The shoulder joint is a complex combination of ligaments, muscles, bones and tendons. All these structures must function correctly to keep the joint in alignment, or the patient could experience pain, decreased range of motion, weakness and discomfort. Athletes in throwing sports must take special care to keep their shoulder healthy or risk developing conditions such as biceps tendinitis.

“The act of throwing something overhand is not a natural movement,” said Ryan J. Krupp, M.D., orthopedic shoulder surgeon at Norton Orthopedic Institute and executive medical director of orthopedics and director of sports health and shoulder reconstruction for Norton Healthcare. “When an athlete is throwing at speeds up to 90 to 100 mph, they put an immense amount of strain and torque on the shoulder, as well as the rest of the arm. Over time and without care, they can develop conditions such as biceps tendinitis.”

Anatomy of the shoulder

There are three main shoulder bones: the upper arm bone (humerus), shoulder blade (scapula) and collarbone (clavicle). The first two bones make up the ball-and-socket shoulder joint. A series of ligaments, tendons and muscles helps keep the joint aligned holding the ball centered in the shoulder socket.

One muscle in the front of the upper arm is the biceps. The upper end of this muscle is attached to the labrum deep in the shoulder joint by two tendons. One tendon, the long head, is attached to the upper part of the shoulder socket, which is known as the glenoid, while the other tendon attaches to the shoulder blade at the coracoid.

Diagnosing biceps tendinitis

“The best way to prevent injury is quality offseason training, and then carrying that through with good arm care throughout the year,” Dr. Krupp said. “But even if someone is taking precautions, they still can get hurt.”

Thorough examination using diagnostic tests such as MRI, combined with physical examination, is key to diagnosing conditions such as biceps tendinitis.

“It’s crucial that we take a hands-on approach,” Dr. Krupp said. “You can’t properly diagnose someone without touching the affected areas.”

Dr. Krupp also recommends examining the nonpainful shoulder, as well as asking about injuries in other places in the body.

“Somebody might have an ankle injury, for example, that wasn’t adequately addressed,” he said. “The issue starts in one place and throws everything else off.”

Biceps tendinitis can emerge if there are issues with the rotator cuff tendons. It also can occur in isolation or in association with arthritis of the shoulder joint, shoulder impingement, chronic shoulder dislocations or a tear in the glenoid labrum, particularly at the biceps attachment site on the upper glenoid.

Treating biceps tendinitis

“Treating shoulder conditions can be tricky,” Dr. Krupp said. “I also have to take into consideration what kind of thrower the patient is exactly. I treat baseball throwers differently than football throwers, for instance.”

Sometimes, the biceps can become inflamed, which is called biceps tendinitis. This condition can present as pain at the elbow or in the shoulder.

Initial courses of treatment might include anti-inflammatory medication, stretching, modifying how the athlete throws, physical therapy and possibly other conservative care.

“Maybe we pull them back from pitching or reduce the number of throws they perform,” Dr. Krupp said.  “In some cases, the athlete may even have to take some time off from throwing if they don’t respond to the treatment.”

When nonsurgical interventions fail, the next step might be a surgery such as a tenotomy or a tenodesis. A tenotomy is the intentional severing of the biceps tendon. In a tenodesis, the surgeon cuts the biceps tendon from its attachment in the shoulder joint and reattaches it in a new location on the humerus.

“We start with a comprehensive examination, looking at the whole picture,” Dr. Krupp said. “What kind of athlete does the patient need or want to be, what is the best way to get them there and how do we keep them in the game?”