Adhesive capsulitis: sonographic changes in the rotator cuff interval with arthroscopic correlation

OBJECTIVE

To evaluate the sonographic findings of the rotator interval in patients with clinical evidence of adhesive capsulitis immediately prior to arthroscopy.

DESIGN AND PATIENTS

We prospectively compared 30 patients with clinically diagnosed adhesive capsulitis (20 females, 10 males, mean age 50 years) with a control population of 10 normal volunteers and 100 patients with a clinical suspicion of rotator cuff tears. Grey-scale and colour Doppler sonography of the rotator interval were used.

RESULTS

Twenty-six patients (87%) demonstrated hypoechoic echotexture and increased vascularity within the rotator interval, all of whom had had symptoms for less than 1 year. Three patients had hypoechoic echotexture but no increase in vascularity, and one patient had a normal sonographic appearance. All patients were shown to have fibrovascular inflammatory soft-tissue changes in the rotator interval at arthroscopy commensurate with adhesive capsulitis. None of the volunteers or the patients with a clinical diagnosis of rotator cuff tear showed such changes.

CONCLUSIONS

Sonography can provide an early accurate diagnosis of adhesive capsulitis by assessing the rotator interval for hypoechoic vascular soft tissue.

Comparison of clinical, ultrasonographic, and postoperative macroscopic findings in cows with bursitis

Clinical, ultrasonographic, and macroscopic findings of bursitis in cows were compared to assess the contribution of diagnosis and therapy planning. Sixteen dairy cows with swelling at the carpal (n = 12) or tarsal (n = 4) region were examined clinically and ultrasonographically and the findings were compared. In 10 patients the bursae were removed in toto. According to the duration of the disease (history) and clinical findings nine and seven patients had acute and chronic bursitis, respectively. Six had fluctuation and in 10 the bursa was firm. Contents were serous (n = 3), serofibrinous (n = 4), serohemorrhagic (n = 2), or purulent (n = 1). Sonographically there was fluid in all bursa except one. Capsule echogenicity varied between hypoechoic and hyperechoic and mean capsule thickness was 9.2 +/- 4.1 mm. Fourteen of the bursae contained free-floating particles. The hyperechoic capsules represented fibrous tissue, and the echogenic/hyperechoic free-floating particles were erythrocytes, purulent exudate, or fibrin masses. Capsule thickness and large free-floating particles could not be detected by clinical examination/centesis alone. However, capsule thickness, bursa contents, and the extent of inflammation could be determined ultrasonographically and this made the decision for different invasive/ operative procedures easier.

[Ultrasound of acute disorders of the shoulder]

Acute pain of the shoulder, with or without associated injury shows specific features that enable differentiation from chronic lesions. Osteo-articular injuries, tendinous lesions, bursitis and moving calcification may produce acute pain. Examination of the acromio-clavicular joint is also essential as acromial lesions are often overlooked in emergency radiology. Along with X-ray radiography, sonography, if adequately performed, is able to determine the etiology of acute pain and to establish lesion staging.

Musculoskeletal infections: ultrasound appearances

Musculoskeletal infections are commonly encountered in clinical practice. This review will discuss the ultrasound appearances of a variety of musculoskeletal infections such as cellulitis, infective tenosynovitis, pyomyositis, soft-tissue abscesses, septic arthritis, acute and chronic osteomyelitis, and post-operative infection. The peculiar sonographic features of less common musculoskeletal infections, such as necrotizing fasciitis, and rice body formation in atypical mycobacterial tenosynovitis, and bursitis will also be presented.

Correlation between ultrasonographic findings and the response to corticosteroid injection in pes anserinus tendinobursitis syndrome in knee osteoarthritis patients

The objectives of this study were to assess the ultrasonographic (US) findings in patients with knee osteoarthritis (OA) with pes anserinus tendinitis or bursitis (PATB) syndrome and to determine the correlation between the US findings and the response to local corticosteroid injection. We prospectively studied 26 patients with knee OA with clinically diagnosed PATB syndrome. A linear array 7 MHz transducer was used for US examination of the knee. Seventeen patients were injected locally with tramcinolone acetonide in the anserine bursa area. Response to local corticosteroid injection was evaluated by pain visual analog scale (VAS), Western Ontario and MacMaster (WOMAC) osteoarthritis index and Global patient/physician assessment using Likert scale. On US examination, only 2 patients (8.7%) showed evidence of PATB. Pain VAS, WOMAC pain index and WOMAC physical function index improved significantly after corticosteroid injection. Global patient assessment revealed that 2 patients showed best response, 6 good, 1 fair, 8 the same, and none worse. It is of note that the 2 patients who showed the best response were those who showed US evidence of PATB. This finding shows that US can serve as a useful diagnostic tool for guiding treatment in PATB syndrome of OA patients.

