We will be performing site maintenance on our learning platform at learn.aaos.org on Sunday, January 29th at 12 AM EST. The site will be down for up to 5 hours. We apologize for the inconvenience.

Fig. 1 BCM characteristics on MRI include abnormal signal in the proximal biceps, subchondral bone, and cartilage loss.
Courtesy of Samuel A. Taylor, MD

AAOS Now

Published 9/1/2015
|
Terry Stanton

Biceps Chondromalacia: The Diagnostic Role of MRI

Imaging can point to pathology in the biceps-labrum complex

Biceps chondromalacia suggests the presence of symptomatic biceps-labrum complex (BLC) disease, and certain MRI features may be useful in identifying features of biceps chondromalacia on preoperative imaging that are not always detected with arthroscopy, according to a study presented at the 2015 annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM) in Orlando, Fla.

Samuel A. Taylor, MD, of Hospital for Special Surgery, summarized issues involving the diagnosis of biceps chondromalacia (BCM), which he defined as an attritional lesion on the humeral head, caused by abrasion of the long head of the biceps tendon.

“Biceps chondromalacia is not a novel concept,” he noted, “but it does suggest the presence of BLC disease. Certain MRI features not only identify biceps chondromalacia, they may be used to predict a symptomatic biceps-labrum complex, even when biceps chondromalacia is not visualized at arthroscopy.”

Dr. Taylor referenced a study that identified a “biceps tendon footprint,” which was observed in 16 percent of patients examined by arthroscopy. It accompanied chondral wear occurring deep to the biceps tendon near the articular margin. The study suggested abnormal biceps tension as its cause.

Another study reported on a “chondral print” seen in 89 percent of shoulders with biceps instability that was often accompanied by a thickened, irritated tendon.

Dr. Taylor and his fellow authors identified two forms of biceps chondromalacia: Junctional, which occurs along the articular margin and results from repetitive sawing biceps motion during excursion, and medial, which is a response to a shearing windshield-wiper effect of the biceps seen in the setting of a pulley lesion or dynamic incarceration of the tendon (Fig. 1).

Imaging, operative findings
For this retrospective review, the investigators compared preoperative MRI with intra-operative findings in the following groups:

  1. Patients operated on for symptomatic BLC disease with demonstrable BCM grossly evident at surgery (n = 34)
  2. Patients operated on for symptomatic BLC disease without demonstrable BCM at surgery (n = 21)
  3. Control groups of patients without clinical BLC disease who were operated on for shoulder instability (n = 29)

Groups 1 and 2 were age-matched, with a mean age of 42 years; the average age of patients in group 3 was significantly younger at 29 years and had a higher predominance of males. The MRIs were scored by a musculoskeletal radiologist who was blinded to intraoperative findings for chondral loss, bone marrow edema, subchondral signal change, and tendinosis or fraying of the biceps tendon.

Groups 1 and 2 were statistically similar to each other, but varied significantly when compared to group 3 (Table 1). This finding, Dr. Taylor explained, was particularly true with regard to cartilage loss, signal in proximal biceps, and subchondral signal change.

“Patients in both group 1 and group 2 underwent subdeltoid biceps transfer for refractory symptoms. Those in group 1, however, had arthroscopically confirmed biceps chondromalacia, while those in group 2 did not. Patients in group 3 served as controls and included patients who underwent an isolated arthroscopic anterior stabilization,” said Dr. Taylor.

Dr. Taylor noted that the MRI images demonstrated good sensitivity, as well as moderate positive and negative predictive values for arthroscopically confirmed biceps chondromalacia. “Interestingly,” he said, “there were no differences between the two symptomatic groups regardless of whether or not biceps chondromalacia was actually identified intra-operatively, but both differed significantly from group 3.”

Moreover, he continued, “These features identified on preoperative MRI performed well to predict symptomatic BLC disease with sensitivities ranging from 60 percent to 86 percent and positive predictive values in the upper 70s.”

Limitations and conclusions
The study’s primary limitations, he noted, were the significantly younger age of the control group and the MRI review by a single radiologist, which prohibited an inter-rater reliability assessment.

Despite these limitations, he said, “MRI may be considered quite useful for identifying symptomatic patients preoperatively based on the aforementional abnormal features. This is important in light of recent literature by our group and others suggesting that gold-standard diagnostic arthroscopy fails to fully evaluate the biceps labrum complex. This was especially the case for concealed pathology within the bicipital tunnel, which was found in 47 percent of 277 chronically symptomatic patients in a recent study by our group.”

Furthermore, he noted, when he and his associates broke down the lesions by location—intra-articular, labrum, and bicipital tunnel—they found the following:

  • 70 percent of patients had more than one lesion
  • 37 percent had lesions in multiple zones
  • 45 percent of those with intra-articular biceps pathology also had tunnel disease
  • 27 percent of patients with a completely normal intra-articular tendon harbored hidden lesions

After his presentation, he told AAOS Now, “The take-home messages from the study are that biceps chondromalacia can be identified on preoperative MRIs by chondral loss, subchondral signal abnormalities, and increased signal in the proximal biceps. Furthermore, these three features on MRI proved highly predictive of symptomatic biceps-labral complex disease regardless of the presence or absence of grossly visualized biceps chondromalacia at arthroscopy.”

Coauthors with Dr. Taylor of “The Role of MRI in Diagnosing Biceps Chondromalacia” are Mary E. Shorey, BA; Hollis Potter, MD; Joshua S. Dines, MD; Joseph T. Nguyen, MPH; and Stephen J. O’Brien, MD, MBA. Conflict of interest information for the authors can be found at www.aaos.org/disclosure

Bottom Line

  • Diagnosis of biceps chondromalacia (BCM) is a useful indicator to a diagnosis of disease in the bicep-labrum complex (BLC).
  • BCM may be defined as attritional chondral wear occurring either as junctional or medial.
  • In this study of three groups of patients—those with BCM at surgery, those without its observation at surgery, and those without clinical BLC pain—MRI was beneficial in the prediction of BLC disease.
  • The MRI findings may be useful regardless of the presence or absence of visualized chondromalacia at arthroscopy and may detect disease not noted by arthroscopy.