pace and prevent relapses.

Injections and regenerative options

Infiltrations can reduce pain in the short term and make it easier to participate in therapy. They do not replace active treatment and are carefully considered.

• Ultrasound-controlled infiltration into the tendon sheath of the LBS: small amount of local anesthetic, if necessary with the addition of cortisone - not intratendinous. Goal: short-term inflammation inhibition and diagnosis confirmation.
• Number/gaps: To minimize risk, only a few, with sufficient gaps. Possible risks: skin/fatty tissue changes, infection, rarely tendon weakening.
• PRP (platelet-rich plasma): May be discussed in select cases; the evidence for LBS is mixed. Decision based on information and expectations.
• Hyaluron/ESWT: Only used to a limited extent for LBS; Decision made on a case-by-case basis, especially in the case of combined shoulder problems.

We discuss the benefits, limitations and possible side effects transparently and make a decision together.

Surgical options – only if there is a clear indication

If symptoms persist for months despite consistent conservative therapy or if there is relevant structural damage, a surgical procedure can be considered. The aim is to reduce pain and improve shoulder function.

• Indications: persistent pain/performance limit >3–6 months, larger partial tears of the LBS, pronounced instability/subluxation of the tendon, combined lesions (e.g. SLAP) – to be examined individually.
• Tenotomy: transection of the LBS with removal from the joint. Advantages: short procedure. Possible disadvantages: visual “Popeye” stomach and occasional muscle cramps.
• Tenodesis: Fixation of the LBS outside the joint (e.g. in the biceps groove). Advantages: more cosmetically stable, potentially less cramps. Requires structured follow-up care.
• Concomitant procedures: Treat impingement or rotator cuff lesions as needed.
• Rehabilitation: Short-term immobilization, early functional mobilization, load build-up in phases; heavy lifting typically only after several weeks.

The decision is always made individually and with no guarantee of complete freedom from symptoms. We value realistic expectations and evidence-based education.

Course, healing time and prognosis

With early and consistent conservative treatment, symptoms often improve within 6-12 weeks. Chronic courses require more time, but often benefit from a structured program and careful stress control.

• Return to everyday stress: often within a few weeks, depending on job/requirements.
• Sport: gradual increase; Overhead athletes often need several weeks to months.
• Relapse prevention: technique training, regular strengthening of the cuff and scapular stabilizers, sufficient regeneration times.

Self-help: acute measures and everyday tips

• Cool acutely (10–15 minutes, 2–3 times daily, pay attention to skin protection).
• Carry close to the body, forearm neutral instead of maximally supinated.
• Sleeping position: lying on your back or on your side with a pillow under your upper arm to relieve pressure on the front.
• Workplace: Move mouse/phone closer, relax shoulders, take regular micro-breaks.
• Gentle exercises: isometric biceps tension without pain, scapula retraction, thoracic spine mobility.
• Warning signals: sudden “snapping” with a bump in the upper arm (Popeye sign), persistent severe pain, significant weakness – please seek medical advice.

Prevention: How to prevent it

• Warm up and progressively increase the load, especially before overhead exercise.
• Technique training in throwing, hitting and climbing movements.
• Regular strength and coordination training for the rotator cuff and shoulder blade.
• Flexibility of the thoracic spine and stretching programs for the front shoulder line.
• Quitting smoking, controlling metabolism (e.g. diabetes) – beneficial for tendon tissue.
• Plan recovery phases and avoid peak loads.

Your treatment in Hamburg

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we combine thorough clinical diagnostics with modern sonography, structured training control and - when appropriate - ultrasound-controlled infiltrations. Our focus is on conservative, everyday therapy planning with clear goals and relapse prevention.

We would be happy to discuss with you individually which measures offer the best chance of long-term improvement in your situation - from home exercise programs to physiotherapy and any further steps that may be necessary.