A. Tsintoni

Andreas Panagopoulos

K. Pantazis

N. D. Roupas

S. Theodoraki

V. Kyriazopoulou

Journal of Medical Case Reports

Springer - Publisher Connector

CASE REPORT Open Access
Spontaneous rupture of the long head of
the biceps tendon in a woman with
hypothyroidism: a case report
K. Pantazis1, N. D. Roupas2, Andreas Panagopoulos1*, S. Theodoraki3, A. Tsintoni3 and V. Kyriazopoulou2
Abstract
Background: Tendinitis can be a presenting complaint in hypothyroidism, with symptomatic relief being obtained
by appropriate management of the primary thyroid deficiency. To the best of our knowledge no other cases of
spontaneous rupture of the long head of the biceps tendon during uncontrolled hypothyroidism have yet been
reported.
Case presentation: This case report describes an unusual case of spontaneous rupture of the long head of the
biceps tendon in a 48-year-old white woman with severe hypothyroidism. She described experiencing a sudden
sharp pain and an audible pop in her right shoulder while using her personal computer. On physical examination
she was positive for Yergason’s sign and a subsequent magnetic resonance imaging scan showed complete
rupture of the long head of her biceps tendon. Laboratory tests revealed significantly elevated thyrotropin levels
(>100 μIU/ml) and very low levels of both triiodothyronine (0.17 ng/ml) and free thyroxine (0.18 ng/dl). She was
switched to a different thyroxin regimen with a progressive dosage increment. She declined surgical re-anchorage
of the tendon but despite the discreet Popeye sign, her overall strength and shoulder function were satisfactory.
After 2 months, she was found to be clinically euthyroid, having normal thyroid function tests (thyrotropin 2.95 μIU/mL,
free thyroxine 1.07 ng/dl). At her last follow-up visit, 1 year post-injury, she reported nearly normal shoulder function in
her daily activities and had a constant shoulder score of 93 points.
Conclusions: The role of thyroid hormones in the synthesis and degeneration of collagen and in the proliferation and
apoptosis of human tenocytes is discussed, providing a possible mechanism whereby hypothyroidism may lead to
tendon tears. This report may have a greater impact among different subspecialties as it presupposes a high degree
of awareness from internists, endocrinologists and orthopedic surgeons.
Keywords: Hypothyroidism, Long head of biceps, Tendon rupture, Thyroid
Background
The thyroid hormones (THs) triiodothyronine (T3) and
thyroxine (T4) play an essential role in the development
and regulation of many tissues and organs and have pro-
found metabolic effects during adult life. Although
muscle involvement in a variety of forms (weakness,
cramps, myalgia) is a common problem in both congeni-
tal and adult-onset hypothyroidism, very few data are
available regarding the effect of thyroid dysfunction on
connective tissue. Tendinitis can be the presenting
complaint in hypothyroidism and symptomatic relief can
be obtained by appropriate management of the primary
thyroid deficiency [1]. Calcified tendinopathy has also
been associated with thyroid dysfunction [2].
To the best of our knowledge there is no published
data reporting the association of thyroid function with
spontaneous tendon rupture. This case is therefore un-
usual and interesting because it describes a middle-aged
woman with severe hypothyroidism diagnosed with
shoulder rotator cuff impingement syndrome and spon-
taneous rupture of the long head of her biceps tendon.
* Correspondence: andpan21@gmail.com
1Department of Shoulder and Elbow Surgery, University of Patras, 26500
Patras, Greece
Full list of author information is available at the end of the article
© 2016 Pantazis et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Pantazis et al. Journal of Medical Case Reports  (2016) 10:2 
DOI 10.1186/s13256-015-0794-2
Case presentation
A 48-year-old white woman presented at the Emergency
Department of our hospital complaining of the acute on-
set of severe pain in her right shoulder. She clearly re-
ported no trauma or strenuous physical activity and
denied any previous shoulder pain or functional impair-
ment. She had been diagnosed with a multinodular goiter
10 years previously and had been treated with near-total
thyroidectomy and subsequent replacement therapy with
levothyroxine. Annual follow-up tests were performed by
her endocrinologist and she stated that her thyroid func-
tion tests had been within the normal range during her
most recent examination 3 months earlier. She was other-
wise healthy and reported taking no other medication
prior to the incident; in particular, she was not taking any
steroids, statins, Ferrum (folic acid) or fluoroquinolone-
based drugs.
A physical examination of her right shoulder revealed
a nearly normal range of motion and muscle strength
but she had positive results from impingement tests. An
