Atypical tear of the long head of the biceps tendon in a young male adult

Abstract

A 34-year-old man, with previous anabolic steroid abuse, presented with right shoulder pain following an underhand bowling swing. Examination indicated a Popeye sign of the right biceps, and positive Speeds, Yergason and O’Brian’s tests. MRI indicated a complete tear of the intra-articular portion of the long head of biceps tendon (LHBT). Interestingly, the tear occurred within the glenohumeral joint allowing the proximal portion of the LHBT to uniquely coil and fold on itself deep to the subscapularis causing mechanical symptoms. He was treated conservatively with physical therapy but failed to achieve pain relief and proceeded with arthroscopic debridement of the folded portion of the LHBT stump, which significantly improved clinical outcomes at 18 months postoperative. We report the first case of an LHBT tear during bowling in a young adult with a rare occurrence of the proximal portion of the LHBT uniquely coiling and folding on itself deep to the subscapularis.

Background

Long head of the biceps tendon (LHBT) ruptures are common biceps pathologies occurring acutely from trauma or subacutely from degenerative changes. Although, infrequently reported, traumatic ruptures can originate from a sudden overload event.¹ More commonly ruptures are secondary to degenerative changes, characterised by collagen fibre disorganisation and mucoid deposits, which weaken the tendon.² LHBT ruptures predominately occur in older male patients in conjunction with rotator cuff tears.^{2 3} As a result, patients experience anterior shoulder pain, tenderness and occasionally shoulder dysfunction. Following the rupture, the biceps muscle retracts distally, classically illustrating a cosmetically unappealing ‘Popeye’ deformity, which may result in weakness in supination and elbow flexion.

LHBT ruptures at atypical anatomical sites and in younger active patients are reported infrequently. Case reports of LHBT ruptures in younger patients have been documented during weightlifting,⁴ arm wrestling,⁵ softball⁶ and water skiing.⁷ Although it is unusual to sustain an LHBT in a younger cohort of patients, risk factors including anabolic steroid abuse may accelerate the natural history of tears.⁴ Biceps pathologies have also been associated with overhead throwing biomechanics, but uncommonly in underhand throwers.⁶

We report a case of an atypical spontaneous tear of the proximal LHBT in a young active adult patient, with a history of anabolic steroid abuse, which occurred during an underhand bowling swing. Interestingly, the LHBT tear occurred within the glenohumeral joint allowing the proximal portion of the biceps tendon to coil and fold on itself deep to the subscapularis causing mechanical symptoms. The folded portion of the biceps tendon was resected arthroscopically with optimal postoperative clinical outcomes.

Case presentation

A 34-year-old, healthy, highly active, left-hand dominant male realtor was evaluated for acute onset of right shoulder pain, which occurred during an underhand bowling swing. As the ball left his right hand, he felt a ‘popping’ sensation and immediately noticed a right biceps deformity. He stopped bowling and iced the area. He presented to the fracture clinic, several weeks later, complaining of continued sharp anterior shoulder pain with forward elevation, internal rotation or with sudden movements of the arm. He described the pain as a sharp, stabbing, burning sensation in the anterior shoulder radiating into the trapezoid and neck region. He rated his pain as an 8 out of 10. His pain interfered with his daily activities, sleep and training. The patient previously abused anabolic steroids for eight consecutive years, has a history of sleep apnoea and had a primary anterior cruciate ligament reconstruction surgery. Aside from this, he had no other medical conditions.

Investigations

A classic ‘Popeye’ sign of the right biceps was apparent, which was asymmetric to the contralateral side (figure 1). No bruising or ecchymosis over the shoulder joint or elbow was observed. There was marked tenderness over the anterior right shoulder and mild reduction of active global glenohumeral range of motion. Signs of impingement and rotator cuff weakness were negative. The Speeds, Yergason and O’Brian’s tests were mildly positive; however, the hook test was normal (table 1).

Figure 1.

Preoperative examinations indicating proximal long head of the biceps rupture. Posterior view of the right biceps indicating a long head of the biceps rupture (A). Anterior view comparing left and right biceps, illustrating a clear Popeye deformity in the right biceps (B). Closer visual of the right biceps with a positive Popeye sign (C). LHB, long head of biceps.

Table 1.