Iliopsoas bursitis following total hip replacement

We report the imaging features of a 52-year-old man presenting with a groin mass and gross lower limb oedema secondary to venous occlusion by massive cystic enlargement of the iliopsoas bursa 4 years after uncemented primary total hip replacement. Ultrasonography of the groin mass demonstrated a large cystic lesion extending into the pelvis. CT showed displacement of the external iliac vessels with venous compression. Bursography showed the bursa's margins and no communication with the hip joint. Diagnostic aspiration excluded infection, but fluid recollection occurred subsequently. Complete resolution of symptoms, including limb swelling, followed surgical excision with no recurrence at the 5-year follow-up. We believe iliopsoas bursitis occurred as a tissue response to polyethylene wear within the prosthetic hip and occurred even in the absence of loosening or a direct communication between bursa and joint.

Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study

BACKGROUND

Numerous studies have demonstrated that therapeutic injections carried out to treat a variety of different pain conditions should ideally be performed under radiological guidance because of the propensity for blinded injections to be inaccurate. Although trochanteric bursa injections are commonly performed to treat hip pain, they have never been described using fluoroscopy.

METHODS

The authors reviewed recorded data on 40 patients who underwent trochanteric bursa injections for hip pain with or without low back pain. The initial needle placement was done blindly, with all subsequent attempts done using fluoroscopic guidance. After bone contact, imaging was used to determine if the needle was positioned on the lateral edge of the greater trochanter (GT). Once this occurred, 1 ml of radiopaque contrast was injected to assess bursa spread.

RESULTS

The GT was contacted in 78% of cases and a bursagram obtained in 45% of patients on the first needle placement. In 23% of patients a bursagram was obtained on the second attempt and in another 23% on the third attempt. Four patients (10%) required four or more needle placements before a bursagram was appreciated. Attending physicians obtained a bursagram on the first attempt 53% of the time vs 46% for fellows and 36% for residents (P=0.64). Older patients were more likely to require multiple injections than younger patients.

CONCLUSIONS

Radiological confirmation of bursal spread is necessary to ensure that the injectate reaches the area of pathology during trochanteric bursa injections.

Early results of endoscopic trochanter bursectomy

Between 1995 and 2000, we performed 45 endoscopic bursectomies in 42 patients (average age 51, range 17-61 years). All patients had at least 6 months of failed conservative treatment, and all responded positively to a sonographic-guided injection with Mepivacaine 0.5%. The bursa was removed using a synovial resector. An additional tractopexie was performed in four cases. We followed 37 patients for 12-48 months. Pre-operatively, the mean modified Japanese Orthopaedic Association (JOA) disability hip score was 40.5 points. It improved to 72.6 points after a mean of 25 months. Severe complications did not occur. The minimally invasive technique requires only stab incisions, and immobilisation and hospitalisation are minimal.

Effects of Repeated Distension Arthrographies Combined with a Home Exercise Program Among Adults with Idiopathic Adhesive Capsulitis of the Shoulder

OBJECTIVE

The purpose of this study was to measure the effect of repeated distension arthrographies combined with a home exercise program on impairments and disability of the upper limb in subjects with adhesive capsulitis of the shoulder.

DESIGN

A total of 15 subjects with idiopathic adhesive capsulitis participated in the study. Intervention consisted of three distension arthrographies with steroid, done at 3-wk intervals, and a home exercise program. The repeated-measures design included five clinical evaluations with disability, pain, range of motion, and pain-free static strength outcomes. Two evaluations done before the first arthrography verified the stability of the condition.

