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

Adhesive Capsulitis of the Shoulder: Current Concepts on the Diagnostic Work-Up and Evidence-Based Protocol for Radiological Evaluation

Adhesive capsulitis is an idiopathic and disabling disorder characterized by intense shoulder pain and progressive limitation of active and passive glenohumeral joint range of motion. Although adhesive capsulitis has been traditionally considered a diagnosis of exclusion that can be established based on a suggestive medical history and the detection of supporting findings at the physical exam, imaging studies are commonly requested to confirm the diagnostic suspicion and to exclude other causes of shoulder pain. Indeed, clinical findings may be rather unspecific, and may overlap with diseases like calcific tendinitis, rotator cuff pathology, acromioclavicular or glenohumeral arthropathy, autoimmune disorders, and subacromial/subdeltoid bursitis. Magnetic resonance imaging, magnetic resonance arthrography, and high-resolution ultrasound have shown high sensitivity and accuracy in diagnosing adhesive capsulitis through the demonstration of specific pathological findings, including thickening of the joint capsule and of the coracohumeral ligament, fibrosis of the subcoracoid fat triangle, and extravasation of gadolinium outside the joint recesses. This narrative review provides an updated analysis of the current concepts on the role of imaging modalities in patients with adhesive capsulitis, with the final aim of proposing an evidence-based imaging protocol for the radiological evaluation of this condition.

Long-Term Outcomes of Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: A Prospective Observational Study

Ultrasound-guided hydrodistention has been established as an effective minimally invasive treatment option for glenohumeral joint adhesive capsulitis (AC). Nonetheless, the long-term outcomes of the procedure have not yet been established. A total of 202 patients with AC were prospectively recruited and followed up for a total of 2 years. Pain and functionality were assessed with the use of the visual analogue scale (VAS) and the disabilities of the arm, shoulder, and hand (DASH) score, respectively, at the beginning and the end of the follow-up period. The relapse of AC over the 2-year period and the effect of diabetes were also evaluated in the treatment cohort. The Mann-Whitney U test was used to compare mean scores at the two time points, and Cox survival analysis and χ2 test were used to assess the effect of diabetes on AC relapse. VAS and DASH scores were significantly lower at 2 years compared with the beginning of the follow-up period (p < 0.001). Diabetes was diagnosed in 38/202 patients (18.8%) and was found to be significantly associated with recurrence of the disease (p < 0.001). In conclusion, in this observational study, we have demonstrated that ultrasound-guided hydrodistention is linked to excellent long-term outcomes for the treatment of AC, which are significantly worse in patients with diabetes.

Adhesive capsulitis and ultrasound diagnosis, an inseparable pair: a novel review

PURPOSE

Adhesive Capsulitis (AC) is a musculoskeletal disorder initially described by Codman in 1934. The disease is characterized by pain-limited restriction in active and passive glenohumeral range of motion (ROM) despite the lack of a structural deficit. In the last decades, arthroscopy and magnetic resonance imaging (MRI) has been the only diagnostic tools able to highlight the characteristic alterations of the glenohumeral capsular-ligament apparatus in AC; nevertheless, both arthroscopy and MRI are burdened by intrinsic limitations. The aim of this narrative review is to summarize the most significant evidence supporting the use of ultrasound (US) for the diagnosis of AC.

METHODS

We extensively searched via PubMed library the terms "frozen-shoulder" and "adhesive capsulitis" each combined with "ultrasound".

RESULTS

We found 3723 papers on PubMed and selected those inherent to AC diagnosis, US imaging, correlation with arthroscopic and MRI findings. Forty papers which were strictly related to the topic of this narrative review were initially chosen, then 20 studies which described and exploited US for AC diagnosis were finally included. Coracohumeral ligament (2.65 ± 0.4 mm) and axillary pouch thickening (3.34 ± 0.8 mm), as well as an increase in vascularity at rotator interval (78/214, 36.44%), represented the commonest US signs useful for AC diagnosis and for which the most significant cut-off values were reported.

CONCLUSIONS

The evidence collected in this review testify that musculoskeletal US is as reliable as MRI for AC diagnosis, therefore we believe that in this context US should be considered a first-line imaging technique.

Clinical/Sonographic Assessment and Management of Calcific Tendinopathy of the Shoulder: A Narrative Review

Shoulder disorders are very common in clinical practice. Among several other pathologies, calcific tendinopathy of the rotator cuff tendons is frequently observed during the ultrasound examination of patients with painful shoulder. The deposition of hydroxyapatite calcium crystals should not be considered as a static process but rather a dynamic pathological process with different/possible patterns of migration. In this paper, we have illustrated how and where these calcium depositions can migrate from the rotator cuff tendons to the peri-articular soft tissues. We have also tried to discuss the issue from the clinical side, i.e., how these particular conditions might impact the specific diagnosis, appropriate rehabilitation plan or interventional approach for optimal functional recovery.

Ultrasound Features for the Diagnosis of Adhesive Capsulitis/Frozen Shoulder: A Systematic Review

While ultrasound has become a preferred tool for musculoskeletal imaging, differing ultrasound findings that have been reported in patients with adhesive capsulitis can create confusion and misconceptions. This systematic review was aimed at summarizing all the ultrasound features currently described in the literature and providing a critical analysis of the sources to allow the readers to make a well-informed decision on the reliability of these features in the diagnosis of this condition. Databases were searched for original studies up to August 2021. Twenty-three studies were included. The QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) tool was used to assess the quality of each selected article. Fourteen ultrasound features were identified. A quality analysis of all ultrasound features was performed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework. All studies exhibited considerable heterogeneity in investigated ultrasound features and methodologies employed; therefore, meta-analysis was not considered to be appropriate. Hence, narrative synthesis was performed. The overall quality of each ultrasound outcome was found to be of "low" to "very low" level, and the generalisability of the results was also thought to be limited. Cautious interpretation and clinical correlation are recommended while applying these ultrasound features in clinical practice.

