Brachialis Tendonitis: A Helpful Guide to Pain at the Front Elbow Crease

Written by: Nurudeen Tijani (Wellness and Pain Relief Fitness Coach)

I've dealt with and overcome a lot of elbow injuries from physical activities, including brachialis tendonitis.

In this article, I share everything I know about this topic, including exercises to avoid and the fastest way to fix this condition.

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Table of Contents:

• Overview
• Causes
• Symptoms
• Affected Joints
• Exercise to Modify/Avoid
• Alternative Exercises
• Non-weightlifting Activities
• Non-surgical Treatment
• Resources

What is Brachialis Tendonitis?

Brachialis tendonitis is a condition that affects the tendon of the brachialis muscle, which lies beneath the biceps. This inflammation causes pain in the lower biceps near the arm joint, primarily during elbow flexion.

Weight lifters and athletes often experience discomfort during exercises like curls and rows. The pain is typically felt in the front crease of the elbow (antecubital fossa), and there may be swelling and tenderness in this area.

To better understand brachialis tendonitis, it's essential to differentiate it from other related conditions:

• Golfer's Elbow: Also known as medial epicondylitis, this condition involves inflammation of the medial elbow tendon that attaches to the inner part of the arm joint. It results from repetitive wrist flexion and forearm pronation, causing pain on the inside of the arm. Despite the name, medial epicondylitis is common among weight lifters, especially those who frequently perform gripping and lifting movements.
• Distal Bicep Tendonitis: This involves inflammation of the biceps tendon at the elbow. Pain is located at the lower bicep, in front of the elbow crease, and is primarily triggered by pulling motions. The pain and discomfort from distal bicep tendonitis are more centralized at the front of the arm compared to brachialis tendonitis, which affects a deeper muscle beneath the biceps.
• Antecubital Pain: This refers to pain in the front crease of the elbow, also known as the antecubital fossa. Both brachialis tendonitis and distal bicep tendonitis can cause antecubital pain, as they affect tendons and muscles around this region. Antecubital pain can result from activities that involve repetitive flexion and extension of the arm joint, such as lifting, pulling, and pushing. This pain worsens with direct pressure or strain on the affected tendons.

While all these condition involve tendon inflammation and pain around the elbow and upper arm, they affect different tendons and muscle attachments, leading to distinct pain patterns and movements that aggravate them.

Brachialis tendonitis is often mistaken for medial epicondylitis due to the proximity of the affected areas, but the key distinction lies in the specific muscle and tendon involved.

The photo above illustrates muscle restrictions in the right brachialis muscle and tendonitis in the tendon. The X indicated in the image is where trigger points in the muscle tend to occur. Trigger points, known as muscle knots, are small, hyperirritable spots within a muscle. They cause pain and tenderness and can develop due to muscle overuse, stress, or injury.

The image below illustrates differences in medial epicondylitis, brachialis, and bicep tendonitis.

Causes of Brachialis Tendonitis

According to the National Institutes of Health, brachialis tendonitis is not typical. Yet, it can be a painful setback for lifters and athletes.

Here are several causes of this condition.

1. Overuse and Repetitive Strain: The most common cause of brachialis tendonitis is repetitive stress on the tendon from frequent elbow flexion. Weight lifters performing high-volume bicep curls, rows, or other pull movements are particularly susceptible as the tendon endures continuous strain.
2. Improper Technique: Poor form during lifting exercises can place undue stress on the brachialis tendon. Using improper grip, incorrect wrist positioning, or excessive weight can exacerbate the strain on the tendon, leading to inflammation.
3. A Sudden Increase in Activity: A rapid increase in workout intensity, frequency, or volume can overwhelm the tendon before it can adapt. This sudden overload can result in microtears and inflammation.
4. Muscle Imbalances: Imbalances between the biceps and brachialis muscles can contribute to tendonitis.
5. Age and Degeneration: As athletes age, their tendons naturally become calcified, less flexible, and more prone to wear and tear. This degeneration can make the brachialis tendon more susceptible to inflammation and injury.
6. Inadequate Warm-Up: Failing to properly warm up the muscles before engaging in intense physical activity can increase the risk of tendonitis. A thorough warm-up prepares the muscles and tendons for the stress of lifting, reducing the likelihood of injury.