RESULTS

There was a significant improvement of all outcomes at the end of intervention. The greatest effects occurred after the first distension arthrography. After the second, less marked, albeit significant, changes were observed in three motions of the shoulder and in the pain level. After the third distension arthrography, very small changes were noted. A comparison between sides revealed incomplete recovery of the range of motion on the affected side.

CONCLUSIONS

These findings showed that two distension arthrographies with steroid combined with a home exercise program reduce shoulder disability and impairments. Adding a third distension arthrography does not seem to provide any further benefit.

Relation between adhesive capsulitis and acromial morphology

PURPOSE

The purpose of this study was to determine whether a relationship existed between primary adhesive capsulitis and acromial morphology.

TYPE OF STUDY

Case control series.

METHODS

Between January 1999 and June 2002, a total of 100 patients (104 shoulders) were diagnosed with adhesive capsulitis. A retrospective chart review was performed of all of these patients. A total of 67 patients (69 shoulders) met the inclusion criteria of primary adhesive capsulitis. The patients' range of motion and signs of impingement were documented. The supraspinatus outlet radiographs were assessed, and each patient's acromial morphology was graded as type I, II, or III. A case control group of 53 patients (58 shoulders) was assessed to determine the validity of our results. This group consisted of a series of new patients that were referred to the clinic during February 2003 for assessment of their shoulders.

RESULTS

The average age of the patients in the adhesive capsulitis group was 52.5 +/- 7.6 years, with 34 women (50.7%) and 33 men (49.3%). The control group had an average age of 51.1 +/- 16.9 years in a series of 19 (35.8%) women and 34 (64.2%) men. The average range of motion was 98.0 degrees +/- 23.5 degrees of forward elevation, and 91.9 degrees +/- 24.3 degrees of abduction. The forward elevation was 165.5 degrees +/- 15.3 degrees and the abduction was 162.4 degrees +/- 18.4 degrees. The predominant acromial morphology in both groups in this study was a type II acromion (75.4% in the adhesive capsulitis group and 74.1% in the control group). The chi-square analysis within the specific groups showed statistically significant differences in the number of type II compared with type I acromions, and type II compared with type III acromions in both series. However, statistical analysis showed no significant difference between the various acromial types when comparing the adhesive capsulitis group with the control group.

CONCLUSIONS

Our results show a significant number of patients with both adhesive capsulitis and, in the control group, type II acromions. We found no statistical difference between these 2 groups. Based on our results, the intrinsic trauma that occurs from subacromial space narrowing caused by the anterior acromial shape, cannot be implicated as the cause of primary adhesive capsulitis.

LEVEL OF EVIDENCE

Level III, case control study.

Sonography of Cubital Bursitis

OBJECTIVE

The purpose of our study was to describe the sonographic appearance of cubital bursitis in three patients and to illustrate the use of sonographic guidance for therapeutic injections.

CONCLUSION

Cubital bursitis, a rare but painful condition of the elbow, can be diagnosed with sonography. Cubital bursitis is seen as distention of the bicipitoradial bursa in the proximal forearm, occasionally with fluid or complex synovial debris in more severe cases. Power Doppler imaging can aid in providing information about active inflammation. Two patients in our series were treated using sonographically guided decompression of the bursa and steroid injection with good clinical results.

Calcific haemorrhagic bursitis anterior to the knee mimicking a soft tissue sarcoma: report of two cases

We describe the radiological and pathological findings of two cases of calcific haemorrhagic bursitis, one involving the superficial infrapatellar bursa and the other the prepatellar bursa. It was the presence of dystrophic calcification within the lesion that suggested a mineralizing soft tissue sarcoma such as synovial sarcoma. As the radiographic and MR features of the two conditions can be similar but the appropriate management very different, rare calcifying haemorrhagic bursitis needs to be included in the differential diagnosis of masses adjacent to the knee joint showing calcification.

[Ultrasound examination of the shoulder--a method description]

Ultrasound examination of the shoulder in orthopaedics is not much used in Norway, but it is an established method in many institutions abroad. According to the literature, good results have been obtained with diagnostic ultrasound for demonstration of rotator cuff ruptures and abnormalities of the long tendon of the biceps muscle. In order to increase the knowledge of this diagnostic modality in Norway, we present the general principles and techniques of shoulder ultrasonography. Examples of normal and pathological ultrasound findings in the rotator cuff and long tendon of the biceps muscle are given.

