A 67-year-old man presented with a 2-year history of bilateral progressive weakness and numbness of the distal upper extremities. He had experienced laminectomy for lumbar spinal stenosis at 66 years old. A physical examination revealed positive bilateral Tinel's sign and Phalen's test as well as bilateral thenar atrophy and bilateral Popeye's sign due to ruptured and retracted distal biceps tendons (Picture 1, 2). He had noticed asymptomatic right Popeye's sign at 62 years old but had not

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... nized the left one until we pointed it out. His capacity for physical activity was limited due to a bilateral leg numbness related to lumber spinal stenosis; therefore, heart failure symptoms did not manifest. The serum B-type natriuretic peptide level was elevated to 190 pg/mL. Electrocardiography showed sinus rhythm, low voltage in limb leads, and left ventricular hypertrophy. A transthoracic echocardiogram revealed a thickened left ventricular wall (interventricular septum: 15 mm) with a decreased left ventricular ejection fraction of 38% and an in-