Initial Treatment for Biceps Tendinitis

Begin with relative rest, ice therapy, NSAIDs, and eccentric strengthening exercises for 3-6 months before considering invasive interventions. 1

First-Line Conservative Management

The foundation of treatment prioritizes non-invasive approaches that address both pain relief and tendon healing:

Reduce activities that cause repetitive loading of the biceps tendon, but avoid complete immobilization which accelerates muscle atrophy and deconditioning 1
For athletes and manual laborers, modify technique to minimize repetitive overhead stresses on the tendon 2, 1

Apply ice through a wet towel for 10-minute periods to provide short-term pain relief and reduce swelling 2, 1

Oral NSAIDs effectively relieve tendinopathy pain and are recommended for short-term symptom control, though they do not alter long-term outcomes 2, 1
Topical NSAIDs provide similar pain relief with reduced gastrointestinal side effects and should be preferred when treating localized biceps tendinitis 2, 1
Paracetamol up to 4g/day can be used as first-line oral analgesic due to its favorable safety profile 3

Eccentric strengthening exercises are the cornerstone of treatment, as they stimulate collagen production, reverse degenerative changes, and increase tendon strength 1
Implement stretching exercises for the biceps complex, which are widely accepted and generally helpful 1
Consider deep transverse friction massage to reduce pain 3, 4

May provide better acute pain relief compared to oral NSAIDs, but do not alter long-term outcomes 2, 1
Critical caveat: Inject peritendinously only—never inject directly into the tendon substance, as this may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 2, 1
Ultrasound-guided steroid injection showed symptomatic improvement in 12 of 16 conservatively treated cases in one case series 5

Braces or supportive bands can help reinforce and unload the tendon during activity, though evidence for effectiveness is limited 2, 1
Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 2, 1
Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 2, 1

Surgery should only be considered if conservative measures fail after 3-6 months of well-managed treatment 1, 6

Surgical options include biceps tenotomy or tenodesis, with choice depending on patient age and activity level 7, 8
Approximately 80% of patients with overuse tendinopathies fully recover within 3-6 months with appropriate conservative treatment, making surgery necessary in only a minority 1

Never completely immobilize the shoulder, as this leads to rapid muscle atrophy and joint stiffness 1
Do not inject corticosteroids directly into the tendon substance—only peritendinous injections should be performed 2, 1
Recognize that biceps tendinitis commonly accompanies rotator cuff tears or SLAP lesions (95% of cases are secondary), so evaluate for associated pathology 6
The presence of joint effusions is uncommon with isolated tendinopathy and should raise suspicion for intra-articular pathology requiring different management 3, 4

Plain radiographs should be obtained initially to rule out other causes of shoulder pain 1
Ultrasonography is preferred for visualizing the overall tendon 6
MRI or CT arthrography is preferred for visualizing the intra-articular tendon and related pathology 6
The most common isolated clinical finding is bicipital groove point tenderness with the arm in 10 degrees of internal rotation 6