Sequential Ultrasound Assessment of Peri-Articular Soft Tissue in Adhesive Capsulitis of the Shoulder: Correlations with Clinical Impairments—Sequential Ultrasound in Adhesive Capsulitis

Recently, ultrasound measurements of the shoulder such as thickening of the rotator interval (RI) and the axillary recess (AR) are suggested as specific indicators of adhesive capsulitis. Herein, we evaluated the sequential changes in ultrasound parameters and clinical impairments and the correlation between the two in the case of adhesive capsulitis through a prospective observational study of 56 patients with adhesive capsulitis. Clinical assessments and ultrasound parameters, including the thicknesses of the RI and AR, were surveyed at baseline and after 1, 3, and 6 months. In 56 patients with adhesive capsulitis, the thickness of the AR significantly decreased at each follow-up evaluation, but the thickness of the RI showed a significant decrease only between the baseline and 1-month evaluation. In repeated analyses of correlation, the thickness of the AR was strongly correlated with all clinical impairments except the pain at rest and range of internal rotation in the affected shoulder. The thickness of AR was correlated with clinical impairments in patients with adhesive capsulitis during the 6 months follow up and could be useful as a surrogate marker in patients with adhesive capsulitis.

Anchoring Apparatus of Long Head of the Biceps Tendon: Ultrasonographic Anatomy and Pathologic Conditions

The long head of the biceps tendon (LHBT) has been recognized as an important generator of anterior shoulder pain, causing a significant reduction in the shoulder flexion range. Various tendinous and ligamentous structures form the anchoring apparatus of the LHBT along its course to maintain its appropriate location during shoulder movements, including the coracohumeral ligament (CHL), superior glenohumeral ligament (SGHL), subscapularis (SSC) tendon and supraspinatus (SSP) tendon as well as the less recognized tendons of pectoralis major (PM), latissimus dorsi (LD) and teres major (TM). Lesions of this stabilizing apparatus may lead to an instability of the LHBT, resulting in pain at the anterior shoulder. Ultrasonography (US) has been increasingly used in the assessment of shoulder injuries, including the anchoring apparatus of the LHBT. An accurate diagnosis of these injuries is often challenging, given the complex anatomy and wide spectrum of pathologies. In this review article, US anatomy and common pathologic conditions that affect the anchoring apparatus of the LHBT are discussed, including biceps pulley lesions, adhesive capsulitis, chronic pathology of SSC and SSP tendons, tears in the PM tendon and injuries to the LD and TM. Knowledge of a normal anatomy, an appropriate scanning technique and US findings of common pathologic conditions are the keys to accurate diagnoses.

[Adhesive Capsulitis of the Shoulder]

Adhesive capsulitis, the so-called 'frozen shoulder', is one of the common causes of pain with a limited range of motion in the shoulder joint. The condition is usually diagnosed through the clinical course and physical examinations; however, several studies on imaging findings of adhesive capsulitis using sonography, MRI, and MR angiography have been reported. In this article, various imaging findings for the diagnosis of adhesive capsulitis-related anatomy are reviewed.

Dynamic Ultrasonographic Measurement of Inferior Joint Capsule Thickness in Patients with Unilateral Frozen Shoulder

The diagnostic value of ultrasonography (US) for frozen shoulder (FS) is not well established. This study aimed to assess the diagnostic value of US measurement of inferior joint capsule (IJC) thickness and evaluate changes in the thickness of the IJC by US depending on arm position. A total of 71 patients with clinically diagnosed unilateral FS who underwent bilateral US measurement of the IJC were enrolled in this study. The US measurement of the IJC was performed with a linear transducer positioned around the anterior axillary line with the shoulder 40° abducted and with neutral rotation of the glenohumeral joint (neutral position). We also measured the IJC thickness in the externally rotated and internally rotated positions with the shoulder 40° abducted. In the neutral position, as well as in the internally rotated and externally rotated positions, the thickness of the IJC on US was significantly higher in the affected shoulder than that in the unaffected shoulder (all p < 0.001). On both the affected and unaffected sides, the US thickness of the IJC in the neutral position was significantly higher than that in the externally rotated position (p < 0.001), but lower than that in the internally rotated position (p < 0.001). Regarding IJC thickness in the neutral position, a 3.2-mm cutoff value yielded the highest diagnostic accuracy for FS, with a sensitivity and specificity of 73.2% and 77.5%, respectively. The area under the curve for IJC thickness was 0.824 (95% confidence interval, 0.76–0.89). US measurement of the IJC in the neutral position yielded good diagnostic accuracy for FS. Because IJC thickness is affected by arm rotation, it is important to measure the IJC thickness in a standardized posture to ensure diagnostic value.

Correlation of Ultrasound Findings With Clinical Stages and Impairment in Adhesive Capsulitis of the Shoulder

Background:

Ultrasound is an essential tool for diagnosing shoulder disorders. However, the role of ultrasound in assessing and diagnosing adhesive capsulitis has not been fully studied.

Purpose:

To evaluate the ultrasound features of adhesive capsulitis and estimate the correlations between clinical impairment and ultrasound parameters.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 61 patients with clinically diagnosed unilateral adhesive capsulitis were retrospectively reviewed using high-resolution ultrasound. To compare ultrasound parameters, we performed ultrasound examinations on both affected and unaffected shoulders. Ultrasound parameters, including thickness of the coracohumeral ligament (CHL), rotator interval (RI), axillary recess (AR), hypervascularity of the RI, and effusion of the long head of the biceps tendon sheath, were measured. Passive range of motion (PROM), visual analog scale for pain, and the Shoulder Pain and Disability Index were used for clinical assessment.

Results:

The CHL, the RI, and the AR in affected shoulders were significantly thicker than in unaffected shoulders (P < .05). CHL thickness in affected shoulders was significantly correlated with PROM limitation, which included forward elevation, abduction, external rotation (ER), and internal rotation (IR) (P < .05). AR thickness correlated with passive forward elevation limitation and passive IR limitation (P < .05). The CHL was significantly thicker in stage 2 compared with stage 1, and the RI was thicker in stage 2 compared with stage 3. The diagnostic cutoff values for adhesive capsulitis were 2.2 mm for CHL thickness (77% sensitivity, 91.8% specificity) and 4 mm for AR thickness (68.9% sensitivity, 90.2% specificity).

Conclusion:

The ultrasound parameters associated with structural changes were correlated with clinical characteristics of adhesive capsulitis. Thickened CHL, RI, and AR were observed in affected shoulders. The cutoff values of 2.2 mm for CHL thickness and 4 mm for AR thickness can be used as cutoff diagnostic values for adhesive capsulitis.

