The Pulley Lesion

Most patients will be completely unfamiliar with the pulley system of the long biceps tendon. Unfortunately, this condition also applies to many physicians who do not deal with shoulder problems on a daily basis. Injuries to this pulley system are by no means uncommon. If an experienced surgeon pays attention, they will frequently encounter injuries in this area.

The pulley system is a connective tissue loop composed of various ligaments and tendon segments. Portions of the subscapularis tendon, the supraspinatus tendon, the superior glenohumeral ligament, and the coracohumeral ligament are involved.

This loop completely surrounds the long biceps tendon and is intended to prevent the tendon from slipping out of the bicipital groove and becoming unstable. The consequence of such instability is tendon chafing and inflammation. In the worst case, the long biceps tendon can even injure the supraspinatus tendon or subscapularis tendon by rubbing back and forth.

You can also clearly see the course of the tendon and the pulley system in the following video.

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Injuries to this pulley system result in instability of the long biceps tendon. The result is often inflammation of the long biceps tendon and pain, primarily localized in the front of the upper arm.

Pulley lesions are classified according to Habermayer. This classification includes four groups.

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Unfortunately, there aren't many therapeutic options. Because the loop of the pulley system is very delicate, most attempts to reconstruct it after a tear have proven unsuccessful. Patients often experience more discomfort after reconstruction than before. For this reason, tendon severance has proven to be a promising treatment option for cases of instability of the long biceps tendon.

Many patients fear a loss of strength in their arm after such a procedure. However, this fear is unfounded. The biceps, as the name suggests, consists of two parts: the short and the long biceps tendon. After severing the long biceps tendon, the short biceps tendon continues to function. The resulting loss of strength was almost immeasurable in many studies.