A 68-year-old man was seen for a sudden onset of left upper arm pain and swelling after he had pulled a blanket from his wardrobe. He also heard a “pop” sound, followed by intense pain, swelling, and weakness in his left upper arm. He also declared that one month ago he had left shoulder pain during shoulder abduction—treated with non-steroidal anti-infl ammatory drugs and blind local corticosteroid injection by his family doctor. He had a 10-year history of diabetes and hypertension (under medical control).

Clinical examination showed swelling at his left upper arm, more prominent when he fl exed his elbow (Popeye’s sign) (Figure 1). Ultrasound examination revealed an empty bicipital groove, debris inside the biceps tendon sheath, inward folding of the transverse humeral ligament (Figures 2 and 3), and empty pulley of the proximal long head of the biceps tendon with protrusion of the deltoid muscle inside the anatomical space of the rotator cuff interval (Figure 4). Panoramic view also depicted the retracted belly of the long head of the biceps muscle (Figure 5). The absence of the long head of the biceps tendon within the bicipital groove and the simultaneous presence of echoic debris are commonly known as “pseudo-tendon”. Care should be taken to interpret this condition not mistake with an anisotropy artifact, tendinosis, or subluxation of the biceps tendon by performing dynamic assessment and toggling the transducer. Accordingly, he was diagnosed with rupture of the long head of the biceps brachii.

Biceps tendon rupture is common. Among patients presenting to an Orthopaedic Trauma Unit over a 5-year period, its incidence has been reported as 0.53/100,000, with a male-to-female ratio of 3:1 [1]. Biceps tendon rupture is the most common during the sixth decade of life (with a mean age of 67.5 years in females vs. 60.0 in males) [1]. The risk factors include older age, smoking, shoulder overuse, chronic diseases such as diabetes, chronic kidney disease, systemic lupus erythematosus, rheumatoid arthritis, chronic steroid, and fluoroquinolone use [1]. Local corticosteroid injection may weaken or retard the healing of an already injured tendon, increasing a risk of rupture [2]. Of note, sonographic examination has high sensitivity (88%), specifi city (98%), and accuracy (97%) to identify biceps tendon full thickness tears [3]. In summary, our case highlights the possible risk of local corticosteroid blind injections nearby tendons whereby precise (sonographic) diagnosis should be the prerequisite before any interventions.

Figure 1. Popeye’s Sign

The red arrow shows a bulbous mass.

Figure 2. Comparative Shoulder Ultrasound Imaging (Short-Axis View [SAX])

The green arrow shows the absence of the biceps tendon within the left bicipital groove with debris inside the biceps tendon sheath (A).The white arrow shows a normal tendon within the right bicipital groove (B). The green arrowhead also shows slight inward folding of the left transverse humeral ligament in contrast to the normal side (white arrowhead).
Abbreviations: GT, greater tubercle; LT, lesser tubercle.

Figure 3. Comparative Shoulder Ultrasound Imaging (Long-Axis View [LAX])

The green arrows show the gap between the proximal and distal sump of the long head of the biceps tendon (A), the white arrows show the normal biceps tendon (B).
Abbreviation: HUM, humerus.

Figure 4. Comparative Shoulder Ultrasound Imaging (Short-Axis View on the Rotator Cuff Interval)

The green arrow shows an empty pulley of the proximal long head of the biceps tendon with protrusion of the deltoid muscle inside the anatomical space of the rotator cuff interval with a small amount of fluid (red markers) underneath (A). The white arrow shows an nor- mal pulley of the proximal long head of the biceps tendon (BT) (B).
Abbreviation: SSP, supraspinatus.

Figure 5. Panoramic Ultrasound Image Obtained Over the Left Biceps Tendon

This picture demonstrates the retracted belly of the long head (LH) of the biceps muscle (green arrow) surrounded by intrafascial he-matoma (considered a post-traumatic hematoma) (red markers).
Note the retracted muscle belly appearing as a (tumoral) mass.
Abbreviation: LAX, long axis view.

The authors declare no confl ict of interest.