Comparison of Shoulder Ultrasonographic Assessments between Polymyalgia Rheumatica and Frozen Shoulder in Patients with Bilateral Shoulder Pain: A Comparative Retrospective Study

This study aimed to assess and compare the ultrasonographic (US) pathologic findings in patients with polymyalgia rheumatica (PMR) and bilateral frozen shoulder (FS). We included 19 patients with clinically diagnosed PMR and 19 patients with stage II bilateral FS. The US evaluation included the assessment of subacromial-subdeltoid (SASD) bursitis, long head of biceps (LHB) tenosynovitis, and posterior and inferior glenohumeral (GH) synovitis. Unilateral SASD bursitis was noted significantly more frequently in PMR patients than in bilateral FS patients (p = 0.001). There were no significant differences in the incidence of unilateral LHB tenosynovitis and posterior GH synovitis between PMR and bilateral FS patients (p = 0.108 and p = 0.304, respectively). Unilateral inferior GH synovitis was more common among bilateral FS patients than among PMR patients (p < 0.001). Bilateral SASD bursitis and LHB tenosynovitis were noted significantly more frequently in PMR patients than in bilateral FS patients (p < 0.001 and 0.049, respectively). Significant differences were not observed in the incidence of bilateral posterior GH synovitis between PMR and bilateral FS patients (p = 0.426). Bilateral inferior GH synovitis was more common among bilateral FS patients than among PMR patients (p = 0.044). The US evidence for bilateral inferior GH synovitis without bilateral SASD showed high specificity (94.7%) with sensitivity (78.9%) for the diagnosis of bilateral FS. SASD bursitis, representing periarticular synovial inflammation, was more common among the patients with PMR than among the patients with bilateral FS. Inferior GH synovitis without SASD bursitis suggests FS rather than PMR in patients with bilateral shoulder pain.

What Is the Diagnosis in Patients with Type 2 Diabetes Who Have a Painful Shoulder? Results from a Prospective Cross-Sectional Study

Background: Patients with diabetes mellitus have higher risk of developing shoulder pathology. However, only adhesive capsulitis is addressed in shoulder pain guidelines as a disorder associated with diabetes. Yet, patients with diabetes are at risk of having several other shoulder disorders, including focal neuropathy. Our aim was to quantify the presence of shoulder disorders using physical examination and ultrasound imaging in patients with type 2 diabetes (T2DM) suffering from shoulder pain in general practice. Methods: In this prospective cross-sectional study, patients with T2DM who had had a painful shoulder for at least four weeks were included. Patients filled out a questionnaire and underwent a physical examination of the shoulders and feet and ultrasound imaging of the shoulder. Results: A total of 66 patients were included, of whom 40.9% (n = 27) had bilateral complaints resulting in 93 symptomatic shoulders. Subacromial pain syndrome was most frequently diagnosed by physical examination (66.6%, 95% CI 51.6–72.0%; p < 0.0001), while ultrasound imaging showed that subacromial disorders were statistically significantly the most prevalent (90.3%, 95% CI 81.9–95.2%). Only two patients (3%) were diagnosed with neuropathic shoulder pain. Conclusion: When choosing treatment, general practitioners should be aware that in patients with T2DM the subacromial region is most frequently affected.

Correlations between clinical features and MRI findings in early adhesive capsulitis of the shoulder: a retrospective observational study

Background

This retrospective study investigated the association between clinical features and MRI findings in patients with early adhesive capsulitis of the shoulder.

Methods

The study included 29 patients with early adhesive capsulitis of the shoulder. The clinical diagnostic criteria were significantly restricted passive range of motion (ROM) and a symptom duration of up to 9 months. Various measurements related to adhesive capsulitis, including humeral and glenoid capsular thickness in the axillary recess, maximal axillary capsular thickness, coracohumeral ligament thickness, and anterior capsular thickness were measured on MRI. Abnormal humeral and glenoid capsular hyperintensity in the axillary recess, abnormal hyperintensity in the rotator interval, and obliteration of the subcoracoid fat triangle were also evaluated. Correlations between MRI findings and clinical features, including limited ROM, pain, and symptom duration were sought.

Results

Maximal axillary and humeral capsular thickness measured on MRI were negatively correlated with ROM for internal rotation. Also, hyperintensity in axillary recess and glenoid capule were correlated with ROM for abduction. Humeral capsular hyperintensity was correlated with ROM for forward flexion. There were no MRI findings that showed correlations with ROM for external rotation and severity of pain. The hyperintensity in the humeral capsule among MRI findings was only correlated with duration of symptoms.

Conclusions

MRI can be useful for assessment of several measures of clinical impairment in patients with adhesive capsulitis. Thickening and hyperintensity of the joint capsule in the axillary recess on MRI is associated with limited ROM and duration of symptoms.

Current advances and research in ultrasound imaging to the assessment and management of musculoskeletal disorders

Currently evidence-based practice has given scientific weight to the physical therapist profession; it is essential that all medical professional and physical therapists know the usefulness of new tools that optimize the effectiveness of their interventions and allow the growing of the scientific knowledge base. The use of ultrasound imaging (USI) by physiotherapists has evolved in recent years, consolidating as an increasingly standardized technique, low cost compared to other imaging techniques, quickly of execution, feasible and reliable tool. USI offers a wide range of opportunities in clinical practice as well as in different research areas. Therefore, ultrasound has been currently used as a diagnostic tool by physicians and in recent years there has been an expansion of the use of ultrasound equipment by non-physicians professionals such as physical therapist or physical trainers, who incorporates USI as a means of assessing musculoskeletal system architecture and composition, musculoskeletal changes in dysfunction, pain or injury conditions, as an interventional technique assisting echo-guided procedures or using the visual real-time information as a biofeedback in control motor approaches, as guiding tool in clinical decisions as well as to improve the understanding of tissue adaptations to exercise or movement. The purpose of this article is to review and provide an overview about the currently research of the USI applications and their benefits for the diagnosis and management in individuals with musculoskeletal conditions.

Shear-Wave and Strain Ultrasound Elastography of the Supraspinatus and Infraspinatus Tendons in Patients with Idiopathic Adhesive Capsulitis of the Shoulder: A Prospective Case-Control Study

Objective

To compare the elasticity of the supraspinatus tendon (SST) and infraspinatus tendon (IST) in patients with idiopathic adhesive capsulitis of the shoulder (ACS) with those in the control groups and to evaluate the relationship between age and tendon elasticity.

