Pulley lesion is damage to the annular band of the long biceps tendon as it enters the biceps groove. It occurs as a result of an accidental injury or by weakening of the tendon attachment, which becomes brittle with age. The treatment of choice is tenotomy.
What is a pulley lesion?
Pulley lesion is damage to the long biceps tendon in the shoulder joint. The long biceps tendon originates at the upper edge of the glenoid cavity, from where it runs freely through the interior of the joint, which it eventually exits through the biceps groove of the humeral head. Compared to the short biceps tendon, which lies outside the shoulder joint, the long biceps tendon is susceptible to injury and overuse due to its prominent course within the joint. The section in the shoulder joint that it traverses is called the pulley system. This is a connective tissue loop composed of various tendon segments and ligaments. Portions of the supraspinatus tendon and subscapularis tendon are included, as are the coracohumeral ligament and the superior glenohumeral ligament. This sling completely encompasses the long biceps tendon in a healthy glenohumeral joint, as it is designed to prevent the long tendon from slipping out of the intertubercular sulcus, which would result in instability.
Causes
In degenerative changes of the shoulder joint, the guidance of the long biceps tendon can become sensitively disturbed. Also, in the setting of what is called a rotator cuff rupture – a shoulder injury in which one or more tendons of the four muscles that make up the rotator cuff are torn. Specifically, if the tendon of the subscapularis muscle is involved, the long biceps tendon in the shoulder joint may leave its original lodgment in the sulcus bicipitis humeri and enter the main joint called the articulatio humeri. In short, the pulley lesion usually develops in connection with an injury to the parts of the subscapularis tendon. External rotation or hyperflexion trauma causes overloading of the ligamentous border of the biceps tendon, which in the worst case leads to an avulsion of the subscapularis tendon with complete destruction of the pulley system. This leads directly to dislocation of the biceps tendon from the biceps groove and can also affect younger patients, for example due to a fall during snowboarding. In older patients, the cause of the pulley lesion is usually a gradual weakening of the tendon attachment that has become brittle with age. For this reason, a gradual tear of the subscapularis tendon and subsequent instability of the long biceps tendon may occur here even without a causative accident.
Symptoms, signs, and complaints
The pulley injury brings with it restricted or irritated motion. As a result of the instability of the Pulley system, which really chafes, inflammation of the long biceps tendon can occur, which is why pain occurs primarily in the front of the upper arm. In addition, the pulley lesion gradually pulverizes the surrounding joint components. The result can be osteoarthritis in the shoulder joint and thinning, and later rupture, of the long biceps tendon. Patients with pulley injury due to an accident have often noticed a tearing sound during the accident. They usually have severe pain in the shoulder, which increases at night. However, spikes of pain are also evident during jerky movements of the arms or when lifting heavy objects with the arm extended. 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 and course of the disease
To diagnose a pulley lesion, the O’Brien test is performed – a patient’s indication of pain after lifting his or her forward-extended, inward-rotating arm against a resistance. In addition to a positive result on the O’Brien test, additional positive subscapularis signs and localized tenderness over the biceps groove are often found with the Pulley lesion. The injured arm has increased external rotation ability compared to the healthy side. X-ray diagnosis allows bony injuries to be ruled out; the imaging procedure also provides information on the overall condition of the shoulder joint, such as whether osteoarthritis is present, whether there are calcium deposits or signs of a previous dislocation.The pulley lesion can be visualized by ultrasound – at least in those pronounced cases where the long biceps tendon has emerged from the biceps groove. MR diagnostics, in turn, can show detachment of the tendon attachment of the subscapularis tendon as a continuity break, not infrequently with fluid influx between the tendon tissue and the humerus. In equivocal cases, MR arthrography can be performed after injection of a contrast agent. MRI then shows the pulley lesion as a widening of the rotator interval.
Complications
The Pulley lesion has a very negative impact on the patient’s quality of life. It usually results in severe limitations in movement, so that the affected person may have to rely on walking aids or on the help of other people in his or her daily life. Various coordination difficulties may also occur as a result of the Pulley lesion and continue to complicate the patient’s daily life. In most cases, this also results in inflammation if left untreated. Furthermore, arthrosis can develop, resulting in severe pain in the shoulder. This pain often spreads to the back. Especially at night, this can lead to insomnia and further to depression and other psychological upsets. Self-healing does not usually occur with the Pulley lesion. Lifting heavy objects is also associated with severe pain for the affected person. Treatment of Pulley lesion is done by surgical intervention and various therapies. In most cases, there are no complications. The life expectancy of the affected person is not affected by the Pulley lesion.
