Long Head of the Biceps Tendon (LHBT) Tendinopathy

What it is

This condition means that the tendon of the long head of your biceps (the upper arm muscle) is irritated or inflamed. The problem can be caused by an injury or by repeated overuse — small strain after strain over time. Usually, this issue isn’t serious, but because it can stop you from doing sports or daily activities, it’s important to treat it properly.

Anatomy (How it’s built)

The biceps muscle has two parts:

• The long head (which has a longer tendon)

• The short head (which sits closer to your chest)

The long head tendon runs through a narrow groove in the upper arm bone (called the bicipital groove) and is held in place by small ligaments (connective bands). These include:

• The superior glenohumeral and coracohumeral ligaments (main stabilizers)

• The transverse humeral ligament, which helps keep the tendon in its groove but is less important than once thought

As the tendon runs over the top of the shoulder joint, it bends sharply and attaches to the upper part of the shoulder blade (the supraglenoid tubercle). Because of this curve, the tendon helps press the upper arm bone into the shoulder socket — meaning it plays a big role in shoulder stability. However, this same position also puts the tendon under stress, which can lead to irritation or even small tears.

Causes

When you lift your arm in front or to the side, especially above shoulder height, the tendon can rub against a bony part of the shoulder blade (the acromion). Normally, shoulder movement is smooth enough to prevent irritation — but certain problems can cause friction or overloading.

Common causes include:

• Sudden jerking or pulling movements with the arm above shoulder level (for example, in sports like swimming, tennis, or volleyball)

• Trying to catch or lift something heavy overhead

• Repeated overhead motions (in sports or work) that cause tiny micro-tears in the tendon over time

Normally, your body repairs small tendon damage. But if you train too often or don’t rest enough, inflammation can build up faster than your body can heal it.

At first, the pain might go away after warming up, giving a false sense of recovery. But continuing to train like this can make things worse.

Other contributing factors include:

• Weak shoulder blade stabilizers

• Shoulder joint looseness or instability

• Tightness in the back part of the shoulder capsule

• Stiffness in the upper back

• A collapsed chest posture

• Too much internal rotation (inward turning) of the shoulder or elbow

These issues can disturb normal shoulder mechanics and cause biceps tendon irritation even in people who rarely move their arms overhead.

Symptoms

Typical symptoms include:

• Pain in the front of the shoulder that may spread down the arm

• Swelling, warmth, or tenderness

• Stiffness in the shoulder

• Pain that appears during lifting the arm above shoulder level — later even at rest or at night

  
  

Differential Diagnosis (Other possible sources of pain)

Because this is a mechanical problem, moving the shoulder should increase or reduce pain.

If the pain:

• Does not change with movement

• Gets steadily worse

• Lasts long and seems unrelated to posture or activity

→ You should see a doctor right away, as it might come from another cause

Pain in the shoulder can also come from:

• Internal organs (e.g., heart, gallbladder, diaphragm) — checked by an osteopath or visceral therapist

• Neck or upper spine compression — checked with special tests by a physiotherapist

Those reasons should be investigated if the pain is in front of the shoulder, but no signs of inflammation can be found.

Diagnosis

Tests like the Speed’s test and Hawkins test are often used. The therapist may press on the tendon groove on both arms to compare tenderness. Ultrasound (USG) can show inflammation or small tears. X-rays help rule out bone injuries or arthritis. An MRI is the best tool if a more serious injury (like a SLAP tear) is suspected.

Treatment

Step 1: Remove what irritates the tendon

• Stop or modify movements that cause pain (for example, correct technique or change the provoking exercise).

Step 2: Improve posture and mobility

• Exercises that open the chest, mobilize the shoulder and neck, and restore proper posture.

• Focus especially on the thoracic spine (mid-back), shoulder, and elbow.

Step 3: Strengthen safely

• Train the biceps with controlled, slow movements (especially the eccentric phase — when lowering the weight).

• Train shoulder rotation muscles (rotator cuff) to support and offload the injured tendon.

• Work within a light pain level (maximum 3/10) if your technique is correct.

• Consult a medical trainer or physiotherapist for the best exercise plan and load.

Step 4: Local stimulation

• Gentle cross-friction massage on the tendon for 5 minutes a day to improve healing and collagen production.

Step 5: General recovery habits

• Drink 2–3 liters of water daily (dehydrated tissues are more injury-prone)

• Sleep 8 hours per night

• Consider physical therapies such as:

  • TECAR therapy (deep tissue heating)

  • Shockwave therapy

  • High-energy laser

  • Infrared lamp

Step 6: Medical options

If pain persists for over 8 weeks despite physiotherapy, an orthopedic doctor may suggest:

• Steroid injection — reduces inflammation and pain quickly but does not fix the underlying damage. Without rehab, symptoms can return.

Step 7: Surgical options (only if all else fails)

• Tenotomy: cutting the tendon to release tension

• Tenodesis: cutting the tendon and reattaching it slightly lower on the arm bone

• Subacromial decompression: shaving part of the acromion bone to create more space for the tendon

Surgery should always be followed by physiotherapy, as it restores strength, movement, and tissue healing.

References (Scientific Sources)

• Krupp RJ et al. Long Head of the Biceps Tendon Pain: Differential Diagnosis and Treatment. J Orthop & Sports Phys Ther, 2009.

• Ahrens PM & Boileau P. The Long Head of Biceps and Associated Tendinopathy. J Bone & Joint Surg, 2007.

• Cook C & Hegedus E. Orthopedic Physical Examination Tests: An Evidence-Based Approach., 2008.

• Kelly AM et al. Arthroscopic Release of the Long Head of the Biceps Tendon. Am J Sports Med, 2005.

• Sharma R & Maffulli N. Biology of Tendon Injury. J Musculoskeletal & Neuronal Interactions, 2006.