Materials and Methods

The Institutional Review Board approved this prospective, case-control study, which was conducted between November 2017 and March 2018, and informed consent was obtained from all participants. Control groups comprised healthy individuals or those with asymptomatic contralateral shoulders. Twenty-five shoulders in 20 participants in the ACS group (14 women; 53.5 ± 7.9 years) and 24 shoulders in 18 participants in the control group (6 women; 52.6 ± 10.5 years) were included. Elastography was performed in the oblique coronal plane at the neutral shoulder position. Mean/maximum/minimum velocity and stiffness from the shear-wave ultrasound elastography (SWE) and strain ratio (subcutaneous fat/target-tendon) from the strain ultrasound elastography (SE) of the SST and IST were evaluated. Statistical analyses were performed using the Mann-Whitney U test, receiver operating characteristic (ROC) curve, and Spearman correlation.

Results

Both velocity and stiffness in SWE were higher, and the strain ratio in SE was lower in participants with symptomatic shoulders than in those with normal shoulders (p < 0.001). SST- and IST-mean velocity, mean stiffness, and strain ratios showed excellent area under the ROC curve (> 0.970). The elastic modulus was little correlated with age (ρ = −0.340–0.239).

Conclusion

SWE and SE indicated that SST and IST were stiffer in patients with ACS than in those with normal shoulders regardless of aging.

Evaluating Correlations of Coracohumeral Ligament Thickness with Restricted Shoulder Range of Motion and Clinical Duration of Adhesive Capsulitis with Ultrasound Measurements

OBJECTIVES

The primary objective of this study is to evaluate, using ultrasound measurements, the correlation between coracohumeral ligament (CHL) thickness and restricted shoulder range of motion (ROM) in patients with adhesive capsulitis (AC). The secondary objective is to investigate the correlation between CHL thickness and disease duration.

DESIGN

Prospective cross-sectional survey.

SETTING

Clinical research of a tertiary care hospital.

METHODS

Overall, 65 patients with clinically diagnosed AC were enrolled. Ultrasound measurements of CHL thickness in the axial oblique plane were obtained under maximal external rotation of the glenohumeral joint. Both Shoulder Pain and Disability Index (SPADI) and shoulder ROM were prospectively evaluated by an experienced investigator. CHL thickness was compared with shoulder ROM and SPADI. The association between CHL thickness and disease duration was also investigated.

RESULTS

Simple linear regression analysis showed significant inverse correlation between CHL thickness and shoulder ROM including external rotation (ER) (r = -0.335, P = .006) and internal rotation (IR) (r = -0.409, P = .001). CHL thickness also correlated with disease duration (r = -0.352, P = .004). Multiple linear regression analysis demonstrated that CHL thickness was significantly associated with restricted ER (r = -0.293, P = .02) and IR (r = -0.363, P = .003) after adjusting for age and disease duration. On the other hand, CHL thickness showed no significant correlation with abduction (r = -0.210, P = .09), flexion (r = -0.170, P = .176), or total SPADI score (r = 0.176, P = .16). Moreover, CHL was significantly thicker in patients with disease duration >6 months (P = .004, difference in means: 0.55 mm, 95% confidence interval: -0.922, -0.183).

CONCLUSIONS

CHL was significantly thicker in later-stage AC. CHL thickness correlated negatively with ER and IR of the shoulder. Furthermore, CHL thickening could be observed in the early stage of the disease course. These imaging findings may assist in confirming the diagnosis of AC, leading to early intervention and treatment options.

In shoulder adhesive capsulitis, ultrasound-guided anterior hydrodilatation in rotator interval is more effective than posterior approach: a randomized controlled study

Abstract

Shoulder adhesive capsulitis, also called frozen shoulder, is a musculoskeletal disorder associated with pain and functional disability. This study aimed to compare the effectiveness of shoulder ultrasound-guided hydrodilatation with corticosteroid, via rotator interval (RI) anteriorly, versus posterior approach, in adhesive capsulitis patients. All patients received exercise program following injection.

Patients and methods

A prospective randomized controlled study among 60 consecutive adhesive capsulitis patients was randomized into two equal groups. Group I received ultrasound-guided hydrodilatation with corticosteroid, saline, and local anesthetic via posterior intra-articular approach; group II received the same ultrasound-guided hydrodilatation via anterior rotator interval approach. Both groups received guided stretching exercises for 3 months after injection. Baseline and 3 months evaluation of pain by visual analogue scale (VAS), shoulder pain and disability index (SPADI), and range of motion (ROM) had been recorded for all patients.

Results

Both groups showed significant improvement 3 months after hydrodilatation regarding VAS pain, external rotation, and SPADI. Only in group II (RI anterior approach) improvement was observed regarding flexion and abduction. There was no improvement regarding extension or internal rotation in either group. When comparing the improvement in both groups after hydrodilatation, group II (anterior approach) showed a statistically significant higher level of improvement regarding VAS pain (p = 0.003), SPADI, flexion, abduction, and external rotation, compared to group I (p < 0.001). Extension, internal rotation, and adduction were not different.

Conclusions

Ultrasound-guided anterior rotator interval hydrodilatation for adhesive capsulitis, followed by guided exercise, is clinically and functionally more effective than the conventional posterior approach.

Ultrasound Microflow Imaging Technology for Diagnosis of Adhesive Capsulitis of the Shoulder

OBJECTIVES

To assess the diagnostic accuracy of Superb Microvascular Imaging (SMI; Canon Medical Systems, Otawara, Japan) at the subcoracoid triangle for adhesive capsulitis of the shoulder, to compare the diagnostic value of SMI with that of conventional ultrasound (US) and power Doppler ultrasound (PDUS) findings, and to investigate the correlation between vascular flow on SMI with clinical features.

METHODS

Our study included 39 patients with a diagnosis of adhesive capsulitis and 35 healthy patients as a control group. The echogenicity in the rotator interval and coracohumeral ligament thickness were assessed with conventional US. Vascular flow in the subcoracoid fat triangle was evaluated with SMI and PDUS (SMI and PDUS areas). A receiver operating characteristic curve analysis was performed to evaluate diagnostic accuracy. The correlation between US findings and the range of motion, pain intensity, and duration of symptoms was also evaluated.

