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A 94-year-old man with a history of aspirin use for coronary artery disease presented with left arm pain and ecchymosis. He experienced sharp pain in his left upper arm during routine exercise including push-ups and lifting weights, 2 days before presentation. Physical examination revealed swelling and tenderness on palpation over the midshaft of the left humerus and an apparent deformity of the biceps brachii, referred to as Popeye sign. We observed extensive ecchymosis distally with massive swelling of the left upper arm (figure 1). Ultrasonography demonstrated the irregularity of the proximal brachialis muscle fibres with heterogeneous hypoechoic lesions diffusely present in and along with the muscle. The long head biceps tendon was intact. The findings were consistent with partial rupture of the brachialis muscle belly with intramuscular and extramuscular haematomas. (figure 2). He was diagnosed as partially muscle rupture of the biceps brachii, and managed non-surgically. The biceps deformity persisted; however, ecchymosis was not observed at the 1-month follow-up (figure 3).
Popeye sign is pathognomonic of proximal biceps tendon rupture. A proximal biceps tendon tear results in bunching of the muscle to form a large painful ball on the upper arm; this bulge is called Popeye sign.1 In this case, the patient developed Popeye sign with ecchymosis secondary to a proximal muscle rupture of the biceps brachii. The biceps muscle receives an abundant blood supply, and it is reasonable to conclude that the history of aspirin use might have contributed to significant bleeding observed in this patient. A previous case report has described Popeye sign with ecchymosis in a patient with a biceps muscle belly tear.2 Although ecchymosis may be observed in patients with biceps tendon rupture, it has rarely been described by previous case reports. Therefore, Popeye sign accompanied by extensive ecchymosis might be a useful indicator to differentiate between a biceps muscle belly tear and a biceps tendon rupture.
Ultrasonography is a reliable tool to distinguish between these entities.3 In cases of biceps tendon rupture, ultrasonography shows the absence of biceps tendon within the bicipital groove. However, in this case, ultrasonographic findings such as the intact biceps tendon, hypoechoic lesions and irregular muscle fibres in the brachialis muscle belly indicate a biceps muscle belly tear.
Biceps muscle belly tears are relatively uncommon and are reported in cases of injuries following motor vehicle accidents, in army paratroopers, and water skiers.4 This injury usually occurs following the application of an external force to the flexed upper arm causing sudden extension of the arm.5 Other risk factors include poor circulation, low amount of subcutaneous fat, and lack of warm-up during sports. In this case of a superelderly patient, we hypothesised biceps muscle tears could occur secondary to overuse of the biceps muscle during lifting weights.
I was surprised when my left upper arm suddenly started hurting and bleeding while I was training, but I was relieved after seeing my doctors. One month later, it was much better.
Routine dumbbell lifting in super elderly patients could cause biceps muscle belly tears.
Popeye sign accompanied by extensive ecchymosis suggests a biceps muscle belly tear.
Ultrasonographic findings such as the intact biceps tendon, hypoechoic lesions and irregular muscle fibres in the brachialis muscle belly indicate a biceps muscle belly tear.
Contributors AH and TN cared the patient and wrote the report. TF and HU read and approved the final version of the report.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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