Pulley Lesion

The pulley lesion is damage to the annular ligamentous lining of the long biceps tendon as it enters the biceps groove. It occurs as a result of an accident or due to weakening of the tendon attachment that has become brittle with age. The treatment of choice is tenotomy.

Pulley Lesion

What is a Pulley Lesion?

The pulley lesion is damage to the long biceps tendon in the shoulder joint. The long biceps tendon attaches to the upper edge of the shoulder joint socket, from where it runs freely through the interior of the joint, which it finally exits through the biceps groove of the humeral head. See topbbacolleges for Definitions of HLHS.

Compared to the short biceps tendon, which lies outside the shoulder joint, the long biceps tendon is prone to injury and overload due to its elevated course within the joint. The section of the shoulder joint that it traverses is called the pulley system. This is a connective tissue loop made up of different tendon sections and ligaments.

Portions of the supraspinatus tendon and the subscapularis tendon are also included, as are the coracohumeral ligament and the superior glenohumeral ligament. In a healthy shoulder joint, this sling completely encloses the long biceps tendon, as it is intended to prevent the long tendon from slipping out of the intertubercular sulcus, which would result in instability.


In the case of degenerative changes in the shoulder joint, the guidance of the long biceps tendon can be severely disturbed. Also in what is known as a rotator cuff tear – a shoulder injury in which one or more tendons of the four muscles that make up the rotator cuff tear.

Especially when the tendon of the subscapularis muscle is affected, the long biceps tendon in the shoulder joint can leave its original location in the sulcus bicipitis humeri and get into the main joint called articulatio humeri. Briefly, the pulley lesion usually arises in connection with an injury to parts of the subscapularis tendon. An external rotation or hyperflexion trauma causes an overload of the ligament border of the biceps tendon, which in the worst case leads to a rupture of the subscapularis tendon with complete destruction of the pulley system.

This leads directly to a dislocation of the biceps tendon from the biceps groove and can also affect younger patients, for example due to a fall while snowboarding. In older patients, the cause of the pulley lesion is usually a gradual weakening of the tendon attachment, which has become brittle with age. For this reason, a gradual tear of the subscapularis tendon and resulting instability of the long biceps tendon can occur here, even without a causative accident.

Symptoms, Signs & Ailments

The pulley injury entails restricted or irritated movement. As a result of the instability of the pulley system, which literally chafes, the long biceps tendon can become inflamed, which is why pain occurs primarily in the front of the upper arm. In addition, the surrounding parts of the joint are gradually worn down by the pulley lesion.

The result can be arthrosis in the shoulder joint as well as thinning and later tearing of the long biceps tendon. Pulley injury patients from an accident have often noticed a tearing noise during the accident. They usually have severe shoulder pain, which is worse at night.

However, there are also peaks of pain with jerky movements of the arms or when lifting heavy objects with an outstretched arm. These complaints do not subside for months. Very severe pain can be a sign for the doctor that there is a complete dislocation of the long biceps tendon.

Diagnosis & course of disease

To diagnose a pulley lesion, the O’Brien test is performed – a pain report from the patient after raising their forwardly extended, internally rotating arm against resistance. In addition to a positive result of the O’Brien test, there are often additional positive subscapularis signs and local pressure pain over the biceps groove in the case of the pulley lesion.

The injured arm has increased external rotation ability compared to the healthy side. Bone injuries can be ruled out by X-ray diagnosis; In addition, the imaging procedure provides information about the overall condition of the shoulder joint, for example whether arthrosis is present, whether there are calcium deposits or signs of a dislocation that has taken place. The pulley lesion can be visualized by ultrasound – at least in those severe cases where the long biceps tendon has come out of the biceps groove.

MR diagnostics, on the other hand, can show the detachment of the tendon attachment of the subscapularis tendon as a discontinuity, often with fluid inflow between the tendon tissue and the humerus. In ambiguous cases, an MR arthrography can be performed after the injection of a contrast medium. In the MRI, the pulley lesion then shows up as a widening of the rotator interval.


The pulley lesion has a very negative impact on the patient’s quality of life. As a rule, there are severe limitations in movement, so that the person concerned may have to rely on walking aids or the help of other people in their everyday life. Various difficulties in coordination can also occur as a result of the pulley lesion and continue to make everyday life difficult for the patient.

In most cases, if left untreated, inflammation will also occur. Osteoarthritis can also develop, leading to severe pain in the shoulder. This pain often spreads to the back. This can lead to insomnia, especially at night, and further to depression and other mental upsets.