For a deep dive into the root causes of tendon injuries, bursitis, chronic versus acute pain, and the fastest way to fix these conditions, check out these resources:

• Elbow Tendonitis
• Tennis Elbow
• Triceps Tendon Pain
• Bodybuilder Elbow: (Bursitis, Elbow Growth, Pointy Elbow)
• How to Treat Elbow Pain from Weight Training
• Elbow Mobility

In the photo below (2017), I perform a bench press while wearing compression sleeves to manage discomfort.

Symptoms of Brachialis Tendonitis

Over the years of lifting weights, I've learned that the sooner you can recognize the symptoms of an injury, the better you'll be at preventing it from worsening.

Here are the signs and symptoms of brachialis tendonitis.

1. Pain in the Lower Bicep: The most prominent symptom of brachialis tendonitis is pain in the lower bicep near the joint. This pain typically intensifies with activities that involve elbow flexion, such as bicep curls or rows.
2. Tenderness and Swelling: The affected area may be tender to the touch, and you might notice swelling around the arm joint. This tenderness can make it uncomfortable to perform everyday tasks that involve bending the arm.
3. Weakness in the Arm: You might experience weakness in the affected arm when lifting objects or performing activities that require elbow flexion. This weakness can impact your overall lifting performance and ability to train effectively.
4. Stiffness in the Joint: Stiffness in the elbow joint, especially after periods of inactivity or in the morning. This stiffness can limit your range of motion and make it difficult to extend the arm.
5. Pain During Specific Movements: Certain movements, especially those that involve lifting or pulling, can trigger sharp pain in the lower bicep. Exercises like bicep curls, rows, deadlifts, and pull-ups are painful for those with brachialis tendonitis.
6. Gradual Onset of Symptoms: Unlike acute injuries that occur suddenly, brachialis tendonitis symptoms develop gradually. You might start with mild discomfort that worsens over time if the condition is left untreated.

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Affected Joints

Brachialis tendonitis primarily affects the elbow; however, the impact can extend to other joints due to compensatory movements and altered biomechanics.

Here's how brachialis tendonitis can affect various joints:

Elbow: The most directly affected joint is the elbow, where the brachialis tendon attaches. Inflammation and pain in this area can severely limit your ability to bend the arm and affect lifting and pulling exercises. Pain in the joint is most pronounced during activities like bicep curls and rows.

Wrist: Due to the interconnected nature of the muscles and tendons in the arm, brachialis tendonitis can cause compensatory strain on the wrist. Lifters may alter their grip or wrist position to avoid pain, which can lead to additional stress and potential overuse injuries in the wrist.

Shoulder: When the elbow is in pain, athletes often adjust their movements to compensate, which can place extra strain on the shoulder joint. Overcompensation can lead to shoulder discomfort or even secondary conditions such as shoulder tendonitis, especially if heavy weights are involved.

Hand: Pain and weakness in the elbow and forearm can also affect the hand. You may notice reduced grip strength or discomfort while holding weights or performing fine motor tasks. This condition can impact exercises that require a firm grip, like deadlifts or pull-ups.

The photo below illustrates the muscle anatomy of the upper limb (arm).

Exercises to Stop, Modify, or Avoid

Managing brachialis tendonitis involves making adjustments to your workout routine. Specific exercises can exacerbate the condition, while modifications can help you continue training without aggravating the injury.

Here are my tips on which exercises to stop, modify, or avoid.