RESULTS

The SMI area was higher in the adhesive capsulitis group than in the control group (2.95 versus 0 mm² ; P < .01). The visualization of vascular flow at the subcoracoid fat triangle was superior with SMI compared with PDUS (P < .01). In the receiver operating characteristic analysis, the SMI area showed higher diagnostic performance, with an area under the curve of 0.90 compared with other US findings. The area of SMI vascular flow was also negatively correlated with external rotation and forward flexion (P < .05) in the adhesive capsulitis group.

CONCLUSIONS

Measurement of vascular flow at the subcoracoid fat triangle using SMI facilitated the diagnosis of adhesive capsulitis. Superb Microvascular Imaging was superior to PDUS in diagnostic performance. Vascular flow was negatively correlated with the range of motion of external rotation and forward flexion.

Voxel-based Three-dimensional Segmentation of the Capsulo-synovium from Contrast-enhanced MRI Can Represent Clinical Impairments in Adhesive Capsulitis

The purposes were to calculate total voxel volume of the entire capsulo-synovial enhanced portion on contrast-enhanced (CE) MRI in adhesive capsulitis, and to investigate its association with glenohumeral joint volume and passive range of motions (ROMs), which are a well-known diagnostic reference standard and clinical hallmark of this condition. Medical records of 169 consecutive patients who underwent ultrasound-guided intraarticular injection with adhesive capsulitis and CE-MRI to exclude other mimicking shoulder diseases were retrospectively reviewed. To calculate total voxel volume of entire capsulo-synovial enhanced portion on CE-MRI, voxel-based 3-dimensional (3D) segmentation was obtained semi-automatically using Fiji, an open-source image processing software. Pearson’s correlation coefficients were analyzed. Sixty patients who met eligibility criteria were included. Total voxel volume showed a significant inverse correlation with the glenohumeral joint volume (r = −0.528, P < 0.001), forward elevation, external rotation, and abduction (r = −0.407, P = 0.001; r = −0.342, P = 0.007; r = −0.275, P = 0.034, respectively). Intra-observer and inter-observer reliabilities, measured by intraclass correlation coefficients (ICC), were excellent (ICC = 0.87 and 0.77, respectively). This study’s results indicate that voxel-based 3D segmentation of entire capsulo-synovial enhanced portion from CE-MRI can represent the severity of clinical impairments, such as obliterated joint volume and limited passive ROMs in adhesive capsulitis.

Accuracy of unguided and ultrasound guided Coracohumeral ligament infiltrations - a feasibility cadaveric case series

BACKGROUND

Coracohumeral ligament (CHL) thickening, contracture, and fibroplasia have been identified in glenohumeral idiopathic adhesive capsulitis (GHIAC). The CHL is the main structure responsible for the range of motion limitations. Favorable outcomes have been reported with CHL surgical release. Intra-articular glenohumeral joint corticosteroid infiltrations are utilized to disrupt the inflammatory process and reduce pain in GHIAC. The aim of this study was to investigate whether the CHL could be accurately targeted with a periligamentous infiltration.

METHODS

A convenience sample of 12 unembalmed cadaver shoulders (mean age: 74.5 years, range 66-87 years) without evidence of previous injury or surgery were utilized in this exploratory double factor feasibility cadaveric (unguided and ultrasound (US) guided) case series. Two clinicians trained in musculoskeletal infiltration techniques carried out the infiltrations on each shoulder with colored latex. One clinician infiltrated without guidance, the other with US-guidance. The injecting clinicians were blinded to the others infiltration procedure and the order was randomized. An anatomist blinded to the infiltration order performed a shoulder dissection and recorded the infiltrate location. Percentage calculation for accuracy of infiltration and a chi-square evaluation of the difference between unguided and US-guided infiltrations was applied.

RESULTS

An accuracy of 75% was achieved for unguided infiltration and 80% for US-guided infiltration techniques. Chi-squared indicated there was no significant difference (p = 0.82) between the unguided and US-guided techniques.

CONCLUSION

US-guided and unguided infiltrations achieved good accuracy targeting the CHL, suggesting infiltrations can specifically and accurately target the CHL. In vivo investigation using such infiltration techniques are warranted.

Shoulder manipulation under targeted ultrasound-guided rotator interval block for adhesive capsulitis

OBJECTIVE

To describe and evaluate the outcome following shoulder manipulation under rotator interval block for the treatment of adhesive capsulitis.

MATERIALS AND METHODS

Patients with adhesive capsulitis referred by our local orthopaedic shoulder surgeons consented to targeted ultrasound-guided injection of the glenohumeral joint via the rotator interval. Inclusion criteria included a failure to respond to conservative treatment and the absence of a full-thickness rotator cuff tear. Twelve millilitres of a mixture of local anaesthetic and steroid was injected into the rotator interval using a 21-gauge needle, with a small volume of the same solution instilled into the subacromial bursa. Following injection, under local anaesthetic block, patients were gently manipulated into abduction, external rotation and internal rotation as far as they could comfortably tolerate. Patients were assessed pre-injection with documented pain scores from 0 to 10 on a visual analogue scale (VAS) and the Oxford Shoulder Score (OSS) questionnaire. Initial follow-up comprised a VAS pain score at 1 h, 24 h and 2 weeks. Clinical review by the referring orthopaedic surgeon was performed at 2 months post-injection. Long-term follow-up involved a VAS pain score and the OSS questionnaire at 5 months.

RESULTS

Forty patients were suitable for inclusion in the study. Twenty-three were female (57.5%) and 17 were male. The mean age was 52 years (range, 31-73 years). Twelve patients were post-operative. The duration of symptoms ranged from 3 months to 18 months. Mean pre-procedure OSS was recorded as 23.3 (range, 4-36). The mean VAS pain score was 7.7 before the procedure (range, 4 - 10), 3.4 at 1 h (range, 0-8), 2.9 at 24 h (range, 0-8), and 1.8 at 2 weeks (range 1-4). Orthopaedic follow-up at an average of 66 days post-injection was recorded in 18 patients. All patients reported initial improvement of their shoulder pain and return to near full range of movement; however, recurrence of adhesive capsulitis symptoms was recorded in 5 patients. One case of rupture of the long head of the biceps tendon was reported, but the patient remained asymptomatic. Long-term follow-up at 5 months was obtained in 31 patients, with a mean OSS of 42 (range, 21-60) and VAS of 2.3 (range, 0-7).

