Distal Bicep Tendonitis and Lower Bicep Pain

 Nurudeen Tijani (T.J.) Founder of TitaniumPhysique | Pain Relief Fitness Coach

Written by: Nurudeen Tijani
Published: May 17, 2024

I've been lifting weights for ten years, and I've dealt with and overcome many elbow injuries, including distal bicep tendonitis (lower bicep pain). Here's how I fixed my injuriesIn this article, I share everything I know about this topic, including exercises to avoid and the fastest way to fix this condition.

For a fast and effective way to eliminate distal bicep tendonitis, Get Started Now.

An illustration of the biceps muscle and tendonitis in the lower bicep tendon

Listen to the article: 19 minutes

Distal Bicep vs. Proximal Bicep Tendonitis vs. Brachialis Tendonitis

Weight lifters and athletes experience various tendonitis, particularly in the upper arm and elbow region. These conditions include distal bicep tendonitis, proximal bicep tendonitis, and brachialis tendonitis.

  • Distal bicep tendonitis affects the tendon that attaches the biceps muscle to the radius (forearm bone) just below the elbow. This condition causes pain in the lower biceps near the elbow, primarily during elbow flexion and forearm rotation. Lifters experience discomfort during exercises that involve heavy pulling or lifting motions, such as curls and rows. Pain is typically felt in the front crease of the elbow (antecubital fossa), and there may be swelling and tenderness in this area.
  • Proximal bicep tendonitis is inflammation of the tendons that attach the biceps muscle to the shoulder, particularly the long head of the biceps tendon. This condition causes pain 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. This condition is associated with other shoulder problems like rotator cuff injuries.
  • Brachialis tendonitis affects the tendon of the brachialis muscle, which lies beneath the biceps. This condition causes pain in the lower biceps near the elbow, primarily during elbow flexion. The pain is felt more towards the inside of the arm and is distinct from distal bicep tendonitis, which is more centralized at the front of the elbow. Lifters experience discomfort during exercises like curls and rows.
  • Antecubital pain refers to pain in the front crease of the elbow. Both distal bicep tendonitis and brachialis 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 elbow, such as lifting, pulling, and pushing. This pain worsens from direct pressure or strain on the affected tendons.

While all three conditions involve tendon inflammation and pain around the elbow and upper arm, their specific locations and the movements that aggravate them differ.

Distal bicep tendonitis, proximal bicep tendonitis, and brachialis tendonitis share similar symptoms but affect different tendons and muscle attachments, leading to distinct pain patterns.

For a deep dive into the root causes of elbow tendonitis, bursitis, chronic versus acute pain, and the fastest way to fix these conditions, you can explore these resources:

Brachialis tendonitis vs Distal bicep tendonitis vs Antecubital pain

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

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 elbow and rotating the forearm can strain the distal biceps 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 biceps 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 biceps tendon, leading to inflammation.
  4. Direct Trauma or Injury: A direct blow to the elbow or sudden forceful movements can cause damage to the biceps tendon. Accidents, falls, or impacts during sports can lead to distal bicep tendonitis.
  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 distal bicep tendonitis.

Don’t let overuse and improper techniques cause lasting damage. Get Started Now.

Nurudeen performs bench presses while wearing elbow sleeves

In this photo (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 distal bicep tendonitis.

  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 elbow or rotating the forearm.
  2. Antecubital Pain: Pain in the front crease of the elbow, also known as antecubital pain, is a distinctive characteristic of distal bicep tendonitis. 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 elbow.
  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 distal bicep tendonitis often worsens with activity and can persist even after the activity has stopped. This lingering pain can affect sleep.

Recognize these symptoms and take action now. Get Started Now.

YouTube video

In this video (2022), I perform variations of bench presses.

Affected Joints

Distal bicep tendonitis primarily affects the lower biceps tendon near the elbow, but its impact can extend to several other joints due to the interconnected nature of the musculoskeletal system.