Arthrographic and clinical findings in patients with hemiplegic shoulder pain11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To identify the etiology of hemiplegic shoulder pain by arthrographic and clinical examinations and to determine the correlation between arthrographic measurements and clinical findings in patients with hemiplegic shoulder pain.

DESIGN

Case series.

SETTING

Medical center of a 1582-bed teaching institution in Taiwan.

PARTICIPANTS

Thirty-two consecutive patients with hemiplegic shoulder pain within a 1-year period after first stroke were recruited.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Clinical examinations included Brunnstrom stage, muscle spasticity distribution, presence or absence of subluxation and shoulder-hand syndrome, and passive range of motion (PROM) of the shoulder joint. Arthrographic measurements included shoulder joint volume and capsular morphology.

RESULTS

Most patients had onset of hemiplegic shoulder pain less than 2 months after stroke. Adhesive capsulitis was the main cause of shoulder pain, with 50% of patients having adhesive capsulitis, 44% having shoulder subluxation, 22% having rotator cuff tears, and 16% having shoulder-hand syndrome. Patients with adhesive capsulitis showed significant restriction of passive shoulder external rotation and abduction and a higher incidence of shoulder-hand syndrome (P=.017). Those with irregular capsular margins had significantly longer shoulder pain duration and more restricted passive shoulder flexion (P=.017) and abduction (P=.020). Patients with shoulder subluxation had significantly larger PROM (flexion, P=.007; external rotation, P<.001; abduction, P=.001; internal rotation, P=.027), lower muscle tone (P=.001), and lower Brunnstrom stages of the proximal upper extremity (P=.025) and of the distal upper extremity (P=.001). Muscle spasticity of the upper extremity was slightly negatively correlated with shoulder PROM. Shoulder joint volume was moderately positively correlated with shoulder PROM.

CONCLUSIONS

After investigating the hemiplegic shoulder joint through clinical and arthrographic examinations, we found that the causes of hemiplegic shoulder pain are complicated. Adhesive capsulitis was the leading cause of shoulder pain, followed by shoulder subluxation. Greater PROM of the shoulder joint, associated with larger joint volume, decreased the occurrence of adhesive capsulitis. Proper physical therapy and cautious handling of stroke patients to preserve shoulder mobility and function during early rehabilitation are important for a good outcome.

[Operative treatment of Haglund's deformity]

The paper presents results of the operative treatment of 22 heel in 18 patients mostly young women from 13 to 31 years old (average 20.6) with Haglund's exostosis. Operative technique consisted in partial resection of the heel with removal of the Achilles bursa. The most valuable was radiological examination for the diagnosis and assessment operative results. The ultrasound examination was helpful of estimation of Achilles tendon and calcaneal bursa. Good results achieved in 16 patients (20 heel) with follow-up from 4 to 20 years (average 9.5). Unsatisfactory results in 2 patients was connected with inadequate bone resection.

Hydrodilatation in the management of shoulder capsulitis

The aim of this study was to research the benefit of hydraulic arthrographic capsular distension (hydrodilatation) in the management of adhesive capsulitis of the shoulder. One hundred and nine shoulders with primary adhesive capsulitis were treated with hydrodilatation. Prior to the procedure, 93 shoulders were painful. Two months following the procedure, 31 continued to have some pain. In the 109 shoulders, the measured range of passive glenohumeral movement improved by approximately 30 degrees in all directions. The procedure was of similar benefit if carried out early or late in the disease process. The absolute improvement in movement range was similar in severe and mild cases. The severe cases in the long term, although improved, still had more restriction in movement and tended to have more pain than the other cases. There was considerable improvement in all the non-diabetic patients. The patients with diabetes responded less well in the long term to hydrodilatation and had an increased requirement for arthroscopic surgery. Effective treatment of adhesive capsulitis can be achieved in the majority of cases with an immediate hydrodilatation of the shoulder. Technically, it is important to achieve maximum distension, preferably with capsular rupture, and to utilize cortisone in the fluid injected.

