Correction: This story has been revised to correct the spelling of Dr. Matzkin's name.
Before Batman, Superman and Captain America, there was another superhero with massive muscles who every little boy aspired to be. But, as one elderly man recently found out, bulging biceps don’t always mean super strength.
Popeye the Sailor Man, alongside his true love Olive Oyl and archnemesis Bluto, has been amazing audiences for generations. For nearly 90 years, Popeye’s most recognizable physical characteristic has been his impressive forearms, which he credits to the consumption of canned spinach.
The distinct, exaggerated muscle protrusion is so closely associated with the comic strip character that a relatively uncommon medical condition is named after him.
“Popeye” sign occurs when one of the tendons that connects the biceps to the shoulder tears, partially or completely, resulting in a visible bulge of the muscle underneath the skin. A classic presentation was published today in The New England Journal of Medicine.
Dr. Naoki Yoshida, who submitted the photograph, said that when he first saw this patient, he immediately became excited.
“It is exactly the same as what I saw in the textbook,” said Yoshida, a young orthopedic surgeon at Shonan Kamakura General Hospital in Japan. “I knew without taking an MRI or X-ray.”
But, he said, “The affected part was actually soft and pillowy, not hard muscle like Popeye.”
Yoshida said the 79-year-old man “tried to lift a rather light cardboard box at home and felt sharp pain” in his shoulder. He looked down and right away saw a bulge on his upper left arm.
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“A physical examination revealed an obvious deformity in the anterior mid-upper arm that became more pronounced during elbow flexion,” when the joint bends, Yoshida wrote in the Journal. “Magnetic resonance imaging (MRI) of the shoulder revealed a complete rupture of the long head of the biceps tendon.”
Dr. Elizabeth Matzkin, an orthopedic surgeon at Brigham and Women’s Hospital in Boston, estimates that she sees “Popeye” sign at least once a week at her busy sports medicine practice.
“Most people come in because they went to lift something heavy and they hear and feel a pop in their upper arm, and they feel pain in their biceps,” she said. “But what usually worries them more is the next day, they have a lot of bruising in that area.”
Matzkin, who is also a spokeswoman for the American Academy of Orthopaedic Surgeons, explained that there are two heads of the proximal biceps tendon, and the long head ruptures far more frequently than the short head.
“The proximal tendon is like a rope,” she said. “Over time and with use, you can fray and wear down the rope.”
It’s no surprise, then, that “Popeye” sign is usually seen in people 55 and older, though some serious tennis players and golfers may experience a biceps tendon tear at a younger age. When those athletes are in pain, Matzkin said, sometimes a rupture “may actually ease their pain, and they may feel even better.” Because the biceps muscle is connected to the shoulder by two tendons, losing one connection does not typically result in a significant loss of strength.
“Occasionally, patients will need physical therapy,” she said, “but by the time they come back in four to six weeks, they’re feeling better.”
Physical therapy was just what the doctor ordered in the case of another man with “Popeye” sign. Internal medicine physician Dr. Jorge Scheirer co-authored a 2013 entry in the Journal of Community Hospital Internal Medicine Perspectives that highlighted the case of a 72-year-old man with “a history of bilateral rotator cuff tears” – a risk factor for tendon tears.
Scheirer, who is now vice president and chief medical information officer at Tower Health in Pennsylvania, said he’s seen four or five cases of “Popeye” sign in his 20-year career.
The best treatment for most patients, he said, is RICE: Rest, Ice, Compression, Elevation.
Both Scheirer and Matzkin said proximal tendon tears can almost always be treated without surgery. An operation would primarily address cosmetic concerns but leave behind a visible scar.
Tears to the distal tendon, which connects the biceps muscle to the elbow, are more rare but usually result in greater disability and need to be reattached with a surgical procedure.
Scheirer said some patients require painkillers, but he avoids prescribing nonsteroidal anti-inflammatory drugs – such as aspirin and ibuprofen – to older patients whenever possible. Studies have linked NSAIDs with increased risk of heart attack, especially in older adults.
Considering his patient’s age and medical needs, Yoshida advised against surgery but did recommended pain relievers. The medication worked, and the man’s pain dissipated in a matter of months. His arm still looks the same, but he’s OK with that.
In the immortal words of Popeye: “I yam what I yam and that’s all what I yam.”
Journalist Chie Kobayashi contributed to this report.