Frequent provocative tests used to assess common biceps and shoulder pathologies

Provocative test	Evaluates	Description	Positive indication	Sensitivity, %/ specificity, %
Speeds test	Proximal biceps/superior labral tear from anterior to posterior (SLAP) lesions	Shoulder flexed to 90° with the elbow extended and the forearm supinated. Patient asked to resist downward force applied by the examiner.	Pain at the bicipital groove	32/7527
Yergason test	Proximal biceps/SLAP lesions	Patient stabilises their arm at their side with the elbow flexed at 90° and forearm pronated. The examiner manually resists supination and patient externally rotates their arm against resistance.	Pain at the bicipital groove	43/7927
Neer test	Subacromial impingement	Examiner stabilises the patient’s scapula while passively flexing the patient’s arm while its internally rotated.	Pain with passive shoulder flexion	72/6028
Hawkins test	Subacromial impingement	Examiner elevates the patient's shoulder to 90° with the forearm in a neutral position and flexes the elbow to 90°. With the arm supported, the humerus is then is rotated internally.	Pain with internal rotation at bicipital groove	79/5928
O’Brian test	SLAP lesions	Patient is standing upright with their arm at 90° flexion, 10° adduction and full internal rotation with their thumb pointing towards the floor and the forearm pronated. The examiner places their hand over the patient’s elbow while the patient to resist the downward force applied to the arm. This manoeuvre is repeated with the patient’s arm rotated with the forearm supinated.	Deep shoulder pain in the thumb-down position, relieved in the supinated position	94/2829
Hooks test	Distal biceps	Patient actively flexes elbow to 90° and supinates forearm. Examiner uses index finger to hook the lateral edge of the distal biceps tendon.	Finger can insert 1 cm beneath tendon	100/10030
Jobes test	Rotator Cuff	Passively elevate the patient’s shoulder to 90° abduction with internal rotation with the thumb towards the floor. Examiner then applies a downward pressure against the arm.	Pain or weakness in this position	88/6231

Radiography indicated no bony abnormalities in the right shoulder. Subsequently, an MRI showed a complete tear of the intra-articular (IA) portion of the LHBT at the bicipital groove. There was a linear serpentine region of T2 hypointensity representing the LHB. The LHBT was fully torn at its point of exit from the glenohumeral joint. A long segment of the LHB was still attached proximally and folded on itself within the joint such that it was interposed between the anterior glenoid and the humeral head just deep to the subscapularis (figures 2–4). The rotator cuff tendons were intact, and no other structural abnormalities were visualised.

Figure 2.

Preoperative MRI T2 axial view in midglenoid depicting the (1) torn edge of the long head of the biceps tendon and the (2) long head of the biceps tendon.

Figure 3.

Preoperative MRI T2 sagittal view in mid rotator interval illustrating the (1) biceps tendon in the rotator interval, the (2) torn biceps tendon folded on itself and the (3) subscapularis myotendinous junction.

Figure 4.

Preoperative MRI of rotator interval sagittal fast spin echo fat saturated proton density image presenting the (1) supraspinatus tendon and muscle, the (2) bright signal/T2 hyperintensity from the oedema and inflammation, the (3) coracohumeral ligament and the (4) subscapularis.

Differential diagnosis

X-ray ruled out the possibility of bony abnormalities, osteoarthritis, acromioclavicular joint lesions or dislocation/subluxation causing right shoulder pain. Loose bodies were ruled out by MRI and X-ray. Rotator cuff tendon pathology was ruled out based on the negative Neer’s, Hawkin’s and Jobe’s tests, and confirmed to be intact on MRI. An isolated LHBT rupture diagnosis was confirmed by a positive the Popeye deformity, positive Speed’s and Yergason tests, and MRI confirmation.

Treatment

The patient was initially treated conservatively through immobilisation, local ice packs and using oral analgesics for 2 weeks. Following this, he began several weeks of physiotherapy; however, his sharp pain did not improve. Due to the ongoing pain, the desire to continue with vigorous activity, and the failure of conservative management, the patient proceed with surgical intervention. Preoperative and postoperative questionnaires, including the Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) and the Simple Shoulder Test (SST), were collected.

