Injuries of the Biceps Pulley System



The biceps pulley system (BPS) consists of capsulo-ligamentous fibres that stabilize the long head of the biceps (LHB) before the tendon enters into the proximal segment of the bony bicipital groove. It is formed by conjoining parts of the superior glenohumeral ligament, the coraco-humeral ligament and supporting fibres from the subscapularis and supraspinatus tendons. Additionally, it creates the junction part of the biceps-labral complex. Numerous reasons like chronic degeneration, repetitive microtrauma as well as an acute trauma can result in a lesion of this anatomical structure. Injuries of the BPS lead to instability of the LHB and result in significant anterior shoulder pain. They are often associated with tears of the rotator cuff and biceps tendon, SLAP lesions or internal antero-superior impingement. Several classification systems describe different groups of pulley lesions depending on the anatomical structures that are involved. In rare cases conservative treatment may result in pain relief using anti-inflammatory medication and physiotherapy, but most of the lesions require proper surgical treatment. According to the literature, repair of the BPS is not an acceptable management choice. In addition to arthroscopic or open repair of the concerned structures, tenotomy and tenodesis of the LHB both seem to be consistent treatment options for most shoulder surgeons resulting in significant pain relief.


Biceps pulley system Long head of the biceps Pulley lesion Rotator cuff interval Biceps tendon instability 


  1. 1.
    Ferrari DA. Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule. Am J Sports Med. 1990;18:20–4.CrossRefGoogle Scholar
  2. 2.
    Habermeyer P, Magosch P, Pritsch M, et al. Anterosuperior impingement of the shoulder as a result of pulley-lesions: a prospective arthroscopic study. J Shoulder Elb Surg. 2004;13:5–12.CrossRefGoogle Scholar
  3. 3.
    Braun S, Horan MP, Elser F, et al. Lesions of the biceps pulley. Am J Sports Med. 2011;39:790–5.CrossRefGoogle Scholar
  4. 4.
    Alpantaki K, McLaughlin D, Karagogeos D, et al. Sympathetic and sensory neural elements in the tendon of the long head of the biceps. J Bone Joint Surg Am. 2005;87:1580–3.PubMedGoogle Scholar
  5. 5.
    Walch G, Nové-Josserand L, Boileau P, et al. Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elb Surg. 1998;7:100–8.CrossRefGoogle Scholar
  6. 6.
    Walch G, Nové-Josserand L, Levigne C, et al. Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J Shoulder Elb Surg. 1994;3:353–60.CrossRefGoogle Scholar
  7. 7.
    Werner A, Mueller T, Boehm D, et al. The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. A histoanatomic study. Am J Sports Med. 2000;28:28–31.CrossRefGoogle Scholar
  8. 8.
    Braun S, Millett PJ, Yongpravat C, et al. Biomechanical evaluation of shear force vectors leading to injury of the biceps reflection pulley: a biplane fluoroscopy study on cadaveric shoulders. Am J Sports Med. 2010;38:1015–24.CrossRefGoogle Scholar
  9. 9.
    Baumann G, Genning K, Boehm D, et al. Arthroscopic prevalence of pulley lesions in 1007 consecutive patients. J Shoulder Elb Surg. 2008;17:14–20.CrossRefGoogle Scholar
  10. 10.
    Hawi N, Liodakis E, Garving C, et al. Pulley lesions in rotator cuff tears: prevalence, etiology and concomitant pathologies. Knee Surg Sports Traumatol Arthrosc. 2017;137:1097–105.Google Scholar
  11. 11.
    Cheng NM, Pan WR, Vally F, et al. The arterial supply of the long head of biceps tendon: anatomical study with implications for tendon rupture. Clin Anat. 2010;23:683–92.CrossRefGoogle Scholar
  12. 12.
    Boileau P, Ahrens PM, Trojani C, et al. Entrapment of the long head of the biceps: the “hourglass biceps”. Another cause of pain and locking of the shoulder. Rev Chir Orthop Reparatrice Appar Mot. 2003;89:672–82.PubMedGoogle Scholar
  13. 13.
    Kibler BW, Sciascia AD, Hester P, et al. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009;37:1840–7.CrossRefGoogle Scholar
  14. 14.
    Schaeffeler C, Waldt S, Holzapfel K, et al. Lesions of the biceps pulley: diagnostic accuracy of MR arthrography of the shoulder and evaluation of previously described and new diagnostic signs. Radiology. 2012;264:504–13.CrossRefGoogle Scholar
  15. 15.
    Vinson EN, Major NM, Higgins LD. Magnetic resonance imaging findings associated with surgically proven rotator interval lesions. Skelet Radiol. 2007;36:405–10.CrossRefGoogle Scholar
  16. 16.
    Motley GS, Guengerich B, Schuller T, et al. The ramp test: an arthroscopic technique for confirming intra-articular subluxation and instability of the long head of the biceps tendon within the shoulder. Arthrosc Tech. 2018;7:e327–e30.CrossRefGoogle Scholar
  17. 17.
    Hart ND, Golish SR, Dragoo SL. Effects of arm position on maximizing intraarticular visualization of the biceps tendon: a cadaveric study. Arthroscopy. 2012;28:481–5.CrossRefGoogle Scholar
  18. 18.
    Bennett WF. Arthroscopic repair of anterosuperior (supraspinatus/subscapularis) rotator cuff tears: a prospective cohort of 2- to 4-year follow-up. Classification of biceps subluxation/instability. Arthroscopy. 2003;19:21–33.CrossRefGoogle Scholar
  19. 19.
    Gilmer BB, DeMers AM, Guerrero D, et al. Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis. Arthroscopy. 2015;31:29–34.CrossRefGoogle Scholar
  20. 20.
    Taylor SA, Khair MM, Gulotta LV, et al. Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex. Arthroscopy. 2015;31:215–24.CrossRefGoogle Scholar
  21. 21.
    Bennett WF. Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy. Arthroscopic appearance and incidence of “hidden” rotator interval lesions. Arthroscopy. 2001;17:173–80.CrossRefGoogle Scholar
  22. 22.
    Braun S, Imhoff AB. Modern treatment strategies for the long head of the biceps tendon. Orthopaede. 2018;47:113–20.. [German]CrossRefGoogle Scholar
  23. 23.
    Gaskill TR, Braun S, Millett PJ, et al. Multimedia article. The rotator interval: pathology and management. Arthroscopy. 2011;27:556–67.CrossRefGoogle Scholar
  24. 24.
    Gurnani N, van Deurzen DF, Janmaat VT, et al. Tenotomy or tenodesis for pathology of the long head of the biceps brachii: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2016;24:3765–71.CrossRefGoogle Scholar

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© ISAKOS 2019

Authors and Affiliations

  1. 1.Department of Orthopaedics, Trauma Surgery and Sports Traumatology, St. Elizabeth-HospitalAcademic Training Hospital of Westphalian-Wilhelms-University MünsterDorstenGermany

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