CONCLUSION

Manipulation under general anaesthesia is a well-recognised treatment for adhesive capsulitis. We report that targeted ultrasound-guided injection of the rotator interval and manipulation of the shoulder under local anaesthetic blockade result in good outcomes in reducing shoulder pain and symptoms of adhesive capsulitis with low recurrence and complication rates.

Adhesive capsulitis: review of imaging findings, pathophysiology, clinical presentation, and treatment options

Adhesive capsulitis, commonly referred to as "frozen shoulder," is a debilitating condition characterized by progressive pain and limited range of motion about the glenohumeral joint. It is a condition that typically affects middle-aged women, with some evidence for an association with endocrinological, rheumatological, and autoimmune disease states. Management tends to be conservative, as most cases resolve spontaneously, although a subset of patients progress to permanent disability. Conventional arthrographic findings include decreased capsular distension and volume of the axillary recess when compared with the normal glenohumeral joint, in spite of the fact that fluoroscopic visualization alone is rarely carried out today in favor of magnetic resonance imaging (MRI). MRI and MR arthrography (MRA) have, in recent years, allowed for the visualization of several characteristic signs seen with this condition, including thickening of the coracohumeral ligament, axillary pouch and rotator interval joint capsule, in addition to the obliteration of the subcoracoid fat triangle. Additional findings include T2 signal hyperintensity and post-contrast enhancement of the joint capsule. Similar changes are observable on ultrasound. However, the use of ultrasound is most clearly established for image-guided injection therapy. More aggressive therapies, including arthroscopic release and open capsulotomy, may be indicated for refractory disease, with arthroscopic procedures favored because of their less invasive nature and relatively high success rate.

Anterior capsular abnormality: another important MRI finding for the diagnosis of adhesive capsulitis of the shoulder

OBJECTIVE

To evaluate the usefulness of anterior capsular abnormality, thickening, and abnormal signal intensity on MRI for the diagnosis of adhesive capsulitis of the shoulder.

MATERIALS AND METHODS

This retrospective study included 29 patients with adhesive capsulitis and 20 controls. Clinical criteria with significant restricted passive motion was used for the diagnosis of adhesive capsulitis. The anterior capsular thickness and signal intensity were evaluated on the thickest portion of anterior glenohumeral joint capsule, located deep to the subscapularis muscle. In addition, the previously known MR findings of adhesive capsulitis, such as humeral and glenoid capsular thickness in axillary recess, maximal axillary capsular thickness, and coracohumeral ligament thickness, were measured. The presence of humeral and glenoid capsular abnormal hyperintensity in axillary recess, abnormal hyperintensity, and obliteration of the subcoracoid fat triangle were also evaluated.

RESULTS

All MRI findings significantly differed between adhesive capsulitis and controls. Among MR findings, multivariable analysis showed that anterior capsular thickness, maximal axillary capsular thickness, and anterior capsular abnormal hyperintensity were variables that could differentiate adhesive capsulitis from the control group, with odds ratios of 7.97, 17.75, and 12.41, respectively (p < 0.05). In ROC analysis, the anterior capsular thickness showed high diagnostic performances with an AUC of 0.897. The cut-off value of anterior capsular thickness at 3.5 mm showed excellent diagnostic accuracy, with sensitivity of 68.97% and specificity of 100%.

CONCLUSIONS

Anterior capsular abnormality, thickening, and abnormal hyperintensity can be used for the diagnosis of adhesive capsulitis of shoulder, in addition to previously known abnormal MRI findings.

Contrast-enhanced Ultrasonography for the Diagnosis of Frozen Shoulder

Introduction:

Adhesive capsulitis (AC), also known as frozen shoulder, is challenging for diagnosis, particularly in early stages. A promising tool is contrast-enhanced ultrasonography (CEUS), which has been successfully applied on musculoskeletal ultrasonography.

Methods and Results:

Two antecedent studies reported the application of CEUS on AC patients although different methods were used. The first research team administered the contrast media intravenously to facilitate detection of microcirculation through observing different distributions of time–intensity curves between the affected and unaffected shoulders. The second study has introduced a pioneering approach, injecting the contrast media mixed with saline directly into the glenohumeral joint. The authors designated this novel method as “US arthrography”. According to our best knowledge, this is the first study reporting the application of intraarticular CEUS in humans.

Conclusion:

Both presented studies reported CEUS to be capable of differentiating shoulders with AC from normal controls.

Accuracy of Two Ultrasound-Guided Coracohumeral Ligament Injection Approaches: A Cadaveric Study

BACKGROUND

Glenohumeral idiopathic adhesive capsulitis is a common shoulder condition that hinders functionality. Addressing the pathology has been extensively researched. Ultrasound (US)-guided injections have shown their efficacy. However, no study has been conducted to compare anatomical accuracy between different approaches in targeting the coracohumeral ligament (CHL).

OBJECTIVE

To investigate whether US-guided injection of the CHL can be performed accurately using either the rotator interval (RI) or the coracoidal (CO) approach.

METHODS

An experimental cadaveric case series.

SETTING

Anatomy laboratory.

SPECIMENS

Both shoulders of 13 Thiel-embalmed cadavers.

INTERVENTIONS

Three physiatrists each injected a 0.1 mL bolus of colored dye in both shoulders of each cadaver using either the RI or the CO approach under US guidance. Each cadaver received a total of six injections (three injections per shoulder). The accuracy of the injection was determined following shoulder dissection by an anatomist.

MAIN OUTCOME MEASURE

The accuracy of the US-guided injection of the CHL.

RESULTS

The RI approach yielded 36 accurate injections, giving it an accuracy of 100%. With the CO approach two injections were deemed inaccurate yielding an accuracy of 94%. There was no significant difference in accuracy between all operators.

CONCLUSIONS

US-guided injection of the CHL can be performed accurately with both the RI and CO approaches. The RI approach was likely to be more accurate.