The patient underwent standard right shoulder arthroscopy in the beach chair position. Diagnostic arthroscopy showed that the middle glenohumeral ligament was quite thickened. The labrum from the two o’clock position up to the anchor was detached from its proximal insertion. With this detached portion of the biceps labrum complex, there was a large and bulbous stalk (figure 5A, B) of biceps tendon, floating freely in the joint space. The distal portion of the biceps tendon was extensively frayed and there was a gap between the proximal and distal segments indicating a complete tear through the mid-portion of the biceps tendon. The superior labrum posterior to the anchor was loose and unstable (figure 6A). The remainder of the diagnostic arthroscopy showed no abnormality.

Figure 5.

Arthroscopic images of the right shoulder from a standard posterior viewing portal. (A) Presents the prominent proximal stump of the long head of the biceps (LHB) tendon floating freely in the joint space beside the humeral head (HH). (B) Demonstrates the large and bulbous stalk of LHB tendon lying next to the glenoid (GD) and the torn superior labrum (SL).

Figure 6.

Arthroscopic images of the right shoulder from a standard posterior viewing portal and standard anterior superior portal. (A) Further revealing the unstable nature of superior labrum (SL) posterior to the anchor along with the prominent proximal stump of the long head of the biceps (LHB) lying next to the glenoid (GD). (B) Completed debridement of the prominent proximal stump of the long head of the biceps and unstable SL. (C) Presenting the extensively frayed distal portion of the LHB tendon.

A standard anterior superior portal was established and the remnant of the prominent biceps stump and included the labrum from the 12 o’clock to the 2 o’clock position was debrided proximally until it was stable (figure 6B). The labrum posterior to the biceps tendon anchor was also debrided until stable. The distal portion of the biceps tendon was extensively frayed (figure 6C) and was debrided until none of it was seen within the glenohumeral joint. A standard distal clavicle excision and subacromial decompression were then performed.

Outcome and follow-up

For 2 weeks postoperative, the patient was maintained in a sling for comfort. As pain reduced, he was able to return to full-time work and began active physiotherapy but avoided any labouring activities involving elbow flexion and forward elevation of the arm until 6 weeks postoperative. At 8 months postoperative, he reported minor episodic pain when lying on his right side and occasion cramping. His pain and function were significantly improved and he returned to normal training. His examination continued to show a ‘Popeye’ deformity, but he had no concerns about the deformity. His examination was otherwise unremarkable. At 18 months postoperatively, both the SST and QuickDASH improved significantly based on the minimal clinical importance difference (table 2) but the patient still had some discomfort with sleeping.^{8 9}

Table 2.

Pre and postoperative clinical questionnaire results

Questionnaires	Preoperative	18 months postoperative	Score difference	MCID
SST Score	7/12 (58.3%)	11/12 (91.6%)	4 (33.3%)	2 (16.6%)
QuickDASH Score
Disability/Symptom Score	54.5	31.8	22.7*	15–20
Work Score	0	0	0
Sports/Arts score	100	62.5	37.5*

*Indicated a significant change based on MCID.

MCID, Minimal Clinical Important Difference; SST, Simple Shoulder Test.

Discussion

The LHBT is a richly innervated tendon, which originates from the superior glenoid tubercle and from the superior labrum, with four different variations identified.^{10 11} Typically, LHBT ruptures occur at the emergence of the bicipital groove near the musculotendinous junction, corresponding to the hypovascular zone. As a result, the biceps muscle mass migrates distally characterising a Popeye deformity. The IA aspect of the LHBT is wide and flat, which passes over the humeral head before entering the bicipital groove.¹² Several anatomical variants of the IA portion have been reported, which may contribute to the pathogenesis of varying injury patterns.^{13 14} Uniquely, in this case, the IA portion of the LHBT coiled and folded on itself deep to the subscapularis causing mechanical symptoms. To the best of our knowledge, this type of rupture and uncharacteristic injury mechanism, as a consequence of repetitive underhand bowling swings and anabolic steroid abuse, has not been reported previously.

