Tendinopathy in the long head of the bicep

Previous newsletters have reviewed the mechanism of injury, pathophysiology, rehab approach, and use of non-steroidal anti-inflammatory medications in the treatment of tendon injuries. Physiotherapist and writer Chris Mallac recently took a deep dive looking at  the tendon of the long head of the biceps (LHB). Injuries to this tendon occur in overhead athletes, swimmers, and cross fit athletes. Be curious about athletes who visit your clinic but don’t play sports at risk high for this injury. Perhaps they wait tables – holding trays overhead stresses this tendon as well. Symptoms include pain on movement, palpation, and weakness of the biceps.

The tendon originates from the supraglenoid tubercle on the scapula and the joint labrum, courses over the humeral head through a synovial sheath, and travels down the bicipital groove on the humerus (see figure 1). Often associated with rotator cuff injuries, tendinopathy of the LHB can occur in isolation from repetitive use or sudden strain. Polish researchers evaluated specimens extracted from arthroscopic bicipital tenodesis in subjects with known tendinopathy of the LHB, and found evidence of degeneration and hypervascularisation (1). The findings were  similar to the known composition of tendinopathy in tendons elsewhere in the body, indicating a pathological process at work, not simply a mechanical one.

Figure 1: Anatomy of long head of the biceps tendon


A recent study at the University of Colorado examined the efficacy of a combination of dry needling, eccentric-concentric exercise, and stretching of the LHBT (2). The researchers treated 10 subjects with chronic LHB tendinopathy during two to eight sessions each. Pain decreased and function increased in this study, but given the small number of subjects, the combination therapy, and the lack of controls, its hard to determine which intervention was efficacious.

What is known is that tendons respond to slow and heavy loads, whether through an eccentric contraction, concentric, or both. Tracy Ward explains in the review of treatment strategies for tendinopathy, how to incorporate these activities into a progressive rehabilitation strategy. In Part II of his examination of the LHB tendon, Mallac demonstrates PNF patterns that recruit the bicep (see figure 2). Exercises using PNF patterns are highly adaptable and customisable, enabling athletes to begin resistance training, and healing, as soon as tolerated.

Figure 2: PNF patterns for LHB tendinopathy

PNF D1 pattern: Left = start position; Right = finish position

PNF D2 pattern: Left = start position; Right = finish position


  1.  Folia Morphol. 2018;77(2): 371–7 
  2. 2018 Jun 22:1-11
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