Distal biceps tendonitis – causes and treatment

Distal biceps tendonitis (also called lower biceps tendonitis) is an injury that typically affects people who do weight training in the gym, but it can also affect those doing certain other sports. In this article, I explain the causes of this lower biceps pain and the treatment for distal biceps tendonitis. There are also some guidelines on how to tell a distal biceps tendon tear from a tendonitis. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.

Some of the links in this article are to pages where you can buy products or brands discussed or mentioned here. We earn a small commission on the sale of these products at no extra cost to you.

In this article:

1. What is distal biceps tendonitis?

2. Sussing out the symptoms: Is it a distal biceps tendon rupture or a tendonitis?

3. Distal biceps tendonitis treatment

4. How we can help

We've also made a video about this:

What is distal biceps tendonitis?

Your biceps muscle is anchored to your skeleton with three tendons: two at the top (here’s a video about injuries to those) and one at the bottom. The lower biceps tendon, which is also called the distal tendon, runs across your elbow and attaches to the bones in your forearm.

Distal biceps tendon anatomy. Picture credit: Wikimedia

The biceps muscle has two functions: It flexes the arm, i.e. it bends your forearm upwards, towards your shoulder, e.g. when you do a bicep curl. It also supinates your hand, which means it turns it outwards, e.g. when you turn a doorknob clockwise with your right hand or counterclockwise with the left.

A tendonitis develops when you overwork or overload the tendon. So, any exercise or work that involves flexion of the forearm or supination of the hand that you overdo can cause an injury of the distal biceps tendon.

It can be a sudden overload, for example when you do one gym session that’s a lot harder than what you usually do, and the next day or hours later it starts aching. Or it can be a cumulative overload, where you've done quite a lot of hard training over several weeks, and the tendon has not had enough time between sessions to repair the micro-damage from the training, so instead the damage accumulates over time.

Sussing out the symptoms: Is it a distal biceps tendon rupture or a tendonitis?

A tendonitis might become gradually more painful during a game or training session. But sometimes, the pain only starts hours later, or you even wake up the next morning and you go, ‘What's wrong with my tendon? It's really painful!’

However, if you’ve experienced a sudden, sharp pain during a training session or game, there’s good reason to suspect that you may have a distal biceps tendon tear rather than a tendonitis.

If this is the case, you need to see a doctor who can do an ultrasound scan or an MRI scan to see the extent of the damage.

The hook test - picture from Bain et al. 2010

You could also do the hook test if you want to get an initial indication of whether you’ve ruptured your tendon. If you tense your biceps muscle, you should be able to feel the distal tendon, and you should be able to hook your finger underneath it. If you can do that, it means that the tendon is not totally torn off. It can still be a partial distal tendon tear if you felt a sudden sharp pain, but there's still some tendon left. If you can't feel your tendon and you can’t hook your finger under it, you really need to see a doctor because you may have actually ruptured your tendon totally.

Another indication of a distal biceps tendon rupture is called the Popeye sign, where your muscle is bunched up on your upper arm even though you’re not tensing it. This could mean that you’ve ruptured either the distal biceps tendon or one or both of the top ones and now the muscle has contracted.

Distal biceps tendonitis treatment

If it is a tendonitis and not a tear, how can you get it better?

When you have a tendonitis, the structure of the tendon changes; it becomes a little bit more pliable, it loses some of its strength, and it can't handle all the stress from the sports you want to be doing. If you carry on with your training or sport as if it’s business as usual, the pain will just escalate and, when eventually have no option but to take it easy and start treating it, your recovery time will be longer.

Relative rest as part of distal biceps tendonitis treatment

This doesn’t mean that you have to take a total break from being active. Careful strength training is the best way to get your tendon back to its full capacity, but first you have to decrease the load on it – the amount of work that you’re asking it to do. This article explains the concept of relative rest within the bigger scheme of recovering from sports injuries in some detail.

How much you have to rest it and what you can do will depend on your case and how bad it is.

Most of the time, if the tendon is acutely flared up, it's good to go easy on exercises that involve flexing the elbow or supinating it. So, if we think of gym exercises, it'll be things like pull-ups and biceps curls that should be reduced. Exercises where you push stuff away from you are usually okay.

The golden rule here is: If it causes you any pain during this first period of recovery, just don't do it, or reduce your weight to a level where it doesn’t hurt. Let’s say you usually use 30 kg with biceps curls; it may mean that with your injured distal bicep tendon, you've got to come right down to about 10 kg and see if it can handle that.

So, you have to establish a baseline of what activities the tendon can still do that don't flare it up. And then you have to use that and slowly build up from there until you get back to the weights that you used to be able to do.

All this is a bit trickier if your activity isn’t weights. Some people can get distal biceps tendonitis through tennis, for example, and I know of a young girl who got it from swimming.

In this case, you have to figure out where the weakness in the kinetic chain is. What is it about your technique that puts too much strain on that tendon? How can you change your technique to prevent this from happening again and to give your injured tendon some respite while you recover?

Strength exercises for distal biceps tendonitis treatment

Even if weight training isn’t your thing, you’ll have to do strength exercises to get the tendon back to at least its original strength, if not stronger than before.

As we’ve seen above, there are two motions that you have to strengthen the tendon for. There’s flexing the elbow so that the forearm moves towards the shoulder, but there’s also turning the hand outwards.

Start really easy

I find with biceps tendonitis – especially the distal tendon – you have to start at a really easy level. Start much lighter than what you think you should. Especially if you're a big bloke or a really strong girl who's been doing lots of heavy lifting, you might think, ‘10 kilos, that's nothing!’ Your distal biceps tendon may not feel the same way.

Monitor the 24-hour response

Often, a tendon won’t tell you that it's hurting while you’re doing the activity; it will only be hours later or even the next day. So, you've got to monitor it over the 24 hours after a strength training session, and if you find that it’s fine, you can go a little bit heavier the next time.

If you find that it's there-or-thereabouts, that it's not quite happy with it but it's sort of okay and it calms down within that same day, I would stick with that session until it's comfortable, and only then should you increase the weight.

Recovery time

Make sure you give your tendon enough recovery time between sessions. Some of our patients do well with twice a week, so that there’s a nice, big recovery gap between sessions. Others can handle three times a week.

Daily activities

Be aware of how your daily, non-sporting activities can influence the healing process. Everyday things like carrying shopping bags or lifting your child up can irritate that tendon.

If you have a job where there's a lot of lifting involved, you're going to have to make a plan to give your tendon a bit of a rest, so have a talk with your manager.

If you can skip one week of house cleaning or get someone else to carry things for you for a couple of weeks, go for it, so that you can better concentrate on your rehab for your distal biceps tendon to strengthen it back up. As it gets stronger, you can integrate those daily activities into your life again.

How we can help

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.

References:

1. Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon)

2. Donaldson, O., et al. (2014). "Tendinopathies around the elbow part 2: medial elbow, distal biceps and triceps tendinopathies." Shoulder & Elbow 6(1): 47-56.

3. Luokkala, Toni, et al. "Distal biceps hook test–Sensitivity in acute and chronic tears and ability to predict the need for graft reconstruction." Shoulder & Elbow 12.4 (2020): 294-298.

4. Bain, Gregory I., and Adam W. Durrant. "Sports-related injuries of the biceps and triceps." Clinics in Sports Medicine 29.4 (2010): 555-576.