Long head of biceps tendinopathy 2026 update

Clinical synthesis based on the international Delphi McDevitt 2022, the BMC 2023 scoping review, the prospective Clin Orthop 2025 data and the meta-analyses of Cook & Purdam, Hegedus and Coombes.

What are the fundamentals to know about long head of biceps tendinopathy?🔗 Copy

How is this condition defined, who does it affect and what are the risk factors?

Long head of biceps tendinopathy, abbreviated LHB or LHBT in the literature, is an essentially degenerative disorder of the tendon in its intra-articular and bicipital portion, with disorganisation of the collagen fibres, an increase in ground substance and neovascularisation. Histopathology shows little or no acute inflammation, which is why the historical term “tendinitis” should be abandoned.¹ ²

The condition is rarely isolated. A scoping review published in 2023 in BMC Musculoskeletal Disorders concludes that the great majority of long head of biceps disorders coexist with rotator cuff pathology, and surgical series report comorbidity in up to 93 % of cases.² ³ A classic distinction is drawn between primary tendinopathy (direct mechanical impingement in the bicipital groove) and the far more frequent secondary tendinopathy, which follows from instability or from lesions of the adjacent structures.

A prospective study published in Clinical Orthopaedics and Related Research in 2025 (n = 500 symptomatic adult shoulders, mean age 55, 49 % men) quantified the effect of age for the first time: the prevalence of long head of biceps abnormalities on MRI rises by about 4 % per year of age and remains strongly linked to concomitant cuff tendinopathy.⁴ This finding recentres the clinical reading: LHB tendinopathy is above all a marker of global degeneration of the subacromial complex. 🧓

The risk factors can be grouped into two categories:

• Extrinsic : repetitive overhead sports (throwing, swimming, tennis, volleyball, weightlifting), an abrupt increase in training load, subacromial impingement, anterior glenohumeral instability and repetitive overhead manual work.⁵ ⁶
• Intrinsic : a zone of relative hypovascularity in the intra-articular portion (the critical zone described by Refior & Sowa in 1995), the morphology of the bicipital groove (shallow, with a prominent medial wall), subscapularis weakness, scapular dyskinesis, ageing and hormonal status (post-menopause).⁵ ⁷ ⁸

What happens in the body, and how does long head of biceps tendinopathy evolve?

The pathophysiology follows the continuum model proposed by Cook & Purdam in 2009 in the British Journal of Sports Medicine, a model that still structures how tendinopathy is read clinically at every site.⁹ Three stages:

1. Reactive tendinopathy : a non-inflammatory proliferative response to acute overload. The tendon thickens transiently to reduce stress. A reversible stage if load is managed.⁹ 📈
2. Tendon dysrepair : a disorganised attempt at healing, with increased proteoglycans, fibre separation, neovascularisation and increased innervation contributing to chronicity.²
3. Degenerative tendinopathy : irreversible structural change, cell apoptosis, marked collagen disorganisation. Increased risk of partial or complete rupture.⁹ ¹⁰ 📉

Left untreated, the natural course tends towards chronicity in a substantial fraction of cases, with worsening of the associated cuff lesions, tendon weakening and a risk of spontaneous rupture (classically presenting as the “Popeye sign”). Conversely, when complete rupture occurs on an advanced tendinopathy, the functional consequences are often modest (a loss of 8-20 % of strength in supination and elbow flexion depending on the series), because the short head and the supinator partly compensate.¹¹

How do you assess and diagnose long head of biceps tendinopathy with certainty?🔗 Copy

Diagnosing LHB tendinopathy is above all a diagnosis of correlation : anterior shoulder pain is non-specific, and the reliability of clinical tests taken in isolation is limited.¹ ² The best strategy combines a careful history, a battery of at least two or three tests that provoke pain in the bicipital groove, differential diagnosis manoeuvres and, where needed, targeted imaging.

Which questions should you ask to understand the patient and their history?

History-taking should explore several lines 🤔 :

• Location : anterior pre-deltoid pain, classically in the bicipital groove, sometimes radiating towards the biceps brachii.³
• Mechanism : gradual onset (overuse, overhead sport) vs acute trigger (resisted supination effort, trauma).
• Joint noises : popping or snapping during glenohumeral rotation → suspect tendon instability, a pulley lesion or a subscapularis tear.⁴
• Aggravating factors : overhead movements, carrying loads, resisted supination, sleeping on the affected side.
• Past history : glenohumeral dislocations, trauma, previous injections, chronic overhead sport, manual occupation.
• Yellow flags : kinesiophobia, low self-efficacy, negative expectation. Chester 2018 (BJSM, n = 1030) showed that these psychological variables predict the outcome of physiotherapy more strongly than the structural clinical examination.⁵

Which clinical tests should you perform, and which other conditions should you rule out?

