The tendon that ruins jiu jitsu, and what 29 experts agreed to do about it

Long before Linda and Francis were colleagues who argue about difficult cases, she was his physiotherapist and he was a shoulder. Two shoulders, eventually, because Brazilian jiu jitsu is not selective. The long head of the biceps tendon on one side, then in time the other.

It took many hours on the table, and the hours got filled with conversation. Medicine, rehabilitation, cases neither of them could crack, life. He was a young doctor then, and he would come in straight off a twenty-four hour shift.

Which produced something she has not seen in another patient. He would fall asleep. Not during the gentle parts. During treatment that genuinely hurt, mid sentence, exhausted past the point where pain could hold his attention. So she would find a movement with a small surprise in it. He would come up off the table, and then resume the conversation at the exact word he had abandoned, as though the previous four minutes had not occurred.

That tendon has a lot to answer for. So it is worth understanding what it actually is, because with this one the anatomy is the entire story.

Why this particular tendon hurts so much

The long head of the biceps starts inside the shoulder joint. Roughly half of it comes off the superior glenoid tubercle, the rest from the superior labrum, and there are four described variations of how it does this.

Then comes the fact worth carrying out of this article. The proximal part of the tendon, the part up inside the joint, is richly innervated. Its sensory fibres carry substance P and calcitonin gene related peptide, which are chemical messengers involved in both transmitting pain and opening up blood vessels. As the tendon travels further down, that neural network becomes sparse.

So this is not a tendon that whispers. It is a structure with a well-staffed alarm system in the exact spot where a shoulder gets loaded, wrung and levered.

From there the tendon leaves the joint, passes through the rotator interval, and runs down a bony channel between the greater and lesser tuberosities called the bicipital groove. Holding it in that channel is a sling built from the coracohumeral ligament, the superior glenohumeral ligament, and fibres borrowed from both the supraspinatus and the subscapularis.

Read that list again with a grappler in mind. The thing keeping this tendon in its groove is partly made of rotator cuff. Which is why in practice biceps problems and cuff problems arrive holding hands.

Why it is so often the wrong diagnosis

Here is where the 2009 clinical commentary in JOSPT is refreshingly blunt, and it is a sentence more clinicians should read. Of all the special tests described for this tendon, no single one offers acceptable sensitivity and specificity. Not one.

Yergason's test, resisted supination producing pain at the front of the shoulder, may be reasonably specific for the biceps but tends to lack sensitivity, meaning it misses cases. Speed's test, resisted forward flexion with the forearm turned palm up, is positive if pain lands over the proximal biceps. O'Brien's active compression test helps point at the labrum instead. Each contributes something. None settles it.

The authors' conclusion is that the clinician has to combine several examination findings with the history, and sometimes imaging or diagnostic injection, to work out what is actually driving the pain. There is no shortcut and no single manoeuvre that ends the argument.

One clinical clue in that paper is genuinely useful and costs nothing. Point tenderness over the bicipital groove is a common finding, and because the tendon sits in a groove on a rotating bone, the sore spot travels laterally and medially as you externally and internally rotate the shoulder. Superficial structures like the anterior deltoid do not move with rotation. Pain that follows the bone is pain from something attached to it.

The tendon rarely goes wrong on its own. Rotator cuff disease, instability, impingement and labral tears keep it company, which is exactly why treating the biceps in isolation so often disappoints.

So what should actually be done

Until fairly recently the honest answer was that nobody had written it down. Then a group led by Amy McDevitt did something sensible: if the trial evidence is thin, ask the people who treat this every day, and do it properly.

They ran a Delphi study, which is a structured way of turning expert opinion into something you can quote. Twenty-nine international experts in the physical therapy management of shoulder pain, three rounds of surveys between February and June 2021, each round feeding back the group's answers so people could reconsider. Consensus was set in advance at 75 percent agreement or higher. Retention across the rounds was excellent, dropping only from 31 participants to 29.

The result: 61 interventions recommended, 9 not recommended, and 15 that could not reach agreement either way.

What they agreed on

• Loading the tendon. All five tendon loading techniques reached consensus, isometrics, concentric and eccentric work included. Then progressive resistance exercise, open and closed chain work, and task specific functional activity.
• Manual therapy, chosen by region. Non-thrust techniques at the glenohumeral joint reached 82.76 percent agreement, thoracic spine 89.66 percent. Soft tissue work at six of eleven regions made the cut. Not everything, and not everywhere.
• Education, and this is where they were unanimous. Four items hit 100 percent agreement: modifying activity and occupation, modifying training and load, explaining the treatment plan, and pain neuroscience education. Twenty-nine out of twenty-nine, on all four.
• Dry needling to the biceps brachii, and separately cognitive behavioural therapy and anti-inflammatory medication.

What they agreed to stop

This is the list patients find surprising, because it is mostly the machines.

• Phonophoresis and interferential current, rejected by 96.55 percent of the panel
• Iontophoresis, rejected by 93.10 percent
• Ultrasound, TENS and neuromuscular electrical stimulation, each rejected by 89.65 percent
• Laser therapy, rejected by 82.76 percent
• Extracorporeal shockwave therapy and dry cupping, also consensus disagree

Seven of nine biophysical agents were voted down, and the vote did not shift between rounds two and three. These experts were not undecided.

Worth noting what did not get rejected: cryotherapy split the room, 58.62 percent for and 41.38 percent against, so ice reached no consensus at all. Neither did moist heat. If somebody tells you the evidence is clear on ice, the experts could not manage it.

How much this is worth

A Delphi study is expert agreement, not proof, and the same research group is admirably clear about that.

So what we have is the considered judgement of twenty-nine experienced clinicians, sitting on top of a research base that is thinner than anybody would like. That is not a reason to ignore it. It is a reason to hold it the right way round: strong on what experienced hands agree about, weak on proof, and honest about the difference.

What we take from it in practice

Three things, and none of them involve a machine.

Load it, do not soothe it. Every loading technique the panel considered reached consensus, and almost every passive modality was rejected. A tendon adapts to demand. It does not adapt to being warmed.

Treat the shoulder, not the tendon. The sling that holds this tendon in place is partly built from rotator cuff fibres, and the pathology travels with cuff disease, instability and labral injury. That is why thoracic spine work reached higher consensus than work at the shoulder joint itself. The painful spot and the problem are not always the same address.

The unanimous items were all conversations. Not a technique, not a device. Explaining what is happening, explaining the plan, and above all changing the load: what the person does at work and what they do in training. Four items at 100 percent, and every one of them requires the patient to actually understand something.

Which brings this back to a jiu jitsu player asleep on a treatment table. The hours that mattered were not only the hands-on hours. They were the ones where a physiotherapist and a doctor argued about mechanism, load, and what the shoulder was going to be asked to do next week. The consensus statement puts that conversation at 100 percent agreement, ahead of everything else on the list.

He did have to be awake for some of it.