Distal Bicep Tendonitis:
(A Helpful Guide to Pain at the Lower Bicep)

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

Article Summary

• I’ve dealt with—and resolved—elbow injuries related to training and physical activity, including distal bicep tendonitis (lower bicep pain).
• In this article, I break down what distal bicep tendonitis actually is, why it develops, and why the pain often persists or returns—based on real-world experience as an athlete, weightlifter, and pain-relief fitness coach.
• While the pain is felt at the lower bicep, the issue is rarely isolated to that structure alone. Understanding how stress is distributed through the surrounding muscles and tendons is key to resolving the problem long-term.

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What is Distal Bicep Tendonitis?

It is a condition that affects the tendon attaching the biceps muscle to the radius (forearm bone) just below the elbow.

This inflammation causes pain in the lower bicep, near the elbow, especially during elbow flexion and forearm rotation.

Lifters and athletes often experience discomfort during exercises involving heavy pulling or lifting motions, such as 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 this injury, it's essential to differentiate it from other related conditions:

• Proximal Bicep Tendonitis: This involves inflammation of the tendons that attach the biceps muscle to the shoulder, particularly the long head of the biceps tendon. Pain is felt in the upper part of the biceps near the shoulder, especially during overhead lifting or pulling motions. Symptoms may include shoulder pain, weakness, and a snapping sound during shoulder movements. It is often associated with other shoulder problems like rotator cuff injuries.
• Brachialis Tendonitis: This affects the tendon of the brachialis muscle, which lies beneath the biceps. The pain is located in the lower bicep near the elbow but is felt more towards the inside of the arm. It primarily occurs during elbow flexion and is distinct from bicep tendonitis, which is more centralized at the front of the elbow.
• Antecubital Pain: This refers to pain in the front crease of the elbow. Both distal bicep and brachialis tendonitis can cause antecubital pain, as they affect tendons and muscles around this region. Antecubital pain can result from repetitive flexion and extension of the elbow, such as lifting, pulling, and pushing, and worsens with direct pressure or strain on the affected tendons.

The photo below illustrates differences in tendonitis of the distal and proximal bicep, brachialis, and pain at the antecubital fossa.

Jump to a specific section of the article:

• Causes
• Symptoms
• Affected Joints
• Exercise to Modify/Avoid
• Alternative Exercises
• Non-weightlifting Activities
• Non-surgical Treatment
• Next Step & Getting Started

Causes of Distal Bicep Tendonitis

According to the National Institutes of Health, bicep tendonitis is common among athletes in overhead sports like bodybuilding and weightlifting.

Here are several causes of this condition.

1. Overuse and Repetitive Strain: Frequent and repetitive motions that involve bending the arm and rotating the forearm can strain the tendon. Activities like weightlifting, particularly with heavy weights, can lead to overuse injuries.
2. Improper Lifting Techniques: Using incorrect form during lifting can place undue strain on the tendon. This list includes jerky movements, lifting weights too heavy, or not maintaining proper alignment during exercises.
3. Sudden Increase in Activity: A rapid increase in the intensity, duration, or frequency of physical activity can overwhelm the lower bicep tendon, leading to inflammation.
4. Direct Trauma or Injury: A direct blow to the elbow or sudden forceful movements can cause damage to the tendon of the lower bicep. Accidents, falls, or impacts during sports can lead to this condition.
5. Age and Degeneration: As we age, tendons calcify, lose elasticity, and become more prone to injuries. Degenerative changes in the tendon can contribute to the development of tendonitis, especially in older athletes.
6. Poor Muscle Conditioning: Weak or imbalanced muscles around the elbow and forearm can increase the risk of tendonitis.
7. Repetitive Arm Movements in Daily Activities: Beyond sports and exercise, repetitive arm movements in daily activities, such as gardening or manual labor, can also contribute to this injury.

For a deep dive into the root causes of tendon injuries, bursitis, chronic versus acute pain, and the most effective way to resolve these conditions, visit the resources below:

• Elbow Tendonitis
• Tennis Elbow
• Golfer's Elbow
• Triceps Tendon Pain
• Elbow Bursitis
• A Helpful Guide to Elbow Pain from Lifting
• Elbow Mobility

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

Symptoms of Distal Bicep 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 this condition.