Endoscopic decompression of the retrocalcaneal space

BACKGROUND

Pain in the retrocalcaneal space can be incapacitating. Patients who do not respond to nonoperative treatment may seek a surgical solution. The first purpose of this paper was to describe and evaluate the efficacy of a minimally invasive procedure to address retrocalcaneal pain caused by retrocalcaneal bursitis, a Haglund spur, and impingement. The second purpose was to compare the endoscopic technique with a standard open technique.

METHODS

Our prospective study included thirty-three heels in thirty consecutive patients with chronic pain in the retrocalcaneal space for which nonoperative treatment had failed and endoscopic decompression was performed. The mean age was forty-nine years (range, nineteen to seventy-nine years). This group was compared with a group of seventeen heels in fourteen patients with the same diagnostic criteria who were treated with an open technique. Both groups of patients were evaluated preoperatively and postoperatively with the AOFAS (American Orthopaedic Foot and Ankle Society) Ankle-Hindfoot Scale, and the patients treated with the endoscopic procedure were also evaluated postoperatively with the University of Maryland 100-point Painful Foot Center Scoring System.

RESULTS

In the endoscopic group, the AOFAS scores averaged 61.8 points preoperatively and 87.5 points postoperatively (p < 0.001). The endoscopic procedures yielded nineteen excellent, five good, three fair, and three poor results at an average of twenty-two months postoperatively. (Three patients were excluded from the study.) In the open-treatment group, the AOFAS scores averaged 58.1 points preoperatively and 79.3 points at an average of forty-two months postoperatively (p = 0.006). The scores after the endoscopic procedures were numerically, but not significantly (p = 0.115), better than those after the open procedures. The time to recovery was the same in the two groups. The endoscopic procedures were performed more quickly than the open procedures (forty-four compared with fifty-six minutes) and were associated with fewer complications (a 3% compared with a 12% rate of infection, a 10% compared with an 18% rate of altered sensation, and a 7% compared with an 18% rate of scar tenderness).

CONCLUSIONS

Endoscopic decompression is a feasible and efficient procedure for the treatment of retrocalcaneal disorders. It produces final results equal to or better than those of an open technique, with a similar recovery time, fewer complications, and a better cosmetic appearance.

Ultrasonography for assessment of subcutaneous nodules

OBJECTIVE

To characterize a variety of subcutaneous lesions by their ultrasonographic (US) appearance, and establish these images as a starting point to measure changes with treatments.

METHODS

Twenty-six patients with 48 subcutaneous nodular swellings of various types were imaged using a portable US machine equipped with a 10 MHz linear transducer. All patients had a known diagnosis of a rheumatic disease. We used US to examine subcutaneous lesions and the underlying cortical surface of the bone or joint. Two measurements of some tophi and rheumatoid nodules were done on different dates to examine reproducibility of the measurements.

RESULTS

Nodular lesions included 20 tophi and 20 rheumatoid nodules, 2 sarcoid nodules, 2 lipomas, and 4 synovial cysts. Tophi most often appeared as heterogeneous masses; hypoechoic areas in 2 tophi were decreased after aspiration of chalky liquid tophaceous material. Occasionally tophi had calcifications appearing hyperechoic with acoustic shadowing. Cortical bone erosions could be seen adjacent to some tophi. The nodules in patients with rheumatoid arthritis were often attached closely to the bone surface and less erosive to bone, allowing the cortical bone to be seen easily. The nodules were more homogeneous. Some showed a central sharply demarcated hypoechoic area, possibly corresponding to necrosis inside the rheumatoid nodules. Nodules were easily measured. The repeated measurements of both tophi and rheumatoid nodules showed excellent reproducibility. Lipomas had different echogenic patterns depending on composition of the associated connective tissue and position of the mass. They could be hypoechogenic, hyperechogenic, or mixed, but were easily distinguished by oval shapes with well demarcated capsules. Synovial cysts seen in this study had a characteristic hypoechoic pattern.

CONCLUSION

Subcutaneous nodules examined by sonography show characteristics and patterns that, although not diagnostic, can be used to help distinguish their etiology. Tophi and rheumatoid nodules can be easily measured and these measurements used to help follow disease progression or response to therapy.