Modify or Avoid Pull Movements and Most Push Movements:

1. Bicep Curl: Avoid underhand (palm-up) variations. Instead, perform reverse (overhand) or hammer curls. These modifications reduce strain on the brachialis tendon.
2. Bench Press: Perform partial reps or use a shortened range of motion (ROM). This adjustment can help minimize strain while maintaining muscle engagement.
3. Lat Pulldown: Avoid overhand or underhand grips. Instead, perform lat pulldowns with a neutral grip (palms facing each other) to reduce stress on the tendon.
4. Pull-Up/Chin-Up: Stop these movements. Replace them with lat pulldowns using a neutral grip (palms facing each other) or machine pulldowns to decrease strain.
5. Overhead Press: Stop overhead press movements, including clean and press and shoulder press. These exercises place significant stress on the arm joint. Avoid them until recovery.
   
6. Row Exercises: Avoid rows, including one-arm rows, bent-over rows, cable or machine rows, and T-bar rows. These movements heavily engage the brachialis and can worsen the condition.
7. Overhead Extension: Stop these movements and consider tricep pushdowns or pulldowns instead, which can be less stressful on the elbow.

Ultimately, listen and pay attention to how your body responds. If an exercise or movement causes pain, stop, modify, or avoid it. Focus on preventing further injury and allow the tendon to heal.

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Alternative Exercises You Can Perform

While recovering from brachialis tendonitis, choose exercises that won't trigger or worsen the pain.

Here are some tips and alternative exercises you can perform to maintain your fitness without aggravating the condition:

1. Opt for Resistance Band or Cable Machine Variations: These alternatives offer controlled resistance and can reduce strain on the tendon compared to barbells, dumbbells, and stationary machines.
2. Consider Performing Partial Reps: Avoid fully bending or extending the arm during the movement. Partial reps help reduce tendon strain and alleviate pain.
3. Use Less Resistance and Focus on More Repetitions: Lighter weights with higher reps can maintain muscle engagement without overloading the tendon.

Back Exercises:

• Lat Pulldown (using Resistance Band): This variation offers a smooth resistance that is easier on the tendon.
• Wide-Grip Lat Pulldown (with Palms Facing In): A neutral grip minimizes stress on the joint.
• Rows (using Resistance Band): Bands provide a less aggressive resistance, reducing strain.
• Machine-Assisted Pull-Up (using Hammer Grip): The hammer grip is more tendon-friendly.
• Banded Pull-Up (using Hammer Grip): Similar to the machine-assisted version, it reduces strain.
• Full Cobra (Supermans): Strengthen your back with minimal elbow involvement.
• Back Hyperextensions: Focus on lower back strengthening without stressing the arm joint.
• Machine-Assisted Dead Hang Stretch: A gentle stretch to decompress the spine and shoulders.
• Back Fly (using Resistance Band): Engage the upper back with less elbow stress.
• Dumbbell Reverse Fly: Lighter weights with controlled movements help target the rear delts.
  
• Band Reverse Flys: Similar benefits to dumbbell reverse flys but easier resistance adjustment.
  

Shoulder and Arm Exercises:

• Machine Deltoid Raise: Isolate the shoulders with controlled movements.
• Dumbbell Shrugs (lower weight, higher reps): Strengthen the traps without heavy strain.
• Lateral Raises (with a Resistance Band): Easier on the tendons while effectively targeting the deltoids.
• Front Raises (with a Resistance Band): Similar benefits to lateral raises with less strain.
• Machine Tricep Extension: Controlled movements to work the triceps without elbow stress.
• Machine Seated Tricep Dip: Provides stability and reduces strain on the joint.
• Cable Kneeling Tricep Extension: Allows for a controlled range of motion that minimizes strain.
• Bicep Curl (partial/half curls focusing on mid-range): Avoid full extension or flexion to reduce tendon load.

Chest Exercises:

• Cable Lower Chest Raise (do not bend the arm): Focus on the chest while minimizing elbow movement.
• Chest Fly (using Resistance Band): Gentle resistance with controlled movement.
• Wall Push-Up or Kneeling Push-Ups (with Wide-Arm): Modify push-ups to reduce strain.
• Machine Inner Chest Press (with Palms Facing In): Use a neutral grip to lessen tendon stress.
• Machine Fly (using Pec Deck Machine): Controlled and isolated movement to work the chest without involving the elbow excessively.