Here's how distal bicep tendonitis can affect various joints:

Elbow:

  • Primary Site of Pain: The elbow is the most directly affected joint in distal bicep tendonitis. The pain, swelling, and tenderness become concentrated in the front crease of the elbow (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 biceps tendon 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 biceps 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 elbow, leading to shoulder discomfort or secondary tendonitis in the proximal biceps 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 of distal bicep tendonitis can affect fine motor skills like typing or handling small objects.

Don’t let distal bicep tendonitis affect multiple joints. Get Started Now.

3D illustration of the human arm muscle anatomy

The photo illustrates the human arm muscle anatomy.

Exercises to Stop, Modify, or Avoid

Due to the essential role of the biceps in flexing the elbow and rotating the forearm, when the distal biceps 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 tendon 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 tendon.

Bench Press:

  • Reason: The bench press involves significant elbow flexion and can strain the biceps tendon, 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 distal biceps tendonitis. 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 biceps tendon.

Lat Pulldown:

  • Reason: Overhand or underhand grips during lat pulldowns put significant tension on the biceps 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 tendon, 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 biceps 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 biceps 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 biceps tendon through stabilization demands.
  • Modification: Consider tricep push/pulldown instead, using lighter resistance and avoiding full elbow extension.

Learn how to effectively manage your condition and protect your elbows. Get Started Now.

YouTube video

I perform wide-grip cable lat pulldown with a neutral grip (palms facing each other).

Alternative Exercises You Can Perform

If you're lifting while still recovering from distal bicep tendonitis, 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 biceps 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 distal bicep tendonitis:

Back Exercises:

  • Lat Pulldown (using Resistance Band): Perform with a neutral grip to minimize strain on the biceps tendon.
  • 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 biceps tendon.
  • Dumbbell Reverse Fly: Keep weights light and movements controlled to avoid straining the biceps tendon. 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 biceps.
  • Tricep Kickback (partial reps with a Resistance Band): Focuses on the triceps without overextending the elbow.
  • 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 biceps tendon.
  • 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.

Maintain your fitness routine while protecting your elbows. Get Started Now.

YouTube video

I perform chest flys using the pec deck machine.

Non-weightlifting Activities That Might Cause Lower Bicep Pain

Various non-weightlifting activities can also aggravate distal bicep tendonitis. 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 biceps 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 distal biceps 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 tendon, 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 biceps 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 tendon. 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 biceps tendon, especially if ergonomics are poor.

Gardening and Yard Work:

  • Reason: Digging, raking, and lifting heavy objects can strain the biceps tendon. 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 biceps 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 biceps tendon, increasing the risk of tendonitis.

Protect your elbows from everyday strains. Get Started Now.

Nurudeen practicing the Crane Pose

I'm practicing the Crane Pose (without pain) during yoga (2019).

Non-Surgical Treatment for the Biceps Muscle and Tendon

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

Non-surgical treatment for distal bicep tendonitis includes RICE 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. 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.
  3. 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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    Resources

    • Proximal Biceps Tendinitis and Tendinopathy
      https://www.ncbi.nlm.nih.gov/books/NBK533002/

    • Brachialis tendinopathy: a rare cause of antecubital pain and ultrasound-guided injection technique
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8363688/

    • Biceps Tendinitis
      https://orthoinfo.aaos.org/en/diseases--conditions/biceps-tendinitis/

    • Distal Bicep Tendonitis
      https://www.assh.org/handcare/condition/distal-bicep-tendonitis

    • The Magnesium Miracle (Second Edition) - Discover the Missing Link to Total Health, By Carolyn Dean, MD, ND: https://www.google.com/books/edition/The_Magnesium_Miracle_Second_Edition/2lBcDAAAQBAJ
    • Genetics of Muscle Stiffness, Muscle Elasticity, and Explosive Strength: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706646/
    • Tendon Pathophysiology
      https://www.physio-pedia.com/Tendon_Pathophysiology
    • What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/
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