Bicep Tendonitis

[DBA]

I got an ultrasound on my left shoulder, which revealed the following:

Mild tendinosis of biceps tendon is noted.

Mild heterogeneity of the subscapularis tendon at the insertion is noted in keeping with tendinitis.
AC joint is unremarkable.

There is heterogeneity at the insertion of supraspinatus tendon suggestive of tendinitis. Infraspinatus and teres minor tendons are normal.

No bursal effusion. No supraspinatus impingement during dynamic assessment. As above.

The doctor said I shouldn't lift weights for 6 months while adding that the timeline could be accelerated with physiotherapy. As I can still perform the main barbell movements with very little pain, I doubt it's really necessary to stop training.

Is there anything I should do differently in light of this diagnosis though?

[Nick D'Agostino]

Did you get the ultrasound because you have pain in the front of your shoulder?

If so, how old are you, how long has this been going on, and what does your programming look like?

Do you have any other hobbies outside of lifting that use your left shoulder a bunch?

[DBA]

Did you get the ultrasound because you have pain in the front of your shoulder?

If so, how old are you, how long has this been going on, and what does your programming look like?

Do you have any other hobbies outside of lifting that use your left shoulder a bunch?

Yes, I got the ultrasound in response to shoulder pain. I had posted about it here back in September. I was feeling shoulder pain at the gym for a few weeks at that point with no noticeable improvement over that time period, although the pain itself was slight. Since then, the pain has become even less severe, but it's still faintly present. I can't really pinpoint which movements specifically are causing or aggravating it other than it not being the deadlift. Sometimes I notice it after squatting, sometimes I don't until the pressing movements, and sometimes I don't even notice it at all.

I'm a 26 year-old male, still using novice programming (squatting three times per week, alternating the bench and press, and doing a pulling variation each workout).

No other physical hobbies.

[Nick D'Agostino]

Hey DBA,

To help narrow down the main contributor to your shoulder pain, you could try changing the exercise order. Try doing bench presses or shoulder presses first in your workout instead of squats. If you don't feel any aggravation while performing those exercises first, it’s likely that your squat grip—specifically, how you are managing/securing low bar position—is the main thing pissing off your shoulder. This is the first step I'd recommend to help identify the issue.

If you find the squat is the main thing pissing off your shoulder, you'll need to post a video squatting so that we can clearly see the bar position on your back as you perform a work set.

Hope this helps!

[Jason Donaldson]

The doctor said I shouldn't lift weights for 6 months while adding that the timeline could be accelerated with physiotherapy. As I can still perform the main barbell movements with very little pain, I doubt it's really necessary to stop training.

I was feeling shoulder pain at the gym for a few weeks at that point with no noticeable improvement over that time period, although the pain itself was slight. Since then, the pain has become even less severe, but it's still faintly present.

I'm not trying to add to Nick's response, just commenting on how facile the "no weights for 6 months" advice is. DBA, you told the doctor that your symptoms are better than two months ago, and you've been training during that time, so clearly, he told you to stop doing that for six months? Just curious if you pointed that out to him...

[DBA]

Hey DBA,

To help narrow down the main contributor to your shoulder pain, you could try changing the exercise order. Try doing bench presses or shoulder presses first in your workout instead of squats. If you don't feel any aggravation while performing those exercises first, it’s likely that your squat grip—specifically, how you are managing/securing low bar position—is the main thing pissing off your shoulder. This is the first step I'd recommend to help identify the issue.

If you find the squat is the main thing pissing off your shoulder, you'll need to post a video squatting so that we can clearly see the bar position on your back as you perform a work set.

Hope this helps!

Sounds good. I'll try benching first my next workout.

I'm not trying to add to Nick's response, just commenting on how facile the "no weights for 6 months" advice is. DBA, you told the doctor that your symptoms are better than two months ago, and you've been training during that time, so clearly, he told you to stop doing that for six months? Just curious if you pointed that out to him...

I didn't bother getting into it. I had no intention of following that advice anyways.