1. Pain in the Lower Bicep: The most common symptom is a sharp or aching pain in the lower bicep near the elbow. This pain can intensify during activities that involve bending the arm or rotating the forearm.
2. Antecubital Pain: Pain in the front crease of the elbow is a distinctive characteristic of this injury. This area is tender and sore when touched.
3. Swelling and Inflammation: The affected area may become swollen and inflamed. This swelling can make the elbow feel stiff and reduce the range of motion.
4. Tenderness and Sensitivity: The lower bicep and the area around the elbow can become highly sensitive to pressure. Touching or pressing on the tendon may cause significant discomfort.
5. Weakness in the Arm: There may be noticeable weakness in the affected arm, especially during activities that require pulling, lifting, or gripping. This weakness can impact overall performance in the gym and daily activities.
6. Difficulty in Performing Certain Movements: Actions such as lifting weights, performing curls, or simple tasks at home that involve lifting objects can become challenging due to pain and weakness in the arm.
7. Popping or Clicking Sensation: Athletes may experience a popping or clicking sensation in the elbow during movement. This symptom can be a sign of tendon irritation or partial tearing.
8. Bruising: In severe cases, there is bruising around the elbow area. Bruising can indicate a serious injury to the tendon, such as a partial tear.
9. Pain During and After Activity: The pain associated with this injury often worsens with activity and can persist even after the activity has stopped. This lingering pain can affect sleep.

Affected Joints

Here's how this condition can affect various joints:

Elbow:

• Primary Site of Pain: The elbow is the most directly affected joint from this injury. The pain, swelling, and tenderness become concentrated in the front crease of the arm (antecubital fossa). Movements that involve bending the elbow, such as lifting or pulling, can exacerbate the pain.
  
• Reduced Range of Motion: Inflammation and pain in the lower bicep can limit the elbow's range of motion, making it difficult to extend or flex the arm.

Wrist:

• Secondary Impact: While the primary pain is at the elbow, the wrist can also be affected due to its role in forearm rotation and gripping activities. Tendonitis can lead to compensatory movements that strain the wrist.
• Weak Grip Strength: Pain in the tendon can result in a weaker grip, affecting lifting weights, holding onto bars, or even carrying objects.

Shoulder:

• Compensatory Strain: The shoulder may experience additional strain as it compensates for the limited functionality of the arm, leading to shoulder discomfort or secondary tendonitis in the proximal bicep tendon.
• Altered Mechanics: Changes in movement patterns to avoid pain can alter shoulder mechanics, potentially causing further issues like rotator cuff strain or impingement.

Hand:

• Grip Weakness: Pain and weakness in the lower bicep and forearm can extend to the hand, making it challenging to perform activities that require grip strength.
• Fine Motor Skills: Severe cases can affect fine motor skills like typing or handling small objects.

The photo below illustrates the muscle anatomy of the arm.

Exercises to Stop, Modify, or Avoid

Due to the essential role of the biceps in flexing the elbow and rotating the forearm, when the tendon is compromised, it is crucial to stop or avoid specific exercises that can exacerbate the condition.

Here is my breakdown of specific exercises and why they should be stopped, modified, or avoided:

Bicep Curl:

• Reason: Bicep curls, especially underhand (palm-up) variations, directly stress the biceps at the elbow. The repetitive flexion and load on the tendon can worsen inflammation and pain.
• Modification: You can try reverse (overhand) or hammer curls that place less strain on the biceps.

Bench Press:

• Reason: The bench press involves significant elbow flexion and can strain the tendon of the distal bicep, especially during the lowering phase. The weight can exacerbate tendonitis symptoms.
• Modification: Perform partial reps or short range of motion (ROM) to minimize elbow flexion and reduce stress on the tendon.

Push-Ups:

• Reason: Standard push-ups require elbow flexion and extension, which can aggravate the distal tendon. The weight-bearing aspect of push-ups further strains the muscles and tendons involved.
• Modification: Perform wall or kneeling push-ups (with a wide-arm stance) to reduce strain on the elbow and bicep tendon.

Lat Pulldown:

• Reason: Overhand or underhand grips during lat pulldowns put significant tension on the lower bicep tendon as the elbow flexes and the forearm rotates.
• Modification: Perform lat pulldowns with a neutral grip (palms facing each other) to reduce stress on the tendon.

Pull-Up/Chin-Up:

1. Reason: These exercises heavily involve the biceps, particularly underhand (chin-up) variations, which can exacerbate tendonitis.
2. Modification: Replace with neutral grip pull-ups or machine-assisted pull-ups using a hammer grip.

Overhead Press:

• Reason: Overhead pressing involves shoulder and elbow movement, which can strain the tendon when performed with improper form or heavy weights.
• Modification: Avoid overhead presses altogether or use light weights with a partial range of motion to minimize strain.

Row Exercises:

• Reason: Rowing movements, including one-arm rows, bent-over rows, and cable or machine rows, involve pulling actions that stress the distal tendon.
• Modification: Stop performing rows that require heavy pulling. You can try lighter resistance bands or machine rows and focus on controlled, partial reps.

Overhead Extension:

• Reason: Tricep overhead extensions require significant elbow flexion and extension, which can indirectly strain the lower bicep tendon through stabilization demands.
• Modification: Consider tricep push/pulldown instead, using lighter resistance and avoiding full elbow extension.

Alternative Exercises You Can Perform

If you're lifting while still recovering from a biceps tendon injury, there are a few essential things to remember to avoid triggering or worsening antecubital pain.

