Pain at the Front of the Shoulder — Could the Biceps Tendon Be the Cause?

Polish version · Explore Shoulder Conditions

Pain at the front of the shoulder can arise from the long head of the biceps tendon, but the source cannot be identified from pain location alone. Biceps tendon pathology often coexists with rotator cuff disease, labral lesions or injury to the structures that stabilise the tendon in the bicipital groove. Diagnosis therefore depends on combining symptoms, clinical examination and appropriately selected imaging.

Where does the biceps tendon run in the shoulder?

The biceps brachii has two proximal attachments around the shoulder. The long head originates near the superior glenoid and labrum, passes through the joint and then enters the bicipital groove of the humerus. Along this course it is stabilised by several structures, including fibres from the subscapularis and supraspinatus tendons and surrounding ligaments.

This is why isolated “biceps tendinopathy” is not the only possible explanation. Pain may come from the tendon itself or its sheath, but also from a rotator cuff tear, a SLAP lesion, biceps tendon instability or another disorder within the shoulder joint.

Which symptoms fit long-head biceps tendon pathology?

• pain at the front of the shoulder, sometimes extending down the front of the upper arm;
• pain that increases when raising the arm, working overhead, throwing or lifting an object;
• pain when reaching behind the body, for example for a seat belt or while putting on a jacket;
• tenderness over the bicipital groove;
• sometimes painful snapping or clicking at the front of the shoulder.

None of these findings is specific. Rotator cuff disease, frozen shoulder, acromioclavicular joint pathology and referred pain from the neck can produce a similar pattern. Speed’s test, Yergason’s test or tenderness over the groove may strengthen the suspicion, but a single positive test does not establish the diagnosis.

A sudden pop and a bulge in the arm — could this be a rupture?

An acute proximal biceps rupture may be accompanied by a pop, bruising and distal displacement of the muscle belly, producing a characteristic bulge lower in the upper arm. Pain can be substantial initially and then settle. Some patients are left with weakness during forearm supination, muscle cramping or a cosmetic concern.

This appearance does not automatically mean surgery is required, particularly when the long head has ruptured and arm function remains good. The decision depends on age, activity level, the dominant arm, occupational demands and associated shoulder lesions.

How is it assessed?

Clinical examination

The examination includes active and passive range of motion, rotator cuff strength, shoulder stability, the cervical spine, and sensation and strength throughout the limb. It is important to establish whether symptoms began after a single injury or developed with repetitive loading. Tendon snapping can suggest disruption of the structures that retain it in the groove, particularly near the subscapularis tendon.

X-ray

X-rays do not show the biceps tendon well, but they may reveal calcification, osteoarthritis, post-traumatic bony changes or another cause of shoulder pain. In an adult with persistent shoulder symptoms, radiographs are often a reasonable initial imaging study.

Ultrasound

Ultrasound can show the portion of the tendon within the groove, fluid around the tendon, thickening, partial or complete rupture and tendon displacement during movement. Dynamic scanning is useful when instability is suspected. The rotator cuff and subacromial-subdeltoid bursa can be assessed at the same examination.

Ultrasound also has limitations. The intra-articular portion of the tendon and its attachment near the superior labrum are more difficult to assess completely. A normal appearance within the groove does not exclude pathology deeper inside the joint.

MRI

MRI can assess the biceps tendon together with the rotator cuff, cartilage, bone and other intra-articular structures. When a superior labral lesion is suspected, MR arthrography may be considered in selected cases. MRI is not necessary for every patient with anterior shoulder pain; it should answer a specific clinical question.

How is biceps-related shoulder pain treated?

Non-operative treatment

Most overload-related symptoms are initially treated without surgery. This usually means temporarily reducing movements that clearly provoke pain rather than completely immobilising the shoulder, followed by a gradual return to loading. Rehabilitation may address range of motion, scapular control, rotator cuff exercises and progressive biceps strengthening.

Analgesic or anti-inflammatory medication should be selected with other medical conditions and current medicines in mind. Cooling may reduce short-term symptoms after overload. If an injection is considered, it should follow a specific diagnosis. In selected situations medication can be placed into the tendon sheath under ultrasound guidance while avoiding injection into the tendon substance itself. Accurate needle placement does not by itself guarantee a durable clinical effect.

When does an orthopaedic surgeon consider surgery?

Surgery is considered mainly when appropriately conducted non-operative treatment does not restore acceptable function, when there is substantial tendon damage or instability, or when surgery is already planned for an associated rotator cuff or labral lesion. Common options include tenotomy, in which the damaged tendon is released, and tenodesis, in which it is detached from its intra-articular origin and fixed to the humerus. SLAP repair is reserved for appropriately selected patients.

There is no single best procedure for everyone. Age, activity, cosmetic concerns, risk of cramping, occupational requirements and the other shoulder lesions all influence the choice.

When is earlier assessment needed?

• after an injury, the arm cannot be raised or there is clear new weakness;
• the shoulder is deformed, markedly swollen or bruising is spreading quickly;
• there is numbness, hand weakness, pallor or cooling of the limb;
• pain is severe even at rest and is accompanied by fever, redness or deterioration in general condition;
• shoulder pain occurs with shortness of breath, chest pressure or sudden general weakness.

Key points

Anterior shoulder pain can come from the long head of the biceps tendon, but associated pathology is common. Ultrasound is particularly useful for dynamic assessment of the tendon within the bicipital groove, whereas MRI better demonstrates intra-articular structures. For most patients, treatment begins with load modification and targeted rehabilitation; a decision about injection or surgery requires identification of the actual pain generator.

References

1. Poboży T et al. Clock-Face Sonography of the Glenoid Labrum: A Pictorial Technical Protocol for Patients Ineligible for MRI/MR Arthrography. Diagnostics. 2025;15(23):3031. DOI: 10.3390/diagnostics15233031. This publication includes assessment of the superior labrum and the region of the biceps attachment; it is not a treatment-effectiveness study for biceps tendinopathy.
2. Lalehzarian SP, Agarwalla A, Liu JN. Management of proximal biceps tendon pathology. World Journal of Orthopedics. 2022;13(1):36–57. DOI: 10.5312/wjo.v13.i1.36. Full text.
3. American Academy of Orthopaedic Surgeons. Biceps Tendinitis. Patient information prepared or reviewed by a member of the American Shoulder and Elbow Surgeons.

Content prepared by: Tomasz Poboży - orthopaedic surgeon.