[DBA]

Hey DBA,

To help narrow down the main contributor to your shoulder pain, you could try changing the exercise order. Try doing bench presses or shoulder presses first in your workout instead of squats. If you don't feel any aggravation while performing those exercises first, it’s likely that your squat grip—specifically, how you are managing/securing low bar position—is the main thing pissing off your shoulder. This is the first step I'd recommend to help identify the issue.

If you find the squat is the main thing pissing off your shoulder, you'll need to post a video squatting so that we can clearly see the bar position on your back as you perform a work set.

Hope this helps!

Alright, sorry for the really late reply, but here's what I noticed:

I will sometimes feel it faintly while squatting or pressing, but it never really affects my ability to push on the movement. When I try to narrow my grip on the squat, I notice it more, so my typical grip is notably wider than SS proposes as the ideal. I also notice it on the rack of the power clean sometimes (but I'm not good at racking in general, hitting my collarbone or upper chest a lot).

It's a bit worse when I chin up or do the lat pulldown. If I'm doing 8+ reps in a set on the latter, the pain will start affecting my ability/willingness to push (or rather pull).

The big problem is the bench press. When I do warmup sets, I will notice it, but it won't compromise anything. During work sets, I've started having the pain become unbearable before I can finish the set.

[j.dixon]

your doctor is well meaning, and some of their advice makes sense (maybe by chance).

The challenge with tendonitis is that you have damage to an area that has comparatively low blood flow (tendon). This means if there is an injury to the muscle/tendon the muscle heals first, but the tendons are slower to heal.

healing times are so variable: anatomical blood flow (location), tear size, tear type, your age, smoking, your health/nutrition/recovery, your ability to let it rest and heal, etc, but 12 weeks is a good number floated around for tendon healing (compare that to 6 weeks for bones).

the six months advice likely comes from one of two scenarios:
- it is a reasonable estimate time for a surgical tendon repair procedure following strict recovery protocol… but in that time physiotherapy will be progressive so there is only full rest early on.
- it could be a rough number that is observed when people don't give their bodies time to heal (i.e due to re-aggravation 12 weeks becomes 6 months). But in this scenario it could also be years to recover.

You were right to note that your doc was very likely overcautious in their 6 months rest advice.

There are different approaches, but one i would advise (and a process i am about to start for my own injury) considering is just take a week off. You might need longer but when your tendon is pain free or nearly pain free, use a broom-handle. Slowly up the weights over time. Mild discomfort is generally ok, but anything overt or sharp or burning is a red flag. go back to lower weights that do not trigger the significant pain. Increased pain after, or the next day from your workout is also a red flag. Back off to weights that do not set your pain back or cause significant symptoms.

Take it slow cause healing tissue is fragile and it is easier to undo healing with too much strain in a one time event, than it is to heal. Your scenario of improving symptoms over time despite continuing to work out means you were on the right track.

In isolation true rest is the ideal, but it is also near impossible. Plus 100% rest can contribute to muscle wasting and imbalances that may cause other issues. generally you want things working and blood flowing, just not to the point where you make the tear worse.

Remember, a badly sprained ankle will never heal if you keep running on it. But you are going to he putting some weight on it sooner or later in the healing process. your biceps tendon is the same. Let your tendon go inflamed too long, push it too hard, and it will tear more and more… likely bother you for the rest of your life when you push it (due to scar tissue and easier reinjury) and one day POP you have a proximal biceps tendon tear (popeye). that hot burning pain that prevents your from finishing your set is your body saying “i am warning you!”. ignore it at your own pearl.

Plus backing off now might set you back 12 weeks, but not backing off may extend this issue for years. In weightlifting (aka healing) the tortoise often beats the hair through sheer consistency. Take a long term view and you will be lifting heavy and feeling great until you are an old man.

[Will Morris]

DBA: just reach out to me via email. You are getting some historically bad information and advice in this thread that is generally made up of antiquated group-think that is only perpetuated in certain sub-specialties in medicine that are not aligned with current rehab science and with talking heads on social media that operate on fear-mongering.