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Proximal Biceps Tendon Rupture (Popeye Deformity)

Proximal biceps tendon rupture is a complete tear of the long head of the biceps tendon at the shoulder, causing sudden anterior shoulder pain (often described as a 'pop'), immediate weakness, and a characteristic distal bulge of the biceps muscle in the upper arm known as the 'Popeye deformity' or 'Popeye sign' from the muscle retracting distally when the proximal anchor is lost. The long head of biceps (LHB) tendon originates from the superior labrum inside the shoulder joint, travels through the bicipital groove of the humerus, and joins the short head to form the biceps muscle belly—when the LHB ruptures proximally (95% of biceps ruptures, vs 5% distal biceps), the muscle retracts down the arm creating the visible bulge. Risk factors include age over 40 years, chronic biceps tendinopathy, rotator cuff tears (50-60% association), corticosteroid injections, smoking, and overhead activities. Despite dramatic appearance, functional loss is surprisingly mild (10-20% loss of supination strength, 5-10% loss of elbow flexion strength) because the short head of biceps remains intact and compensates. Treatment options include conservative management (acceptable for sedentary individuals and elderly patients—90% satisfactory outcomes despite cosmetic deformity), biceps tenotomy (simple release allowing further retraction—quick recovery but persistent cosmetic deformity and 10-20% risk of muscle cramping), or biceps tenodesis (reattaching tendon to humerus restoring length-tension relationship—best cosmetic and functional outcomes 85-95% but longer recovery 4-6 months and higher complication rate 10-15%).

📅Last reviewed: January 2026🏥Bones & Joints

📖What is Proximal Biceps Tendon Rupture (Popeye Deformity)?

Proximal biceps tendon rupture is a complete tear of the long head of the biceps tendon at the shoulder, causing sudden anterior shoulder pain (often described as a 'pop'), immediate weakness, and a characteristic distal bulge of the biceps muscle in the upper arm known as the 'Popeye deformity' or 'Popeye sign' from the muscle retracting distally when the proximal anchor is lost. The long head of biceps (LHB) tendon originates from the superior labrum inside the shoulder joint, travels through the bicipital groove of the humerus, and joins the short head to form the biceps muscle belly—when the LHB ruptures proximally (95% of biceps ruptures, vs 5% distal biceps), the muscle retracts down the arm creating the visible bulge. Risk factors include age over 40 years, chronic biceps tendinopathy, rotator cuff tears (50-60% association), corticosteroid injections, smoking, and overhead activities. Despite dramatic appearance, functional loss is surprisingly mild (10-20% loss of supination strength, 5-10% loss of elbow flexion strength) because the short head of biceps remains intact and compensates. Treatment options include conservative management (acceptable for sedentary individuals and elderly patients—90% satisfactory outcomes despite cosmetic deformity), biceps tenotomy (simple release allowing further retraction—quick recovery but persistent cosmetic deformity and 10-20% risk of muscle cramping), or biceps tenodesis (reattaching tendon to humerus restoring length-tension relationship—best cosmetic and functional outcomes 85-95% but longer recovery 4-6 months and higher complication rate 10-15%).

🔬What Causes It?

  • Chronic biceps tendinopathy (degenerative tendon changes from overuse, aging—50-60% proximal biceps ruptures occur in setting chronic tendinosis, not acute healthy tendon tear)
  • Eccentric overload during lifting (lowering heavy weight under control, sudden eccentric load exceeds tendon tensile strength—final straw in degenerative tendon)
  • Associated rotator cuff tears (50-60% proximal biceps ruptures occur with rotator cuff pathology—altered shoulder biomechanics overload biceps as secondary stabilizer)
  • Corticosteroid injections near bicipital groove (weakens tendon, predisposes to rupture within 3-6 months post-injection—avoid injecting directly into tendon)

⚠️Risk Factors

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You may be at higher risk if:

  • Age over 40 years (degenerative tendon changes, reduced vascularity—95% proximal biceps ruptures occur in patients over 40)
  • Chronic shoulder pain and biceps tendinitis (long-standing inflammation, degeneration predisposes to rupture)
  • Rotator cuff tears or shoulder impingement (biceps acts as secondary humeral head stabilizer, overloaded when rotator cuff deficient—biceps rupture common sequela)
  • Smoking (reduces tendon vascularity, impairs healing—increases rupture risk 2-3 fold)
  • Previous corticosteroid injections into shoulder (tendon weakening—rupture risk highest 3-6 months post-injection)
  • Overhead occupations or sports (painters, electricians, swimmers, baseball pitchers—repetitive overhead loading degenerates LHB tendon over time)

🛡️Prevention

  • ✓Gradual progression of overhead activities and lifting (avoid sudden eccentric overload—warm up adequately, progress weight lifting gradually to allow tendon adaptation)
  • ✓Treatment of chronic shoulder impingement and rotator cuff tendinopathy (biceps overload secondary to rotator cuff dysfunction—address primary pathology prevents biceps rupture)
  • ✓Avoid direct corticosteroid injection into biceps tendon (inject into bursa or subacromial space, NOT bicipital groove—tendon injection risks rupture within 3-6 months)
  • ✓Smoking cessation (improves tendon vascularity, healing capacity—reduces rupture risk 50%)