When should you see a doctor?
Pulley lesion should always be treated by a physician. Since there is no self-healing in this condition and often a worsening of the general condition, medical treatment is essential. As a rule, a doctor should be consulted for pulley lesions when inflammation occurs in the affected tendon. Due to the inflammation, the patient suffers from severe pain that can spread to the whole arm. The pain occurs not only in the form of pain on exertion, but also as pain at rest and can lead to significant sleep complaints. Furthermore, the development of osteoarthritis may also be indicative of the Pulley lesion, resulting in severe pain in the patient’s shoulders. In this case, the affected person can no longer stretch his arm properly and thus suffers from significant limitations in his everyday life. In the first instance, an orthopedist or an accident physician can be consulted for a Pulley lesion. Further treatment usually takes place through surgery, so a stay in a hospital is also necessary.
Treatment and therapy
Returning the tendon to its natural course is difficult or impossible because the leading structures themselves are damaged. In addition, the connective tissue loop of the pulley system is so delicate that reconstruction attempts after its rupture usually fail. Where reconstruction was possible, patients often had more complaints afterwards than before. For this reason, transection of the tendon has become the treatment of choice. The absence of the long biceps tendon is far less problematic than the absence of the short one: more than ninety percent of the strength of the biceps muscle is developed by the short tendon, so that the loss of the long tendon can be well compensated. Removal of the portion of the long biceps tendon that runs in the joint is called tenotomy (“cutting”). 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 purpose, the surgeon uses a titanium anchor. In contrast, a repair of the ligamentous attachment including preservation of 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 three to four weeks of immobilization to ensure healing of the misplaced tendon.
Prevention
Because the pulley lesion occurs either as a result of an accident or with advancing age due to natural wear and tear of the joint, only general preventive measures can be recommended to prevent accidents.
Aftercare
In Pulley lesion, the severity of the disease and the therapy determined by the specialist determine the extent of follow-up care. Generally, the Pulley lesion is first treated conservatively. Aftercare then focuses on continuing therapeutic treatments. In the long term (period of two to four months), physiotherapy is used to try to alleviate the patient’s pain and improve the shoulder’s movement function. Exercises to strengthen the shoulder muscles can accelerate the recovery process. Drug therapy is also regularly adapted to the symptoms. However, the pulley lesion does not usually heal completely conservatively. The affected person must accept functional deficits in the shoulder area. During follow-up care, techniques should therefore be learned that can reduce the strain on the shoulder girdle in everyday life. After surgery for the Pulley lesion (cutting the tendon or attaching it to the bone), the shoulder remains in a Gilchrist bandage for six weeks. However, the long biceps tendon receives immediate passive exercise postoperatively. Secondary ruptures (rupture of the tendon elsewhere) and displacement of the muscle belly can thus be prevented. In the case of surgical therapy, the focus of post-operative treatment is on exercising the shoulder muscles by means of physiotherapy. Physical applications such as electrotherapy (stimulation current) and cold are also generally prescribed by the specialist. In about 95 percent of all cases, good results can be expected after surgery.
What you can do yourself
A pulley lesion must first be diagnosed and treated by a doctor. Depending on the severity of the lesion, the patient can take a variety of measures to help with therapy. First, exercise is important. Physiotherapy, yoga and the like can support the retraction of the tendon. Then, under certain circumstances, a complete recovery is possible and patients 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 have already been severely damaged. In this case, therapy focuses on relieving the pain and strengthening the remaining tendons to such an extent that the limited range of motion is optimally compensated. This can be achieved by stretching exercises, but also by a surgical procedure 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 can be achieved by taking a comprehensive medical history, supported by a complaints diary in which, among other things, the first occurrence of the typical complaints should be noted. Based on this information, the physician can find the trigger of the ligament damage and initiate further measures. It is important to eliminate the cause, for example by refraining from weight training or changing professions.