Self-healing does not usually occur in the case of a pulley lesion. Lifting heavy objects is also associated with severe pain for those affected. Pulley lesions are treated with surgery and various therapies. Usually there are no complications. The life expectancy of the person affected is not affected by the pulley lesion.

When should you go to the doctor?

The pulley lesion should always be treated by a doctor. Since this disease does not heal itself and the general condition often deteriorates, medical treatment is essential. As a rule, a doctor should be consulted for a pulley lesion if the affected tendon becomes inflamed. As a result of the inflammation, the patient suffers from severe pain that can spread to the entire arm.

The pain occurs not only in the form of stress pain, but also as rest pain and can lead to significant sleep disorders. The development of arthrosis can also indicate the pulley lesion, resulting in severe pain in the patient’s shoulders. The affected person can no longer stretch his arm properly and thus suffers from significant limitations in his everyday life.

In the first place, an orthopedist or an accident doctor can be consulted for the pulley lesion. Further treatment usually takes place through surgery, so that a stay in a hospital is necessary.

Treatment & Therapy

Returning the tendon to its natural course is difficult if not impossible, since the leading structures themselves are damaged. In addition, the connective tissue loop of the pulley system is so delicate that attempts to reconstruct it usually fail after it tears. Where reconstruction was possible, patients often had more complaints afterwards than before.

For this reason, cutting the tendon has become the therapy of choice. The absence of the long biceps tendon is far less of a problem than the absence of the short one would be: More than 90 percent of the power development of the biceps muscle is developed via the short tendon, so that the loss of the long tendon can be easily compensated.

The removal of the portion of the long biceps tendon that runs inside the joint is called a tenotomy (“cutting through”). In addition, a so-called tenodesis (“relocation”) can be performed – the relocation of the tendon attachment to the area of ​​the biceps groove on the humeral head if the natural course of the tendon cannot be preserved. For this, the surgeon uses a titanium anchor.

On the other hand, repairing the ligament border and preserving the anatomical course of the biceps tendon is usually not promising. The operation is performed arthroscopically under general anesthesia and takes about sixty minutes. This is followed by immobilization for three to four weeks to ensure that the tendon that has been laid can heal.


Since the pulley lesion occurs either as a result of an accident or with advancing age due to natural joint wear, only general preventive measures to prevent accidents can be recommended.


In the case of a pulley lesion, the severity of the disease and the therapy specified by the specialist determine the scope of follow-up care. Basically, the pulley lesion is first treated conservatively. Aftercare then focuses on continuing the therapeutic treatments. In the long term (two to four months), physiotherapy is used to relieve the patient’s pain and improve the movement function of the shoulder.

Shoulder strengthening exercises can speed up the recovery process. Drug therapy is also regularly adapted to the symptoms. However, the pulley lesion usually does not heal completely conservatively. The affected person must accept functional deficits in the shoulder area. During aftercare, techniques should therefore be learned that can reduce the stress on the shoulder girdle in everyday life.

After surgery on the pulley lesion (cutting the tendon or attaching it to the bone), the shoulder remains in a Gilchrist cast for six weeks. However, the long biceps tendon is passively exercised immediately after the operation. Secondary ruptures (rupture of the tendon elsewhere) and displacement of the muscle belly can be prevented in this way. In the case of surgical therapy, the focus of aftercare is on exercising the shoulder muscles using physiotherapy. Physical applications such as electrotherapy (stimulation current) and cold are also generally prescribed by the specialist. In around 95 percent of all cases, good results can be expected after an operation.

You can do that yourself

A pulley lesion must first be diagnosed and treated by a doctor. Depending on the severity of the lesion, the patient can take various measures to support the therapy. First of all, physical activity is important. The retraction of the tendon can be supported by physiotherapy, yoga and the like. A complete recovery may then be possible and the patient can move the affected arm again without pain.

In most cases, it is no longer possible to return the tendon to its natural course of movement because the structures themselves are already severely damaged. In this case, the therapy focuses on relieving the pain and strengthening the other tendons to such an extent that the limited mobility is optimally compensated. This is achieved through stretching exercises, but also through an operation in which the tendon is strengthened with the help of a band.

In addition to these symptomatic measures, the cause of the pulley lesion must be determined. This is achieved through a comprehensive anamnesis, supported by a complaints diary in which, among other things, the first appearance of the typical complaints should be noted. Based on this information, the doctor can find the cause of the ligament damage and initiate further measures. It is important to eliminate the cause, for example by giving up weight training or changing jobs.