The Anatomy of the Biceps Pulley

  • Giovanni Di Giacomo
  • Alberto Costantini
  • Andrea De Vita
  • Nicola de Gasperis
  • Luigi Piscitelli


The pulley has recently been described as a structure that aids in the prevention of biceps instability. The biceps pulley or “sling” is a capsule ligamentous complex that acts to stabilize the long head of the biceps tendon in the bicipital groove. The pulley complex is composed of the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon and is located within the rotator interval between the anterior edge of the supraspinatus tendon and the superior edge of the subscapularis tendon.

The interest in the pulley lesions has increased in recent times, due to the biceps instability it could generate. A better understanding of the anatomy, functions, and subsequently pathology of the pulley can help to treat the patients in a more effective manner for the biceps pathology but also for all the other pathologic conditions associated with the pulley lesions, like anterosuperior impingement, superior labrum anterior, and posterior lesions.


Biceps tendon pulley 


  1. 1.
    Kessel L, Watson M. The painful arc syndrome. Clinical classification as a guide to management. J Bone Joint Surg Br. 1977;59(2):166–72.CrossRefGoogle Scholar
  2. 2.
    Lippmann R. Frozen shoulder, periarthritis, bicipital tenosynovitis. AMA Arch Surg. 1943;47:283–96.CrossRefGoogle Scholar
  3. 3.
    Bennett WF. Arthroscopic repair of anterosuperior (supraspinatus/subscapularis) rotator cuff tears: a prospective cohort with 2- to 4-year follow-up. Classification of biceps subluxation/instability. Arthroscopy. 2003;19:21–33.CrossRefGoogle Scholar
  4. 4.
    Dierickx C, et al. Variations of intraarticular portion of the long head of the biceps tendon: a classification of embryologically explained variations. J Shoulder Elb Surg. 2009;18(4):556–65.CrossRefGoogle Scholar
  5. 5.
    Aalto K, et al. Medial dislocation of the tendon of the long head of the biceps brachii. Acta Orthop Scand. 1979;50(1):73–7.CrossRefGoogle Scholar
  6. 6.
    Nakata W, et al. Biceps pulley: normal anatomy and associated lesions at MR arthrography. Radiographics. 2011;31(3):791–810.CrossRefGoogle Scholar
  7. 7.
    Walch G, Edwards TB, Boulahia A, et al. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elb Surg. 2005;14(3):238–46.CrossRefGoogle Scholar
  8. 8.
    Van Holsbeek M, Introcaso JH. Musculoskeletal ultrasound. 1st ed. St. Louis: Mosby-Year Book; 1990.Google Scholar
  9. 9.
    Verma N. Long head biceps tendon: surgical techniques and complications. Instructional course lecture 271: American Academy of Orthopaedic Surgeons; 2012.Google Scholar
  10. 10.
    Burkhead WZ, Arcand MA, Zeman C, Habermeyer P, Walch G. The biceps tendon. In: Rockwood CA, Matsen FA, Wirth MA, Lippitt SB, editors. The shoulder, vol. 2. Philadelphia, PA: Saunders; 2004. p. 1059–119.Google Scholar
  11. 11.
    Refior HJ, Sowa D. Long tendon of biceps brachii: sites of predilection for degenerative lesions. J Shoulder Elb Surg. 1995;4(6):436–40.CrossRefGoogle Scholar
  12. 12.
    Gleason PD, et al. The transverse humeral ligament, a separate anatomical structure or a continuation of the osseous attachment of the rotator cuff? Am J sport Med. 2006;34(1):72–7.CrossRefGoogle Scholar
  13. 13.
    Werner A, Mueller T, Boehm D, Gohkle F. The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval. Am J Sports Med. 2000;28:28–31.CrossRefGoogle Scholar
  14. 14.
    Bain GI, Itoi E, Di Giacomo G, et al. Normal and pathological anatomy of the shoulder: Springer; 2015.Google Scholar
  15. 15.
    Petersson CJ, et al. Spontaneous medial dislocation of the tendon of the long biceps brachii. An anatomic study of prevalence and pathomechanics. Clin Orthop Relat Res. 1986;(211):224–7.Google Scholar
  16. 16.
    Lapidus PW, Guidotti FP. Common shoulder lesions report of 493 cases. Calcific tendinitis, tendinitis of long head of biceps, frozen shoulder, fractures and dislocations. Bull Hosp Joint Dis. 1968;29(2):293–306.PubMedGoogle Scholar
  17. 17.
    Habermeyer P, et al. Anterosuperior impingement of the shoulder as a result of pulley lesions: a prospective arthroscopic study. J Shoulder Elb Surg. 2004;13(1):5–12.CrossRefGoogle Scholar
  18. 18.
    Bennett WF. Correlation of the SlAP lesion with lesions of the medial sheath of the biceps tendon and intra-articular subscapularis tendon. Indian J Orthop. 2009;43(4):342–6.CrossRefGoogle Scholar

Copyright information

© ISAKOS 2019

Authors and Affiliations

  • Giovanni Di Giacomo
    • 1
  • Alberto Costantini
    • 1
  • Andrea De Vita
    • 1
  • Nicola de Gasperis
    • 1
  • Luigi Piscitelli
    • 1
  1. 1.Department of OrthopaedicConcordia Hospital for “Special Surgery”RomeItaly

Personalised recommendations