Slideshow
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Figure 1. Image of right arm at rest showing bruising.
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Figure 2. Image of right arm making a muscle.
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Figure 3. Image of uninjured left arm making a muscle.
A 61-year-old man presents with bruising and deformity to his right arm that occurred 2 days ago. The patient notes that he has had 3 to 4 months of shoulder pain when lifting and pulling objects with his right shoulder. He was lifting a weight off the ground 2 days ago when he felt a sharp pop in the shoulder. The patient reported significant pain at the time of the injury followed by bruising and deformity in his biceps muscle (Figures 1 and 2). The shoulder pain has improved and he can now move the shoulder with near painless motion. His left biceps is unaffected with a normal muscle contour (Figure 3).
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The patient has a rupture of the proximal biceps tendon consistent with his history and physical examination. The proximal ends of the biceps muscle attach to the shoulder bone via the long and short head of the biceps tendon. The long head of the biceps tendon attaches inside the shoulder at the superior glenoid and the short head attaches at the coracoid process outside the shoulder joint.1,2
The long head of the biceps, if injured or inflamed, can be a pain generator as the proximal tendon degenerates and tears with time and repetitive shoulder motion.1 Symptoms often start with partial tearing of the tendon; as the tear increases, the tendon can spontaneously rip from its attachment to the labrum. The biceps muscle belly then retracts distally causing the classic Popeye deformity.1,2
It is important to educate patients that rupture of the long head of the biceps does not result in any weakness or disability, despite the deformity. The proximal biceps is still attached via the short head of the biceps tendon on the coracoid. Surgical repair including exploration and tenodesis is only considered for cosmetic reasons and is rarely performed.1 Some patients may be relieved to hear that John Elway, NFL quarterback for the Denver Broncos, won 2 Superbowls AFTER he tore his proximal biceps.2 He had a Popeye deformity and was treated with observation and return to football activities to tolerance.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.
References
1. Frank RM, Cotter EJ, Strauss EJ, Jazrawi LM, Romeo AA. Management of biceps tendon pathology: from the glenoid to the radial tuberosity. J Am Acad Orthop Surg. 2018;26(4):e77-e89. doi:10.5435/JAAOS-D-17-00085
2. Gill TJ. CORR Insights®: does biceps tenotomy or tenodesis have better results after surgery? A systematic review and meta-analysis. Clin Orthop Relat Res. 2021;479(7):1574-1576. doi:10.1097/CORR.0000000000001743.
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