The landmark meta-analysis by Hegedus (BJSM 2012, updated 2017) concluded that no single test has sufficient diagnostic value to confirm or rule out LHB involvement.¹ ² The sensible strategy is to combine several tests with palpation. A recent diagnostic study in a surgical population (Erickson 2019) confirmed that,as a cluster, the Upper Cut plus palpation give the best characteristics (sensitivity 88 % in parallel, specificity 93 % in series).⁶ ⁷

Differential diagnosis: a non-negotiable step 🎯

The high prevalence of concomitant conditions calls for a structured approach:

• Subscapularis tear : the tendon forms the roof of the biceps pulley; its rupture is the major mechanical cause of LHB instability. The Belly-press and the Lift-off should be performed systematically.⁸
• SLAP lesion (biceps anchor): the Biceps Load II (Kim 2001, n = 127) remains the best-performing single test (sens 89.7 %, spec 96.9 %).⁹
• Subacromial impingement : Neer and Hawkins-Kennedy can provoke referred pain in the groove without any primary LHB involvement.
• Suprascapular nerve entrapment at the spinoglenoid notch: posterolateral pain that may be felt anteriorly, weak external rotation, infraspinatus atrophy. To be considered where conservative treatment fails unexpectedly.¹⁰
• C5-C6 radiculopathy : cervicobrachial pain, motor or sensory deficit, positive Spurling.

Imaging

• Dynamic ultrasound : the first-line investigation. It assesses thickening, tenosynovitis and subluxation on rotation. Operator-dependent.¹¹ ¹²
• MRI : sensitivity 67-94 %, specificity 75-100 % depending on the lesion; it remains the gold standard for the global work-up (LHB + cuff + labrum + bone).¹³
• MR arthrography : useful where a SLAP lesion or a refractory pulley lesion is suspected.

Should patients with long head of biceps tendinopathy be classified?

Yes. Classification improves interprofessional communication, guides treatment and refines the prognosis. A scoping review published in 2025 (PMID 40606699) surveyed every existing system (Walch, Habermeyer, Lafosse, Boileau, Itoi, Bennett) and proposed a new 4-stage arthroscopic classification (A: normal, B: erythema, C: fraying, D: labral involvement).¹⁴

For clinical physiotherapy practice, the functional classification by anatomical zone is the most workable:

1. Zone A, extra-articular (bicipital groove) : tendinopathy, tenosynovitis. Responds well to conservative treatment (exercise, MT, education).
2. Zone B, junction / pulley : a lesion of the reflection pulley (Habermeyer / Bennett), often associated with a partial tear of subscapularis and supraspinatus. A cause of instability (subluxation, dislocation). Treatment is often surgical.¹⁵
3. Zone C, intra-articular : SLAP lesion, involvement of the biceps anchor. The strategy depends on age, activity and severity.

Which treatment strategies are the most effective for long head of biceps tendinopathy?🔗 Copy

Where do you start? What is the recommended hierarchy of interventions?

Conservative treatment is the undisputed first line. The international Delphi by McDevitt (Int J Sports Phys Ther 2022, 29 experts) established consensus on 61 interventions recommended for LHB tendinopathy, organised around four pillars: education, therapeutic exercise, adjunctive manual therapy and load management.¹ The consensus recommends maintaining the conservative approach for at least 12 weeks before any escalation to surgery (tenotomy or tenodesis).¹ ²

What is the place of exercise, and is there a superior approach?

Exercise is the central pillar and the intervention with the strongest consensus (strong recommendation, McDevitt 2022). No single modality has shown absolute superiority, but effective programmes share:

• Progressive loading : isometric (analgesia, Rio 2015) → heavy slow isotonic resistance (HSR, Kongsgaard / Beyer) → ballistic and plyometric work for overhead athletes.³ ⁴ ⁵
• Rotator cuff strengthening : essential, because humeral centring determines the mechanical load on the LHB.⁶
• Scapular control : lower trapezius, serratus anterior. Scapular dyskinesis is a major contributing factor in the painful shoulder.⁶ ⁷
• Pain tolerance : a simple rule validated by Smith 2017. Pain ≤ 4/10 during exercise, stable or decreasing within 24 h, allows load to progress.⁸

Manual therapies, technologies: how effective are they really?

