Pain at the front of the shoulder - most commonly a biceps tendon issue, can be a tricky condition to settle quickly.

Even the best strength programs may still fall short if the root, underlying cause of that pain is overlooked.

In this article, we hope to shed some light on some of the mechanical issues that could be setting the front of your shoulder up for persistent pain.

Each factor is genuinely hard to appreciate unless you're specifically looking out for them, which makes addressing them all the more important.

So without further ado, let's highlight three top underlying causes of biceps tendon pain at the front of the shoulder.

Think of Your Shoulder Pain as the Last Straw

When trying to genuinely solve your biceps tendon pain, it's crucial to appreciate why that exact part of your body has become an issue.

Why is it just one side and not both?

Why is the front sore and not the side?

Why does it hurt with one specific motion but not another?

And to answer these types of questions we need to appreciate some fundamental principles of good shoulder function.

Your shoulder tissue is designed to be used and loaded a certain way. A move away from this ideal pattern has the potential to cause an issue over time. So when trying to understand why one specific part of your shoulder has become sore, we need to understand what can cause this genuine change in your shoulder mechanics.

Remember, shoulder injury and pain is often the last straw and not the start of something new.

Hidden stiffness, tightness, or weakness will force a change in the way your shoulder is positioned and used - ultimately setting something else up for failure.

In short, we need to understand that your bicep tendon is likely to be sore for a reason. We just need to figure out what that reason is if we are to settle it quickly and stop it from wanting to return.

A Lack of Shoulder Internal Rotation

One of the main - and most underrated underlying causes of bicep tendon pain is a lack of shoulder internal rotation.

For those unaware, shoulder internal rotation is basically the ability to turn your palm down with your arm outstretched and also reach behind your back.

Shoulder rotation is important as it allows the shoulder girdle to remain in a strong, stable posture - making use of all surrounding musculature. With reduced shoulder, internal rotation it’s much harder to keep your shoulder back in a good position when using it.

As a result, it becomes easy for the shoulder to "dump" forward and increase the load on the biceps tendon.

As you can see from the image above, this man’s shoulder subtly tilts forward as opposed to sitting straight up and down. In both the middle and far-right images, you can actually see the tip of his humerus/shoulder sitting forward. And as soon as that shoulder wants to tilt forward the bicep tendon gets included more in the conversation.

It's vitally important that you be able to recognize how your shoulder sits at rest. Because its virtually impossible to pick this up while moving.

So with this in mind, stop reading this article for just a minute and go find a mirror. Turn side-on and see how your shoulder is positioned.

Does your arm sit vertically with your shoulder back? Or does your shoulder tilt forward?

If it does, you may have just witnessed one of the main, hidden causes of your biceps tendon pain.

If this is you, consult the video below for some simple ways to increase the amount of shoulder internal rotation and allow that shoulder to sit back where it should.

Posterior Shoulder Capsule Stiffness

Similar to a lack of shoulder internal rotation, a restricted shoulder capsule at the back can fundamentally alter how we load the biceps tendon at the front.

For those unaware, the shoulder capsule is a strong tissue that surrounds the shoulder joint. It sits a little deeper than all of our hardworking shoulder muscles.

Traditionally we equate capsular stiffness with a condition like frozen shoulder, but it may also be present in your biceps tendon pain.

The idea here is that by "tightening" the capsule at the back, we force the shoulder to sit a little more forward than it should - again exposing the biceps tendon.

Interestingly, posterior capsule stiffness can also contribute to a decrease in shoulder internal rotation. So it goes without saying that it may also need to be addressed if looking to improve how you're loading that biceps tendon.

In this video, we demonstrate how to do the insanely helpful posterior shoulder capsule stretch.

Furthermore, here are a number of highly effective shoulder capsule stretches using a power band.

Upper Back Joint Stiffness

Another relatively hidden feature to mention is the presence of upper back joint stiffness. And it's important to note that this is not the same thing as tight upper back muscles. Instead, we're talking about restrictions of the thoracic spinal joints and the costovertebral joints (rib joints).

Normal shoulder function requires normal upper back strength and mobility. As we begin to accrue upper back tightness and stiffness, we begin to affect the shoulder blades' ability to move and function correctly. And in the case of anterior shoulder pain and biceps tendon dysfunction, stiffness at the back can force the shoulder to tilt forwards unnecessarily.

Alternatively, stiffness in the upper back joints makes it hard for us to pull our shoulders back into a good position again. It acts like a physical block that stops the shoulder blade from being able to posteriorly tilt and retract with ease. So it goes without saying that it’s important to restore normal motion to the upper back in order to restore normal loading to the tissue at the front of the shoulder.

In the video below, we demonstrate a simple way to mobilize a stiff upper back with a ball.

A simple exercise like this can make it easier to pull those shoulders back, ultimately re-orientating an overloaded biceps tendon in the process.

Don’t Forget About Your Strength Exercises

It’s worth noting that there are also a number of shoulder strength exercises that may benefit your biceps tendon pain. Rotator cuff and scapular stabilizer exercises are particularly helpful for any attempts to restore normal function to a painful shoulder.

You may also come across some eccentric bicep exercises if your tendon has become particularly dysfunctional.

However, the main point of this article is to open your eyes to the broader mechanical issues that may have set your anterior shoulder up to fail. And while strength exercises have an important role to play in solving biceps tendon dysfunction, they may not reverse some of the hidden muscular, capsule, and/or joint restrictions.

Conclusion

If you are suffering from anterior shoulder pain, it’s important to make sure you have the area properly assessed and treated. It’s also important to take a step back and consider what may have set your shoulder up to become sore in the first place.

Issues like a lack of shoulder internal rotation, posterior capsule stiffness, and upper back restrictions can genuinely short-circuit even the strongest shoulders. So it’s important to make sure you have these assessed as well to make sure you have the whole story.

If you’d like one of our highly skilled PT’s take a look at your shoulder please don’t hesitate to give us a call on (949) 443 5442.

Alternatively, why not join in one of our monthly shoulder pain workshops? It’s completely free and a great way to learn a little more about your shoulder and what you could be doing to help solve it.

Register your interest here!