What is the treatment for biceps tendinosis?

Treatment of Biceps Tendinosis

Begin with conservative management consisting of relative rest, cryotherapy, eccentric strengthening exercises, and topical or oral NSAIDs for pain relief, reserving surgery only for patients who fail to improve after 3-6 months of consistent conservative treatment. 1

Understanding the Condition

Biceps tendinosis is a degenerative condition, not an inflammatory one, which is a critical distinction that should guide treatment decisions. 2, 1 The condition commonly affects the long head of the biceps tendon and frequently occurs alongside rotator cuff pathology. 3, 4 Approximately 80% of patients with tendinopathies recover completely within 3-6 months using conservative management alone. 1, 5

Initial Conservative Management (First 3-6 Months)

Activity Modification

• Implement relative rest by reducing activities that provoke pain, while continuing activities that do not exacerbate symptoms to maintain function and prevent muscle atrophy. 1, 5
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning. 6, 5

Pain Relief Modalities

• Apply cryotherapy using melting ice water through a wet towel for repeated 10-minute periods to provide acute pain relief. 1, 5
• Use topical NSAIDs as first-line pharmacological treatment due to fewer systemic side effects compared to oral formulations. 6, 1, 5
• Oral NSAIDs can be used for symptomatic pain relief when topical agents are insufficient. 6, 5

Rehabilitative Interventions (Core of Treatment)

• Prescribe eccentric strengthening exercises as the primary therapeutic intervention, as these are highly effective and may reverse degenerative changes in the tendon. 1, 7, 8 The evidence for eccentric training is particularly strong, with case series demonstrating significant improvements in pain and function. 7, 8
• Implement deep transverse friction massage to help reduce pain. 1, 5
• Include stretching exercises of the biceps muscle as part of the rehabilitation program. 7

Adjunctive Treatments

• Consider corticosteroid injections into the biceps tendon sheath for diagnostic and therapeutic purposes, though these provide only acute pain relief without changing long-term outcomes and should be used cautiously as they may inhibit healing. 5, 3, 4

Surgical Intervention

Reserve surgery exclusively for patients who have failed conservative management after 3-6 months of consistent treatment, or if there is severe damage to the biceps tendon. 1, 3 Surgical options include biceps tenotomy or tenodesis, which can provide substantial pain relief even when rotator cuff repair is not possible. 4

Critical Pitfalls to Avoid

• Do not misdiagnose biceps tendinosis as "tendinitis" (an inflammatory condition), as this leads to inappropriate treatment focus on anti-inflammatory measures rather than addressing the underlying degenerative process. 2, 1
• Always assess for underlying biomechanical issues or technique problems, especially in athletes, as failure to address these leads to recurrence. 1
• Do not rely solely on anti-inflammatory treatments, as the condition is degenerative, not inflammatory. 5
• Avoid premature surgical intervention before completing an adequate trial of conservative therapy. 1, 3

Diagnostic Considerations

When diagnosis is uncertain, ultrasonography is preferred for visualizing the overall tendon, while MRI or CT arthrography is better for visualizing intra-articular pathology and associated rotator cuff tears or SLAP lesions. 3, 9 The most common isolated clinical finding is bicipital groove point tenderness with the arm in 10 degrees of internal rotation. 3