What is Responsible for This Man’s Popeye Deformity?
A 78-year-old male came into the clinic for a routine follow-up visit. He has a history of vertigo that has been associated with unsteadiness and multiple falls. He complained of a fall on his outstretched arms 4 months prior that resulted in a deformity of his right biceps muscle.
Physical exam revealed a right bicep muscle with significant bulge at rest, more noticeable upon flexion (Figures 1 and 2).
(Answer and discussion on next page)
Answer: Popeye deformity
History. A 78-year-old male came into the clinic for a routine follow-up visit. He has a history of vertigo that has been associated with unsteadiness and multiple falls. He complained of a fall on his outstretched arms 4 months prior that resulted in a deformity of his right biceps muscle.
Physical examination. Physical exam revealed a right biceps muscle with significant bulge at rest, more noticeable upon flexion (Figures 1 and 2).
Discussion. The role of the long head of the biceps tendon (LHBT) has been extensively investigated, and yet remains controversial. Studies have shown that it does contribute to shoulder stability by reducing stress on the inferior glenohumeral ligament as well as increasing resistance to torsional forces.1
The most frequent site of injury of the LHBT is at the origin, which allows the biceps to bunch distally, resulting in a bulging deformity. This deformity is called the Popeye deformity, stemming from the cartoon Popeye, the Sailor—a good guy underdog with bulging forearms, a mean uppercut, and a penchant for canned spinach.
The rupture of the long head of the biceps accounts for approximately 96% of all biceps brachii injuries.2 The patients will most often describe hearing a “clicking” or “pop” sound, with or without shoulder pain.
Diagnosis. There are several physical exam tests described in the literature, none of which are proven to be superior to one another. Evaluation of the injuries is also controversial. Plain films are usually not useful in evaluating tendon injuries. There has been debate over whether MRIs are necessary to diagnose these tears.
Ultrasound has been proven as an effective method to diagnose long head biceps ruptures.3 The accuracy of ultrasound along with the cost benefit over MRI make it an obvious choice of diagnosis not only for biceps tendon ruptures, but also for impingement, rotator cuff tears, and biceps tendinitis. MRI evaluation is usually reserved for symptoms not alleviated by conservative management.
Treatment. Repair of the biceps tendon is also debatable. Most observational studies indicate that rupture of the LHBT results in mild/moderate decrease in strength and muscle endurance, limited to the distal upper arm. The decrease in strength is not always noticeable, often reserving repair to those with jobs requiring manual labor and repetitive forearm rotation/flexion.
Former Denver quarterback John Elway tore his proximal biceps tendon and went on to win 2 Super Bowls without any surgical repair. He claimed that the tear stopped much of his shoulder discomfort and allowed him to throw without pain. There are also cosmetic repair options, which is often used in younger patients.4
Given that our patient was an elderly male who was actually pleased with his new muscle development, he was advised to continue with conservative measures with the intention to refer him to physical therapy if he developed any additional symptoms.
1.Pagnani MJ, Deng XH, Warren RF, et al. Role of the long head of the biceps brachii in glenohumeral stability: a biomechanical study in cadaver. J Shoulder Elbow Surg. 1996;5(4):255-262.
2.Elser F, Braun S, Dewing CB, et al. Anatomy, function injuries and treatment of the long head of the biceps brachii tendon. Arthroscopy. 2011;27(4):581-592.
3.Read JW, Perko, M. Shoulder ultrasound: diagnostic accuracy for impingement syndrome, rotator cuff tear, and biceps tendon pathology. J Shoulder Elbow Surg. 1998;
4.Deutch SR, Gelineck J, Johannsen HV, Sneppen O. Permanent disabilities in the displaced muscle from rupture of the long head tendon of the biceps. Scand J Med Sci Sports. 2005;15(3):159-182.