The diagnosis and management of shoulder pain

Diagnosis is crucial in decision-making when treating a patient with shoulder pain. Ultrasound is also very important in the diagnostic and therapeutic pathway, especially when surgery is being considered. This article outlines the diagnostic pathway using the patient’s history, physical examination and ultrasound examination. It is important to correlate the clinical assessment with the imaging signs. It is also important to treat the patient and not the images as there may be abnormalities detected on imaging that are not symptomatic. The article covers the important diagnosis of subdeltoid subacromial bursitis, glenohumeral joint capsulitis, calcific tendinosis, acromioclavicular joint osteoarthritis and long head of biceps tendinosis. It will guide the reader in how to use the findings to treat, using ultrasound-guided injection and other techniques, including steroid injections, hydrodilatation, barbotage and extracorporeal shockwave treatment. These are discussed with the knowledge from over 30 years of experience with a literature review evidential support. I have included tips to make these procedures more effective in treatment and final outcome. There is discussion regarding the use of steroid injections in the presence of a rotator cuff tear and how to proceed if the patient has more than one disease process. The sensible use of steroids and local anesthetics are included, bearing in mind that lidocaine and high concentrations of long-acting local anesthetics are chondrotoxic and should not be injected into joints.

Ultrasound measurements of axillary recess capsule thickness in unilateral frozen shoulder: study of correlation with MRI measurements

OBJECTIVE

The aims of this study were to compare the ultrasound thickness of the affected axillary recess capsule (ARC) with that of the unaffected ARC in patients with frozen shoulder (FS), to analyze whether the ultrasound measurements of the ARC thickness correlate with those obtained using MRI, and to assess whether the ultrasound thickness of the ARC correlates with the patterns of range of motion limitation.

MATERIALS AND METHODS

Forty-four patients with clinically diagnosed unilateral FS and MRI evaluation performed ultrasound measurement of ARC. The ultrasound measurement of the ARC thickness was performed with the patients in a supine position with their shoulder abducted by 40°. The ARC thickness was also measured by MRI on oblique coronal images by another physician blinded to the ultrasound measurements. With both ultrasound and MRI, ARC thickness was determined at the widest portion of the capsule.

RESULTS

The ultrasound thickness of ARC was significantly higher in the affected shoulder (4.4 ± 1.1 mm) than in the unaffected one (2.2 ± 0.5 mm) (p < 0.001). The ultrasound thickness of the ARC in the affected shoulder correlated with that measured by MRI (8.9 ± 1.9 mm) (p < 0.001, r = 0.83). The ARC thickness, whether measured by ultrasound or MRI, was not significantly related to the limitation of movement in specific directions.

CONCLUSION

Ultrasound can demonstrate the difference in ARC thickness between affected and unaffected shoulders in patients with unilateral FS. The ARC thickness measured by ultrasound correlates with that measured by MRI.

Ultrasound-guided coracohumeral ligament release

Long-term follow-up of patients with adhesive capsulitis (AC) reveals that approximately half of them suffer from a limited range of shoulder motion, particularly external and/or internal rotation. We report the surgical technique and short-term clinical outcomes of ultrasound-guided release of the thickened coracohumeral (CH) ligament in 8 patients (9 shoulders) with AC. Passive external rotation with the arm by the side significantly increased from an average of 18° preoperatively to 47° immediately after CH ligament release. VAS and ASES scores were improved at 3months follow-up in all 9 shoulders, and maintained at 6months follow-up in 6 shoulders. No procedure-related adverse events developed over the 6-month follow-up period. Ultrasound-guided release for thickened CH ligament is a reliable and effective minimally invasive surgery for persistent limited external rotation due to AC of the shoulder.

Dynamic ultrasonography of the shoulder

Ultrasonography (US) is a useful diagnostic method that can be easily applied to identify the cause of shoulder pain. Its low cost, excellent diagnostic accuracy, and capability for dynamic evaluation are also advantages. To assess all possible causes of shoulder pain, it is better to follow a standardized protocol and to perform a comprehensive evaluation of the shoulder than to conduct a focused examination. Moreover, a proper dynamic study can enhance the diagnostic quality of US, especially when the pathology is not revealed by a static evaluation. The purpose of this article is to review the common indications for dynamic US of the shoulder, and to present the basic techniques and characteristic US findings.

Sonography in diagnosis of adhesive capsulitis of the shoulder: a case-control study

PURPOSE

Adhesive capsulitis (AC) of the shoulder has been a diagnosis of exclusion on sonography due to lack of specific diagnostic criteria. This study prospectively assesses the efficacy of sonography using multiple static and dynamic parameters for diagnosis of AC.

MATERIALS AND METHODS

Shoulder sonography was performed independently by two musculoskeletal radiologists on 90 subjects (60 symptomatic and 30 controls). All symptomatic subjects were subjected to an MRI. Based on clinical and MRI diagnosis, three groups were made: AC (n = 30), painful shoulders (PS) (n = 30), and control group (CL) (n = 30). The sonographic parameters studied were: coracohumeral ligament (CHL) thickness, increased soft tissue in rotator interval (static parameters) and restriction of abduction and external rotation on dynamic scanning. These were compared within the three groups and the accuracy of each parameter in isolation and in combination for diagnosis of AC was calculated.

RESULTS

Sonographic visualisation of CHL (96.7%) and its mean thickness (1.2 mm) were highest in the AC group (p < 0.01). A cut-off value of 0.7 mm was found to be accurate (sensitivity 93.1%, specificity 94.4%) for diagnosing AC. Increased soft tissue in the rotator interval was seen in the AC group and had a high sensitivity of 86.2% and specificity of 92.8%. On dynamic scanning, restriction of external rotation was specific (sensitivity 86.2%, specificity 92.8%), whereas restriction in abduction was non-specific (specificity 6.7%). Inter-observer agreement was substantial for CHL visualisation (kappa 0.66). Overall, sonography, using multiple parameters, revealed a high sensitivity and specificity (100 and 87%, respectively) for diagnosis of AC of the shoulder.

CONCLUSION

Sonography revealed a high accuracy for diagnosing AC of the shoulder and in differentiating it from other causes of painful shoulder. It, thus, has the potential to be adopted as a preferred imaging modality.

Imaging of the coracoglenoid ligament: a third ligament in the rotator interval of the shoulder

OBJECTIVE

The coracoglenoid ligament (CGL) forms part of the anterosuperior capsuloligamentous complex of the shoulder. Although it has received attention in the anatomical literature, it has not been investigated on imaging. The purpose of this study is to determine the percentage value and the interobserver agreement of identification and classification of the CGL on MR and MR arthrography (MRA) imaging.

