Distal right bicep tendonopathy

Medical Q&A [Moderated]
1

Hello docs,

I have been having pain on my right distal bicep tendon, on the inside of the elbow, for the past 1-1.5 years, especially when I flex the bicep with my arm externally rotated, i.e. palm up and when I squat. It started during my SSLP, when I started to add chin-ups to my routine. I always had trouble with chinups, being weak and overweight, and although I did get up to two reps, I soon stopped because it was only making the tendon pain worse. I am not sure if the chin-ups created the problem or exasperated something that was created by squatting. The pain after a hard set was too much and my right arm would tremble. I found I could not do another squat set and bench pressing was also out of the question. After reading a bit I experimented with the position of my elbows on the squat and making sure I was not pulling on the bar when grinding and it seems to have reduced the stress, but the problem has not gone away. I still feel it when I squat, it flares up on some days when the intensity is higher than usual and I find that my bench press is underdeveloped compared to my other lifts (104kg 1erm vs 200kg for the squat, 220 for the deadlift). I tried some lat pull downs with moderate weights the other day and sure enough the pain increased a bit. I know it might have been nocebo, but there is definitely something there, because the effect is consistent every time I put some stress on it. I recently read Jason’s article on the mixed grip and higher incidences of distal bicep tendon tears using the mixed grip and I thought I had an aha moment, because I have been doing all my deadlifts like this, with my right hand in an underhand grip. I bought some straps and have been using them for a couple of weeks now, but I have seen no improvement and the tendon still hurts when I squat or directly apply stress to it (e.g. curls).

How would you suggest I attack this? Different hand grip on the squat? Isometric bicep curls?

2

Are you sure it’s a bicep tendon? Or could it be flexor tendinopathy (i.e., golfer’s elbow)?

It may be a bit too sensitized to train “through”, and you may need more substantial training adjustments in the short term - for example, high bar squatting, deadlifting w/ straps, and taking a break from the chins/pulldowns.

3

Hi Austin,

thanks for the answer. I am relatively sure it is the distal bicep tendon. I feel the pain exactly in the middle of the inside area, right between median cubital and cephalic veins. Could be wrong though, I am not a doctor. :slight_smile: The pain definitely becomes worse when I flex the bicep and release after a few seconds.

I have started deadlifting with straps since a couple of weeks ago, but no substantial improvement yet, though I realise it is still early. Chinups have been out of the pictures for a few months now, the load is just too much. I will try some high bar squatting to see if it helps. I read that eccentric exercises with low loads help the tendon heal, is that true and if so, would it apply in this case?

4

We’ve historically used eccentric-focused / tempo-work for tendinopathy, although some of the unique benefits of this approach have come into question more recently. However, low loads (depending on how low we’re talking, of course), are generally not ideal for tendons, which require a bit higher loading compared to skeletal muscle in order to generate a response. I still frequently use tempo work as an inherently load- and fatigue-limiting condition, to prevent people from going crazy and doing too much too soon.