Exercises for biceps related pathology: from low over moderate to high load

Ann Cools, Clinical Pearls / Thursday, February 28th, 2019

During the rehabilitation of biceps related pathology, such as tenosynovitis, SLAP lesions, or postoperative treatment after a biceps tenodesis or tenotomy, we have to take into account biceps load during the different stages of the rehabilitation. During the protective phase, or the phase of high irritability, minimal load should be put on the biceps, whereas moderate load should be applied in the intermediate phase, and high load is warranted during the advanced or sports specific phase.

But how can we determine biceps load? This may be examined in many ways, for example measuring the tensile load on the tendon, biomechanical components around the glenohumeral joint, strength measurements, examining the mechanical properties of the biceps etc… One of the methods to examine biceps tendon load during rehabilitation exercises is by electromyography, quantifying the amount of muscle activity during the exercise, and thus – indirectly – the amount of load on the tendon.

Based upon 2 studies, published by Cools et al. (AJSM 2014) and Borms et al. (AJSM 2017), we can offer a continuum of exercises from low (<20%) over moderate (20-50%) to high (>50%) muscle activity (expressed in % of the maximum during exercises performed with a 10RM resistance).

In general, exercises for the scapular muscles (e.g. “rowing” video 1) or the rotator cuff (e.g. “sidelying external rotation” video 2) generate low activity in the biceps. Exercises focusing on biceps function (e.g. “uppercut” video 3 or “forward flexion in supination” video 4) give moderate biceps activity, on the condition that they are performed slowly. High activity can only be provoked by quick or plyometric exercises (e.g. “reversed punch” video 5).

Video 1
Video 2
Video 3
Video 4
Video 5

We should note however that both studies only looked at muscle activity, and did not consider biomechanical (stretching, friction or compression forces) on the long head of the biceps, so these recommendations should always be combined with clinical reasoning when applied on a patient with biceps related shoulder pain.

Written by: Ann Cools


Cools Am, Borms D, Cottens S, Himpe M, Meersdom S, Cagnie B. Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. Am J Sports Med. 2014, 42(6):1315-1322

Borms D, Ackerman I, Smets P, Van den Berge G, Cools AM. Biceps Disorder Rehabilitation for the Athlete. Am J Sports Med. 2017 Mar;45(3):642-650

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