anteroposterior X-ray of her shoulder was normal apart
from a mild proximal elevation of the head and moderate
arthritis in her acromioclavicular joint (Fig. 1). No evi-
dence of calcified tendinitis was detected.
She was managed conservatively with cryotherapy,
sling immobilization of her shoulder and non-steroidal
anti-inflammatory drugs (NSAIDs). However, within a
week she again attended our Emergency Department,
presenting with extreme pain in her shoulder, fever up
to 38.5 °C and mild symptoms of upper respiratory tract
infection (nonproductive cough and nose dripping). She
described a sudden sharp pain and an audible pop in her
right shoulder while using her personal computer (PC).
A physical examination revealed positive Neer, Hawkins
and Yergason’s signs and a positive Jobe’s test. After or-
thopedic consultation she was admitted to our Internal
Medicine Department for further evaluation. Laboratory
analysis revealed significantly elevated thyrotropin (TSH)
levels (>100 μIU/ml) and very low levels of both T3 (0.17
ng/ml) and free T4 (0.18 ng/dl). Of interest, her creatine
phosphokinase (CPK) levels were found to be within the
normal range. Two inflammation markers were also
within the normal range: erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP). Chest radiography,
urine analysis and urine and blood cultures were negative.
A magnetic resonance imaging (MRI) scan of her right
shoulder revealed a complete rupture of the long head of
her biceps tendon (Fig. 2a–c).
She was switched to a different thyroxin regimen with
a progressive dosage increment. She was re-evaluated by
our Out-patient Department 3 weeks after the hormone
replacement treatment was started to discuss the pos-
sible surgical re-anchorage of her ruptured biceps ten-
don. She had significantly improved, having positive
impingement tests only in the extremes of motion. Des-
pite the discreet Popeye sign, the overall strength of her
biceps tendon was satisfactory and she consequently de-
cided against any surgical treatment. This prevented a
proper histopathological examination during surgery and
thus the confirmation of our clinical findings. After 2
months, she was re-evaluated by her endocrinologist and
she was found clinically euthyroid, with tests showing
normal thyroid function (TSH 2.95 μIU/mL, free T4 1.07
ng/dl).
At her last follow-up visit, 1 year post-injury, she
reported nearly normal shoulder function in her daily
activities and had a constant shoulder score of 93 points.
Discussion
Shoulder pain is a common presenting symptom ob-
served at primary care offices and sports medicine
clinics. Rotator cuff pathology is the most common
finding among patients with shoulder pain asking for
medical treatment [3]. In a recent systematic review
(2004), Oh et al. [4] showed that rotator cuff prob-
lems accounted for more than 4.5 million clinician
visits and approximately 40,000 surgeries every year
in the USA. Rotator cuff impingement is primarily a
disease of middle-aged and older patients. Tendinitis
or tear of the long head of the biceps tendon has
been associated with impingement pathology but the
exact cause of tearing is unknown and probably
multifactorial. Age, overuse, corticosteroid use, hyper-
thyroidism, subacromial impingement, heavy activities
or acute injuries may all contribute to the development of
long head tears. To the best of our knowledge, the present
case report is the first to report hypothyroidism as a
Fig. 1 Anteroposterior X-ray of the patient’s right shoulder
demonstrating mild proximal elevation of the head and moderate
arthritis in her acromioclavicular joint
Pantazis et al. Journal of Medical Case Reports  (2016) 10:2 Page 2 of 4
possible cause of subacromial impingement syndrome and
complete tear of the long head of the biceps tendon.
Although there are no data to suggest an association
between thyroid disorders and tendon tears, there is
sufficient evidence to suggest a relationship between TH
action and collagen metabolism [5, 6]. More specifically,
hyperthyroidism is accompanied by increased rates of
catabolism of both soluble and insoluble collagen, while
hypothyroidism is characterized by decreased synthesis
and degeneration of collagen. Hypothyroidism also in-
hibits epimerase, which results in reduced chondroitin
sulfate and elevated hyaluronic acid, hence weakening
the matrix. Moreover, it causes accumulation of glycos-
aminoglycans (GAGs) in the extracellular matrix (ECM),
being involved in the pathogenesis of carpal tunnel syn-
drome during hypothyroidism and predisposing patients
to tendon calcification [7].
THs have known effects at the cellular level on the pro-
liferation and differentiation of bone and cartilage. The
hypothyroid state appears to induce abnormalities in these
tissues, which results in such clinical manifestations as