1. Use Resistance Bands or Cable Machines: These tools allow for more controlled movements and can reduce the strain on the lower bicep tendon compared to barbells and dumbbells.
2. Perform Partial Reps: Avoid fully bending or extending the arm during movements. This modification helps reduce the strain on the tendon and can alleviate pain.
3. Use Less Resistance and Focus on More Repetitions: Lighter resistance with higher reps can help maintain muscle endurance without exacerbating tendonitis.
4. Listen to Your Body: If an exercise or movement causes pain, stop, modify, or avoid it. This practice will help you prevent further injury and allow the tendon to heal.

Here are some alternative exercises for different muscle groups that are less likely to trigger or worsen the injury:

Back Exercises:

• Lat Pulldown (using Resistance Band): Perform with a neutral grip.
• Rows (using Resistance Band): Maintain controlled movements and avoid heavy pulling.
• Full Cobra (Supermans): Focuses on lower back muscles without straining the biceps.
• Back Hyperextensions: Strengthens the lower back and avoids direct strain on the biceps.
• Back Fly (using Resistance Band): Works the upper back and shoulders, avoiding direct stress on the biceps.

Shoulder and Arm Exercises:

• Machine Deltoid Raise: Isolates the shoulders without significant biceps involvement.
• Dumbbell Shrugs (lower weight, higher reps): Focuses on the traps, avoiding strain on the lower bicep tendon.
• Dumbbell Reverse Fly: Keep weights light and movements controlled. Alternatively, use resistance bands for a controlled, low-impact exercise.
• Lateral Raises (with a Resistance Band): Strengthens the shoulders with minimal biceps involvement.
• Front Raises (with a Resistance Band): Works the anterior deltoids, avoiding direct strain on the lower bicep.
• Tricep Kickback (partial reps with a Resistance Band): Focuses on the triceps without overextending the arm.
• Tricep Pulldown/Pushdown (partial reps with a Resistance Band): Engages the triceps with controlled movements.
• Bicep Curl (partial reps with a Resistance Band): Avoid full range of motion to reduce tendon strain.

Chest Exercises:

• Cable Lower Chest Raise (do not bend the elbow): Focuses on the lower chest without involving the biceps.
• Chest Fly (using Resistance Band): Works the chest muscles with minimal strain on the lower bicep.
• Wall or Kneeling Push-Ups (with Wide-Arm): Reduces strain on the biceps by changing the angle of the push-up.
• Machine Fly (using Pec Deck Machine): Targets the chest while minimizing biceps involvement.

Non-weightlifting Activities That Might Cause Pain

Here are some activities that might cause or worsen lower bicep pain:

Yoga:

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

Arm-Wrestling:

• Reason: This activity involves intense, sudden, and forceful elbow flexion and forearm rotation, which can put significant stress on the tendon. The rapid movements required in arm wrestling can easily lead to overuse or acute tendon injury.

Rock Climbing:

• Reason: Rock climbing requires continuous and often intense gripping and pulling actions. These movements place a considerable load on the biceps, especially during overhang climbs or when making dynamic moves to reach holds. The repetitive nature of climbing can exacerbate tendonitis symptoms.

Tennis and Racquet Sports:

• Reason: These sports involve repetitive forearm movements, especially during serves and volleys, which can strain the bicep tendon. The high-impact nature of hitting the ball can also contribute to tendon stress.

Manual Labor:

• Reason: Jobs that involve heavy lifting, repetitive arm movements, or using tools that require gripping can lead to overuse of the biceps. Activities such as shoveling, hammering, or operating machinery can exacerbate tendonitis.

Typing and Computer Use:

• Reason: Prolonged periods of typing or using a mouse can cause repetitive strain injuries, including to the bicep tendon, especially if ergonomics are poor.

Gardening and Yard Work:

• Reason: Digging, raking, and lifting heavy objects can strain the tendon of the lower bicep. Repetitive motions and heavy loads can contribute to or worsen tendonitis.

Playing Musical Instruments:

• Reason: Musicians who play instruments that require repetitive arms and hand movements, such as violinists, guitarists, and drummers, can develop tendonitis from overuse.

Throwing Sports (Baseball, Softball, Football):

• Reason: The repetitive throwing motion in sports like baseball and softball places significant stress on the tendon, particularly during the acceleration and deceleration phases of the throw.

Gymnastics:

• Reason: Gymnasts perform numerous movements that involve gripping, pulling, and supporting their body weight with their arms. For example, swinging on bars, tumbling, and balancing can strain the bicep tendon, increasing the risk of tendonitis.

Non-Surgical Treatment for the Biceps Muscle and Tendon

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

Non-surgical treatment for distal bicep tendonitis includes heat and ice therapy, self-myofascial release (SMR) of the biceps muscle, 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 an effective and reliable way to 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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