Biceps pulley injury

Last revised by Fabio Macori on 5 Mar 2024

Biceps pulley injuries can be challenging and difficult to diagnose. They can be missed during open and arthroscopic examination, and therefore have sometimes been referred to as a “hidden lesions”.

Anterior extension of supraspinatus tendon tears may involve the rotator interval capsule. This allows impingement of the long head of biceps (LHB) tendon between the acromion and coracoacromial ligament, resulting in biceps tendinopathy.

  • traumatic: after falling on an outstretched arm with full external or internal rotation, as well as a backward fall on the hand or elbow

  • secondary to rotator cuff tears

Bennett classification 1 of biceps subluxation instability:

  • type 1: injury of the intra-articular subscapularis tendon without the involvement of the medial head of coracohumeral ligament (CHL)

  • type 2: injury of the medial sheath (composed of SGHL-medial CHL ligament complex), without subscapularis involvement

  • type 3: injury involving both the medial sheath and subscapularis tendon

  • type 4: injury involving the supraspinatus and lateral head of CHL

  • type 5: injury involving all structures; intra-articular subscapularis tendon, medial sheath, supraspinatus tendon and lateral CHL

Superior glenohumeral ligament (SGHL), coracohumeral ligament and rotator interval capsule structures have intermediate signal filling the rotator interval and surrounding the biceps tendon. These structures may appear thickened when the shoulder is internally rotated as the rotator interval structures will not be taut in this position. Intra-articular fluid (effusion or contrast arthrography) allows better visualization. 

  • identifying the abnormality is not always possible on MRI, however, if there is biceps tendon subluxation/dislocation a biceps pulley injury may be suspected

  • injury to the superior border of subscapularis tendon has is suspicious for a reflection pulley

  • type 1 and type 2 lesions: may not be distinguished between on MRI

  • type 3: the biceps tendon can dislocate into the joint

  • type 4: the combination of rupture of the lateral coracohumeral ligament and loss of the normal tension of the medial coracohumeral ligament allows the biceps tendon to sublux superficial to the subscapularis tendon and coracohumeral ligament

  • type 5: the biceps tendon is free to dislocate anteriorly or into the joint

Treatment is controversial but mostly biceps tenodesis is usually preferred. There are few published studies on surgical repair.

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