epiphyseal dysgenesis, aseptic necrosis, possibly crystal-
induced arthritis, and an arthropathy characterized by
highly viscous non-inflammatory joint effusions primarily
affecting the knees, wrists, and hands. Neuropathic and
myopathic symptoms accompanying hypothyroidism may
manifest as joint region abnormalities when in fact there
is no underlying arthropathy [8, 9].
Apart from the relationship between TH action and
collagen metabolism, a recent study demonstrated the
presence of TH receptors in healthy and pathologic ten-
dons, thus suggesting a possible role in the proliferation
and apoptosis of human tenocytes [10]. Tenocytes are
specialized fibroblasts which contribute to tendon ECM
component homeostasis through a wide variety of com-
plex mechanisms. In vitro, THs enhance tenocyte growth
and counteract apoptosis in healthy tenocytes isolated
from tendons in a dose-dependent and time-dependent
manner [10]. These results reinforce the concept of a
physiological role of THs in the homeostasis of tendons,
providing a possible mechanism whereby hypothyroidism
may lead to tendon tears.
The range of manifestations of myxedema includes
stiffness, joint pain, joint swelling, calcium pyrophosphate
dihydrate (CPPD) crystal deposition disease, popliteal
cysts, ligamentous laxity and flexor tendon sheath thick-
ening. Needle synovial biopsy studies have shown only
mild inflammation in the thick synovium. These findings
suggest that the musculoskeletal problems caused by hy-
pothyroidism are treatable [11], despite the lack of unan-
imity regarding the course of musculoskeletal symptoms
and signs after treatment of the thyroid dysfunction. Sev-
eral authors have reported complete disappearance, while
others have reported only a decrease in symptoms and
signs. Kloppenburg et al. [12] concluded that muscu-
loskeletal complaints due to thyroid dysfunction would re-
main present in half the patients even after restoration of
thyroid dysfunction, and in the long run the vast majority
of patients would have persistent or renewed musculoskel-
etal complaints. Clinical and electrophysiological studies
suggest that hypothyroid patients do have a myopathy ra-
ther than a functional muscle disease [13].
Tendinitis has been reported as a frequent complaint
in cases of hypothyroidism while symptomatic relief is
obtained by the treatment of the primary deficiency.
Symptoms can be protracted, resulting in lost working
time and lower quality of life. The majority of patients
respond well to either operative or non-operative treat-
ment. Despite this, patients develop symptoms at a
younger age, resist conservative treatment and more fre-
quently undergo surgical treatment than patients with
no associated endocrine disease [2].
Fig. 2 Magnetic resonance imaging scan of the patient’s shoulder. a T2/turbo spin echo /spectral presaturation with inversion recovery sagittal
oblique view: fluid in her biceps tendon sheath with the long head of her biceps tendon torn and turned downwards. b T1 spectral presaturation
with inversion recovery and gadolinium sagittal view: biceps tendon turned downwards. c Discontinuation of the long head of her biceps tendon in
the sheath and edema at the region of subscapularis tendon
Pantazis et al. Journal of Medical Case Reports  (2016) 10:2 Page 3 of 4
Conclusions
Spontaneous rupture of the long head of the biceps ten-
don is a rare complication of hypothyroidism. THs have
known effects at the cellular level on the proliferation
and differentiation of connective tissues and collagen
formation. The hypothyroid state appears to induce ab-
normalities in these tissues, which results in clinical
manifestations.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KP and AP analyzed and interpreted the patient data regarding the
orthopedic disease. NR and ST analyzed and interpreted the patient data
regarding the metabolic disease. KP, NR and AT made the literature search
and wrote the manuscript. KP and AP also prepared the illustrations. AP and
VK critically reviewed the manuscript from the orthopedic and metabolic
perspective. All authors read and approved the final manuscript.
Author details
1Department of Shoulder and Elbow Surgery, University of Patras, 26500
Patras, Greece. 2Division of Endocrinology, Diabetes and Metabolic Diseases,
Department of Internal Medicine, University of Patras, 26500 Patras, Greece.
3Department of Internal Medicine, University of Patras, 26500 Patras, Greece.
Received: 29 April 2015 Accepted: 23 December 2015
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Spontaneous rupture of the long head of the biceps tendon in a woman with hypothyroidism: a case report

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Spontaneous rupture of the long head of the biceps tendon in a woman with hypothyroidism: a case report

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