• Corticosteroid injections : the landmark meta-analysis by Coombes (Lancet 2010, 41 RCTs) remains the reference. Benefit in the short term (4-8 weeks), but results equal to or worse than placebo in the medium and long term, and a cumulative risk of tendon weakening. To be reserved for very painful cases alongside an exercise programme, ideally ultrasound-guided.⁹
• Extracorporeal shockwave therapy (ESWT) : the Brindisino meta-analysis (Physiotherapy Research International 2024, 21 RCTs) shows a significant effect on pain and function in calcific cuff tendinopathy at 24 weeks. The data on isolated LHB tendinopathy are insufficient, but extrapolation is reasonable where cuff comorbidity is established.¹⁰
• Manual therapy : glenohumeral, scapulothoracic and thoracic mobilisations, soft-tissue release of subscapularis. A modest but consistent benefit alongside exercise (it never replaces exercise).¹¹
• Physical modalities (TENS, laser, ultrasound): low to very low level evidence, symptomatic value only.

Beyond the physical: how do you educate the patient and address psychological factors?

Education is a treatment in its own right, not an add-on. Three priority lines:

1. Explaining the condition : tendinopathy is a problem of load capacity, not a “tear” or “irreversible damage”. This reframing reduces kinesiophobia.¹² ¹³
2. Active load management : pacing, planning, alternating phases of stress and recovery. Tools: an activity diary, a smartphone app.
3. Adherence to the exercise programme : the patient must understand that this is the principal intervention and that the benefits are gradual (4 to 12 weeks before the peak effect).

Chester 2018 (BJSM, n = 1030) showed that psychological factors (self-efficacy, expectation of recovery, severity of pain at rest) are more strongly associated with the outcome than structural clinical signs.¹³ Assessing kinesiophobia (TSK-11), catastrophising (PCS) and depression (PHQ-9) should be part of the initial work-up.

The biceps, victim or culprit? Understanding the coupling with the rotator cuff.🔗 Copy

Why are more than 90 % of LHB tendinopathies associated with the cuff?

The BMC 2023 scoping review and several surgical series converge: between 36 % and 93 % of long head of biceps disorders coexist with rotator cuff involvement, particularly of subscapularis and supraspinatus.¹ ² The prospective Clin Orthop Relat Res 2025 study (n = 500 MRIs) confirms the linear LHB-cuff-age association.³ This near-systematic comorbidity has led several authors to reframe the fundamental question: is pain attributed to the LHB primary (disease of the tendon itself) or secondary (excessive demand compensating for a failing cuff)?

This finding has major therapeutic implications :

• Treating the biceps in isolation (stretching, self-massage, local injection) without correcting the cuff or scapular deficit is bound to fail.
• The exercise programme must be centred on the cuff and the scapula, the biceps being only a secondary component.
• The initial assessment must systematically include the cuff tests (Belly-press, Lift-off, Jobe, drop arm, external rotation lag sign).

How do you assess the overhead athlete: a stratification strategy?

The overhead athlete (thrower, swimmer, tennis player, volleyball player, baseball player) has a specific risk profile: repetitive overload, micro-traumatic anterior instability, scapular dyskinesis and internal rotation deficit (GIRD) combined. Cools 2015 (Braz J Phys Ther) proposes a structured 4-step approach to prevention and return to play:⁴

1. Identify the risk factors : GIRD > 18°, total arc of motion deficit > 5°, visible scapular dyskinesis, weak external rotation.
2. Establish normative criteria : ranges of motion, isokinetic strength, strength ratios (internal/external rotation).
3. Apply a prevention programme : posterior stretching (sleeper stretch), specific cuff and scapular strengthening, motor control.
4. Return-to-sport criteria : strength ≥ 90 % of the contralateral side, IR/ER ratio ≥ 0.66, sport-specific plyometric tests without pain.

How do you secure lasting recovery and prevent recurrence?🔗 Copy

How do you make the patient an active participant in their recovery through self-management?

Patient autonomy is a major predictor of therapeutic success.¹ ² Three concrete pillars:

• Symptom monitoring : the patient learns to use pain as a signal. A simple validated rule (Smith 2017): pain ≤ 4/10 during exercise, stable or decreasing within 24 h.³
• Load management (pacing) : avoid spikes in activity, use a diary or an app, watch the acute-to-chronic workload ratio (ACWR < 1.3-1.5 in athletes).⁴
• Autonomy in the exercise programme : the patient understands the “why” of each exercise and knows how to progress or regress according to their response. A simple programme, doable at home, with functional goals.⁵

When and how should a safe return to sport and to activity be planned?

Return to sport (RTS) must be criteria-based and not based on a fixed delay.⁶ ⁷ Progression follows the rehabilitation continuum:

1. Pain control : isometrics in non-provocative positions (Rio 2015).⁸
2. Restoring load capacity : HSR (Heavy Slow Resistance, Kongsgaard/Beyer) for the cuff and the biceps, up to 3-4 sets of 6-8 repetitions at 80 % of 1-RM, 2-3 times a week for 12 weeks.⁹
3. Energy storage and release : progressive plyometrics, with medicine-ball throws, ballistic press-ups and push-press.
4. Return to sport : submaximal sport-specific patterns, then controlled progression of volume and intensity.