LHBT ruptures often occur in patients over the age of 50 and are unusual in younger patients. Since our patient is considerably younger than the usual population, a comprehensive medical history was taken, indicating anabolic steroids abuse. Although the exact effect of anabolic steroids on human tendon architecture remains inconclusive, one possibility is that anabolic steroids contributes to substantial muscular hypertrophy without any increases in tendon strength causing the tendon to rupture when responding to a sudden stress. Alternatively, animal models^15–17 have demonstrated that anabolic steroids may alter the tendon’s collagen structure, consequently reducing tendon elasticity and increasing tendon stiffness causing tendon failure during the activity.¹⁸ A clinical study¹⁹ demonstrated that anabolic steroid abusers were substantially more prone to the upper body tendon ruptures. A previous case study reported LHBT tears in three relatively young bodybuilders⁴ with one patient admitting anabolic steroid usage. It is quite possible that anabolic steroids abuse, as seen in our patient’s case, accelerated the natural history of the degenerating LHBT causing it to spontaneously rupture.

Underhand throwing activities uncommonly produce LHBT ruptures. However, our patient sustained an LHBT rupture while performing an underhand bowling swing. Another case study reported an underhand throwing motion contributing to an LHBT rupture in a young individual.⁶ Although the exact function of the LHBT has yet to be elucidated, two predominate functions have been proposed, including humeral head depression and glenohumeral joint stabilisation to prevent superior and anterior glenohumeral translation.^{20 21} During underhand throws, the biceps may be placed under greater stress at the end range of the throw by providing deceleration force at both the elbow and shoulder, while resisting shoulder distraction forces prior to ball release.^{6 22} This increased glenohumeral motion and deceleration force production during multiple bowling incidences coupled with the long-term anabolic steroid usage may have resulted in the progressive tenosynovitis and delamination of the tendon.

An MRI may be required in patients with clinical signs of an LHBT rupture to make an accurate diagnosis and to address concomitant shoulder pathology. If mechanical symptoms are present with clinical signs of an LHBT rupture, then MRI may provide excellent visualisation of the superior labral complex, biceps tendon, bicipital groove and the possibility of an IA retraction of the LHBT, as seen in this case.

In elderly and sedentary patients with bicipital pathology who were unsuccessful with prolonged conservative therapies, a biceps tenotomy is the preferred, however, biceps deformity, cramping and weakness have been reported.^{23 24} Biceps tenodesis is recommended for young, athletic or labouring patients with bicipital pathology requiring full supination strength or for cosmesis, however, extensive rehabilitation, stiffness, persistent pain, and risks failure, fracture and neurovascular injury are possible complications.²⁴ Both techniques are viable options with their respective risks and benefits. In fact, the literature has indicated both procedures to produce favourable clinical results in adults.²⁵ Therefore, selection criteria should be driven by the surgeon’s experience and the patient’s desires. Arthroscopic debridement of the IA portion of the LHBT has also been suggested for partial tears with delamination and fraying.²⁶ Since our patient was not concerned with preserving the biceps contour or continuing with competitive sport but desperately required pain relief from his mechanical symptoms, he proceed to debride the prominent bicipital stump.

We present a case of an atypical spontaneous tear of the LHBT in a young adult patient, in which the IA portion of the LHBT coiled and folded on itself deep to the subscapularis within the glenohumeral joint producing mechanical symptoms. Anabolic steroids abuse, coupled with repetitive microtrauma sustained from underhand bowling swings, may have contributed to this atypical spontaneous tear of the LHBT. Mechanical symptoms following LHBT ruptures may be caused by a prominent bicipital stump, prompting the need for MRI, and can be alleviated with arthroscopic debridement. Debridement of the prominent LHBT stump can provide good clinical outcomes and patient satisfaction with limited complications.

Learning points.

• Long head of biceps tendon (LHBT) tears are unusually presented in young adults, therefore, a comprehensive medical history should be acquired to learn if the patient has previously abused anabolic steroids and a physical examination to observe for a Popeye deformity.

• Repetitive microtrauma sustained from underhand bowling swings, or any underhand throwing activities, can exacerbate the risk of spontaneously tearing the LHBT and should be considered a possible injury in underhand throwers.

• LHBT tears can occur within the glenohumeral joint allowing for the rare occurrence of the proximal portion of the biceps tendon to coil and fold on itself deep to the subscapularis causing persistent mechanical symptoms.

• MRI is the gold standard for confirming biceps pathologies, including a prominent proximal stump of the LHBT.

• If mechanical symptoms persist despite conservative treatment, then arthroscopic debridement of the prominent LHBT stump may alleviate mechanical symptoms and produce favourable clinical outcomes and satisfaction in young patients.