Long Head of Biceps Tendonitis Protocol: A specialized program for patients with anterior shoulder pain who do not require a biceps tenodesis

The long head of the biceps (LHB) tendon is a common source of anterior shoulder pain, particularly in active individuals and those performing repetitive overhead activities. LHB tendonitis frequently coexists with subacromial impingement and rotator cuff dysfunction, as the tendon runs directly through the bicipital groove and enters the glenohumeral joint. While surgical options such as biceps tenodesis or tenotomy are available, clinical evidence demonstrates that a structured, phase-based non-operative rehabilitation program is highly effective in resolving symptoms. This protocol focuses on controlling initial tendon sheath inflammation, correcting scapular dyskinesis to optimize subacromial clearance, strengthening the rotator cuff to stabilize the humeral head, and progressively loading the LHB tendon eccentrically to promote tissue remodeling and restore long-term function.

Phase I: Pain Control, Activity Modification, & Tissue Protection (Weeks 0 to 4)

Goals:

• Control pain and reduce inflammation surrounding the LHB tendon and bicipital groove.
• Protect the inflamed tendon from mechanical irritation and overload.
• Restore and maintain pain-free active-assisted range of motion (AAROM).
• Initiate gentle periscapular activation and sub-maximal isometrics in neutral.

Precautions & Restrictions:

• Avoid active, resisted elbow flexion and forearm supination (direct LHB loading).
• Avoid repetitive overhead reaching, throwing, or lifting.
• Limit activities that provoke sharp, anterior shoulder pain.
• No heavy carrying (e.g., groceries, bags) with the affected arm.

Suggested Exercises:

• Pendulum exercises (Codman's) for passive joint distraction and pain modulation.
• Active-assisted range of motion (AAROM) using a wand or pulley in forward flexion and external rotation (limited to pain-free limits).
• Periscapular activation: scapular squeezes (retractions), shrugs, and scapular depression.
• Sub-maximal, pain-free glenohumeral isometrics (external rotation, internal rotation, abduction) performed with the elbow at the side and supported in neutral.

Criteria to Progress:

• Significant decrease in localized anterior shoulder pain and resting discomfort (VAS score < 3/10).
• Pain-free active-assisted elevation to at least 120 degrees.
• Ability to perform sub-maximal isometrics without triggering bicipital pain.

Phase II: Restoring ROM & Rotator Cuff/Periscapular Strengthening (Weeks 4 to 8)

Goals:

• Regain full active range of motion (AROM) in all planes without compensatory movements.
• Strengthen the rotator cuff to improve humeral head depression, reducing subacromial compression on the LHB.
• Correct scapular dyskinesis to provide a stable base for shoulder motion.
• Introduce very light, pain-free isometric biceps activation.

Precautions & Restrictions:

• Avoid rapid, sudden, or heavy concentric biceps loading.
• Avoid overhead activities if compensatory shrugging (shoulder hiking) is present.
• Modify any exercise that reproduces pain at the bicipital groove.

Suggested Exercises:

• Active range of motion (AROM) progression: forward flexion, scaption, and external rotation without shrugging.
• Resisted rotator cuff strengthening: band external and internal rotation (with a towel roll tucked under the elbow).
• Side-lying external rotation using a light dumbbell.
• Prone periscapular strengthening: prone Ys, Ts, and Ws to target the middle/lower trapezius and rhomboids.
• Serratus anterior activation: wall slides and scapular push-ups.
• Gentle, pain-free isometric biceps flexion (elbow bent at 90 degrees, pushing up against the opposite hand at 10-20% effort).

Criteria to Progress:

• Full, pain-free active range of motion in all planes, including overhead elevation.
• Good scapular control during active elevation.
• Tolerance of sub-maximal biceps isometrics and light rotator cuff strengthening without symptom exacerbation.

Phase III: Progressive Biceps Loading & Eccentric Remodeling (Weeks 8 to 12)

Goals:

• Introduce progressive, controlled tensile loading to the LHB tendon to stimulate remodeling.
• Emphasize eccentric biceps strengthening (the clinical standard for tendonitis rehabilitation).
• Maximize strength, endurance, and coordination of the rotator cuff and scapular stabilizers.

Precautions & Restrictions:

• Avoid sudden or ballistic biceps loading.
• Exercises must remain pain-free; monitor for post-exercise soreness lasting more than 2 hours.
• Perform all movements under strict control, avoiding fatigue-induced compensation.

Suggested Exercises:

• Eccentric biceps curls: assist the arm into flexion concentrically with the healthy hand, then slowly lower the weight (3 to 5 seconds) using only the affected arm (start with 1-2 lbs and progress).
• Eccentric forearm supination: slowly rotate a light hammer or dumbbell from supination to pronation, controlling the descent.
• Resisted shoulder scaption raises (up to 90 degrees) with light dumbbells.
• Rhythmic stabilization: manual perturbations in varying degrees of elevation to train dynamic joint control.
• Progressive chest press and overhead press with light dumbbells or bands, focusing on a slow, controlled eccentric phase.

Criteria to Progress:

• Pain-free completion of the progressive eccentric loading program.
• Symmetrical rotator cuff and scapular strength (within 10-15% of the unaffected side).
• No pain or catching during daily functional tasks.

Phase IV: Advanced Conditioning & Functional Return (Weeks 12+)

Goals:

• Restore full muscular strength, power, and local endurance of the upper extremity.
• Gradually reintegrate sport-specific or work-specific movements.
• Establish a long-term maintenance program to prevent recurrence.

Precautions & Restrictions:

• Ensure a thorough warm-up before any heavy lifting or sport-specific training.
• Do not exercise to the point of extreme muscle fatigue, which compromises joint stability.

Suggested Exercises:

• Advanced biceps loading: progressive concentric-eccentric curls, hammer curls, and supinated band work.
• Dynamic upper body strengthening: push-ups (progressing from wall to floor), chest press, and rows with higher resistance.
• Dynamic stabilization: single-arm planks, planks with shoulder taps.
• Light plyometrics: medicine ball chest passes, overhead tosses, and rebounder drills (for athletes).
• Gradual return-to-sport or work-specific simulation program.

Criteria to Progress/Return to Play:

• Symmetrical strength and endurance compared to the unaffected side.
• Full, pain-free active movement across all functional and athletic ranges.
• Clearance from Dr. Veillette or your physical therapist for full activity.

These guidelines represent a standard non-operative rehabilitation protocol. Individual recovery rates vary significantly depending on the severity of the tendonitis, chronicity of symptoms, and general patient health. Your physician or physical therapist may modify this protocol specifically for you.

Disclaimer: This protocol is for educational purposes and is not a substitute for professional medical advice. Always consult your doctor or physical therapist before performing any exercises or modifying activity restrictions.