What is the treatment for chronic bicep tendinopathy?

Treatment for Chronic Bicep Tendinopathy

The most effective treatment for chronic bicep tendinopathy involves a combination of relative rest, eccentric strengthening exercises, and cryotherapy, with surgery reserved only for patients who fail conservative management after three to six months. 1

Initial Conservative Management

Rest and Activity Modification

• Relative rest and reduced activity are essential first steps to prevent further tendon damage and promote healing 1
• Patients should decrease activities that involve repetitive loading of the biceps tendon, particularly overhead motions 2

Pain Management

• Cryotherapy (ice application) provides effective acute pain relief for tendinopathy 1
  • Most effective method: repeated applications of melting ice water through a wet towel for 10-minute periods 1
• NSAIDs may provide short-term pain relief but do not affect long-term outcomes 1, 3
  • Topical NSAIDs can be effective with fewer systemic side effects 1
• Corticosteroid injections into the biceps tendon sheath may provide more effective acute pain relief than oral NSAIDs 1, 2
  • Caution: these do not alter long-term outcomes and should be used judiciously 1, 3

Rehabilitative Interventions

Exercise Therapy

• Eccentric strengthening exercises are highly effective for treating tendinopathy and may reverse degenerative changes 1
• A combined eccentric-concentric exercise program with stretching has shown promising results specifically for biceps tendinopathy 4
• Exercise protocols should focus on gradually increasing load tolerance of the biceps tendon 5

Manual Therapy and Other Modalities

• Dry needling combined with exercise has shown beneficial outcomes in patients with chronic biceps tendinopathy 4, 5
• Deep transverse friction massage may help reduce pain in tendinopathies 1
• Extracorporeal shock wave therapy appears to be a safe, noninvasive treatment option, though it is expensive and shows inconsistent results 1, 3, 6
• Therapeutic ultrasound, corticosteroid iontophoresis, and low-level laser therapy have uncertain benefits 1, 6

Advanced Interventions

Newer Treatments

• Preliminary work with growth factors and stem cells shows promise but requires further study 3
• Sclerotherapy and nitric oxide patches have shown some positive early results but need larger trials to confirm effectiveness 3

Surgical Management

• Surgery should be considered only if conservative measures fail after three to six months of consistent treatment 1, 2
• Approximately 80% of patients with tendinopathies fully recover with conservative management within three to six months 1
• Surgical outcomes can be inconsistent and involve significant morbidity, making it truly a last resort option 3

Common Pitfalls and Considerations

• Misdiagnosing biceps tendinopathy as an inflammatory condition ("tendinitis") rather than a degenerative condition ("tendinosis") can lead to inappropriate treatment focus 1, 2
• Biceps tendinopathy is commonly accompanied by rotator cuff tears or SLAP lesions, which may require additional treatment considerations 2
• The most common clinical finding in biceps tendinitis is bicipital groove point tenderness with the arm in 10 degrees of internal rotation 2
• Failure to address underlying biomechanical issues or technique problems (especially in athletes) may lead to recurrence 1
• Overreliance on passive modalities without implementing active rehabilitation strategies can delay recovery 5

Diagnostic Considerations

• Ultrasonography is preferred for visualizing the overall tendon structure 2
• MRI or CT arthrography is better for visualizing intra-articular tendon pathology 2
• Local anesthetic injections into the biceps tendon sheath can be both therapeutic and diagnostic 2

1, 3, 4, 2, 6, 5