Non-weightlifting Activities That Might Cause Pain

While weightlifting is a common cause of brachialis tendonitis, non-weightlifting activities can also trigger or exacerbate the condition. Awareness of these activities can help you avoid further pain.

Yoga: Yoga poses that require weight-bearing on the arms, like downward-facing dog or plank pose, can strain the brachialis tendon and exacerbate pain.

Arm-wrestling: This activity places significant stress on the arm joint and forearm muscles, particularly during intense matches. The sudden and forceful movements can aggravate the brachialis tendon, leading to increased pain and inflammation.

Rock Climbing: Rock climbing requires substantial grip strength and forearm engagement, which can strain the brachialis tendon. The repetitive pulling and gripping motions involved in climbing can exacerbate tendonitis, especially if the tendon is already inflamed.

Tennis: Playing tennis, especially with a one-handed backhand stroke, involves repetitive and forceful wrist and elbow movements that can stress the brachialis tendon. The quick, powerful motions can lead to inflammation and pain.

Rowing: Rowing, whether on a machine or in a boat, involves repeated pulling motions that heavily engage the elbow and forearm muscles. The continuous flexion and extension can strain the brachialis tendon, worsening tendonitis symptoms.

Gardening: Digging, raking, or using heavy gardening tools require repetitive gripping and pulling. These movements can stress the brachialis tendon, leading to inflammation and discomfort.

Typing and Computer Work: Extended periods of typing or using a mouse can cause repetitive strain on the forearm and elbow muscles. Poor ergonomics and prolonged use can exacerbate brachialis tendonitis, resulting in pain and stiffness.

Playing Musical Instruments: Certain musical instruments, such as the guitar, violin, or piano, involve repetitive wrist and elbow movements. Continuous practice without adequate breaks can lead to overuse injuries, including brachialis tendonitis.

Manual Labor: Jobs that involve repetitive lifting, pulling, or gripping—such as construction work, carpentry, or assembly line tasks—can place significant stress on the brachialis tendon. The repetitive nature of these tasks can contribute to tendon inflammation.

Non-Surgical Treatment for the Brachialis Muscle and Tendon

As explained above, brachialis tendonitis, golfer's elbow, and bicep tendonitis can cause pain at the front crease and inside part of the arm. As such, getting checked is always a good idea to ensure no structural issues with the joint.

Non-surgical treatment for brachialis tendonitis includes heat and ice therapy, self-myofascial release (SMR) of the biceps and brachialis, and elbow mobility/strengthening exercises.

1. Ice Therapy: Applying ice to the affected area helps reduce pain and swelling in the elbow. Ice therapy can decrease inflammation and provide relief from burning pain. Apply ice packs for 15-20 minutes several times daily, especially after activities that cause discomfort.
2. Heat Therapy: Wrap or apply a heat pad around the biceps to help relieve muscle tension and improve blood flow to the area, which can promote healing. However, do not apply heat directly to the elbow joint if there is a sensation of burning pain, as this typically indicates tendon inflammation that could worsen with heat. Also, avoid heat therapy if there is bruising on the skin, as it may exacerbate swelling.
3. Self-myofascial Release (SMR): SMR involves using tools like foam rollers or massage balls to release tight and tense muscles. Restricted muscles exert tension and strain tendons. When you release these muscles, they become more pliable and elastic, reducing the pulling tension on the tendon and joint. SMR is the fastest way to treat and alleviate muscle and tendon pain.
4. Elbow Strengthening Exercises: Weak or pliable muscles from injury or SMR can cause surrounding joints to become weaker. Strengthening exercises help restore muscle and joint stability, speeding up recovery. Incorporate elbow mobility and strengthening exercises to support tendon healing and improve overall function.

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