What do real clinical cases teach us about long head of biceps tendinopathy?🔗 Copy

Case 1: young volleyball player, isolated tendinopathy (Inglis 2024)

A case report published in 2024 (PMC11262752) documents the rehabilitation of a young volleyball player with proximal biceps tendinopathy. The programme combined education about the condition, load management, eccentric exercise with a kettlebell, kinesiotaping and a structured progression over several weeks.¹ The course was favourable, with a gradual return to play. This case illustrates the value of a targeted conservative programme in an overhead athlete without major structural cuff involvement.

Case 2: the diagnostic challenge of suprascapular nerve entrapment

Reviews of suprascapular neuropathy series (Memon 2018, n = 88) show that these entrapments often present with anterolateral shoulder pain, sometimes with weak external rotation and infraspinatus atrophy. The diagnosis is regularly made late because clinical biceps tests can be positive (referred sensitisation), delaying treatment.² The further work-up includes EMG and nerve conduction studies and an MRI looking for a paralabral cyst at the spinoglenoid notch. Treatment ranges from targeted rehabilitation to surgical decompression.

Case 3: Boileau's hourglass biceps and spontaneous rupture

The landmark series by Boileau (J Shoulder Elbow Surg 2004) described 21 patients with an “hourglass biceps”: a hypertrophic intra-articular tendon, trapped in the groove when the arm is elevated, causing pain and marked restriction.³ A dynamic intraoperative test reproduces the phenomenon. Every case but one was associated with a cuff tear. Treatment consists of tenotomy or tenodesis after resection of the hypertrophic intra-articular portion. The arthroscopic technique for identifying and managing it was specified by Xu 2022 (Arthroscopy Techniques, PMID 35782846).⁴

The spontaneous rupture of the LHB on chronic tendinopathy produces the famous “Popeye sign” (Pawar 2020, J Orthop Case Reports). The deformity is striking, but the functional consequences are modest after rehabilitation: strength loss is estimated at 8-20 % in supination and elbow flexion, often compensated by the short head and the supinator.⁵ Conservative treatment is preferred in older, less active patients; tenodesis is discussed in younger or active patients and in those concerned about appearance.

How do you apply these recommendations concretely in your practice?🔗 Copy

When and to which other health professionals should you refer?

Referral is not an admission of failure, it is part of patient-centred care.

• GP / sports physician : the pivot of a coordinated pathway. Systematic referral where red flags are present (non-mechanical night pain, weight loss, fever, progressive neurological deficit, Finucane 2020).¹
• Rheumatologist : suspected rheumatoid arthritis, spondyloarthritis or polymyalgia rheumatica in the older patient.
• Orthopaedic surgeon : failure of conservative treatment at 12 weeks, subscapularis tear, hourglass biceps, irreparable pulley lesion, symptomatic type II SLAP lesion in the young athlete.²
• Psychologist / CBT : predominant yellow flags (marked kinesiophobia, catastrophising, depression). CBT alongside physiotherapy improves outcomes in chronic musculoskeletal pain.³
• Strength and conditioning coach : optimise the return to the sporting movement, plan load, monitor the ACWR.

How do you measure outcomes and overcome barriers to implementation?

The use of PROMs is indispensable. For the shoulder, the validated and recommended tools are:

• DASH (Disabilities of Arm, Shoulder, Hand), 30 items, MCID ≈ 10 points.
• QuickDASH , the short 11-item version, MCID ≈ 8 points.
• ASES (American Shoulder and Elbow Surgeons), 100 points (pain 50 + function 50), MCID ≈ 12-17 points.
• SPADI (Shoulder Pain and Disability Index), 13 items, MCID ≈ 8-13 points.
• VAS / NPRS for pain, MCID ≈ 2 points.

The Goal Attainment Scaling (GAS) makes it possible to individualise the goals (3-5 goals rated -2 to +2) and to quantify attainment; its psychometric validity in rehabilitation was reconfirmed by Krasny-Pacini 2019.⁴

The barriers to implementing recommendations are well documented (Slade 2022, JOSPT): lack of time, low confidence, long-held clinician beliefs, lack of institutional support.⁵ The effective strategies:

1. Interactive continuing education : practical workshops beat passive reading.
2. Audit + feedback : analysing your actual practice, identifying the gaps.
3. Local opinion leaders : “champions” within practices or networks.
4. Integrated tools : PROMs and GAS inside the patient record software, to reduce the administrative burden.