MATERIALS AND METHODS

Retrospectively, 280 MR and 150 MRA examinations were evaluated for detection of the CGL by two musculoskeletal radiologists. On the MRA examinations the CGL configuration in relation to the superior glenohumeral (SGHL) and coracohumeral ligament (CHL) was classified into five types. Additionally, the percentage of intra-articular appearance of the CGL and its mean thickness value were calculated. Finally, a possible correlation between pathological condition and anatomical type was evaluated on MRA.

RESULTS

The CGL could be identified in 56%/54% of MRI and in 76%/77% of MRA examinations. On MRA, the CGL was detected as distinct structures in 37%/35% of cases and it appeared fused (partially or totally) with the SGHL and/or CHL in 39%/42%; it was absent in 12%/12% and it appears undistinguishable in the remaining cases. The interobserver agreement was excellent (κ = 0.98 for detection on MRI; p = 0.927 for classification of anterosuperior anatomy on MRA; κ = 0.873 and 0.978 for identification on sagittal and axial external rotation MRA respectively; κ = 0.943 for classification as intra- or extra-articular on MRA).

CONCLUSIONS

The CGL can be reliably identified on MRI and MRA.

Adhesive Capsulitis of the Shoulder: Evaluation With US-Arthrography Using a Sonographic Contrast Agent

Adhesive capsulitis (AC) is a painful and disabling disorder, which caused restricted motion and chronic pain of shoulder. Intracavitary contrast-enhanced ultrasound has been recently applied to assess obstructive bile duct diseases, tubal patency, vesicoureteric reflux and so on. The aim of this study was to detect the value of US-arthrography by injecting the contrast agent SonoVue into glenohumeral joint compared with US in diagnosing AC. Utrasound (US) and US-arthrography images of 45 patients with AC were compared with that of 45 control subjects without AC with MRI as a gold standard. Patients with AC had a significantly thickened coracohumeral ligment (CHL, 3.1 mm) and inferior capsule (3.5 mm) on US, and a decreased volume of axillary recess (1.14 ml) on US-arthrography compared with the control subjects (1.59 ml). Filling defect (91.1%) and synovitis-like abnormality (75.6%) in the joint on US-arthrography were more sensitive than that of rotator interval abnormality (71.1%), thickened CHL more than 3 mm (64.4%), thickened inferior capsule more than 3.5 mm (66.7%) on US respectively for diagnosis of AC. Consequently, US-arthrography was more effective method than US for assessment of AC. Filling defects of joint cavity and synovitis-like abnormality in the joint are characteristic US-arthrography findings for diagnosing AC.

Sonographic Evaluation of Structural Changes in Post-Stroke Hemiplegic Shoulders

Background

Stroke and hemiplegia are frequent complications of stroke. This study was performed to sonographically evaluate post-stroke hemiplegic shoulders and explore possible relationship(s) between the sonographic findings and clinical indices.

Material/Methods

Forty-five stroke patients and 45 age- and sex-matched controls were recruited. Standard sonographic examination of both shoulders was performed to assess for joint subluxation, rotator cuff tears, tendinosis, subacromial-subdeltoid bursitis or effusion and adhesive capsulitis.

Results

Hemiplegic shoulders exhibited significantly higher number of pathologies compared to the unaffected shoulders and shoulders of controls (p=0.000). One or more structural abnormalities were found in all 45 (100%) hemiplegic shoulders, 25 (55.6%) unaffected shoulders of the stroke subjects, and 39 (43.3%) control shoulders. The most frequent pathologies in the hemiplegic shoulders were the following: tendinosis of the long head of bicep tendon (48.9%), inferior shoulder subluxation (44.4%), co-existing subacromial-subdeltoid bursa/long head of bicep tendon sheath effusion (44.4%), and long head of bicep tendon sheath effusion only (40%). Tendinosis of the long head of bicep tendon was commoner in hemiplegic shoulders with poor motor status than those with good motor status.

Conclusions

Hemiplegic shoulders have significantly higher number of structural abnormalities than unaffected shoulders and the shoulders of controls. Hemiplegic stroke patients should undergo ultrasonography of the hemiplegic shoulder to define the nature and extent of soft tissue injuries prior to physical therapy.

Incidence and prognostic factors for postoperative frozen shoulder after shoulder surgery: a prospective cohort study

PURPOSE

Frozen shoulder is a potential complication after shoulder surgery. It is a clinical condition that is often associated with marked disability and can have a profound effect on the patient's quality of life. The incidence, etiology, pathology and prognostic factors of postoperative frozen shoulder after shoulder surgery are not known. The purpose of this explorative study was to determine the incidence of postoperative frozen shoulder after various operative shoulder procedures. A second aim was to identify prognostic factors for postoperative frozen shoulder after shoulder surgery.

METHODS

505 consecutive patients undergoing elective shoulder surgery were included in this prospective cohort study. Follow-up was 6 months after surgery. A prediction model was developed to identify prognostic factors for postoperative frozen shoulder after shoulder surgery using the TRIPOD guidelines. We nominated five potential predictors: gender, diabetes mellitus, type of physiotherapy, arthroscopic surgery and DASH score.

RESULTS

Frozen shoulder was identified in 11% of the patients after shoulder surgery and was more common in females (15%) than in males (8%). Frozen shoulder was encountered after all types of operative procedures. A prediction model based on four variables (diabetes mellitus, specialized shoulder physiotherapy, arthroscopic surgery and DASH score) discriminated reasonably well with an AUC of 0.712.

CONCLUSIONS

Postoperative frozen shoulder is a serious complication after shoulder surgery, with an incidence of 11%. Four prognostic factors were identified for postoperative frozen shoulder: diabetes mellitus, arthroscopic surgery, specialized shoulder physiotherapy and DASH score. The combination of these four variables provided a prediction rule for postoperative frozen shoulder with reasonable fit.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Sonography of the Coracoid Process Region

Sonography is widely known as an accurate imaging tool for assessment of the rotator cuff of the shoulder, the long head of the biceps tendon, and joint disorders, but it is rarely performed to evaluate the coracoid process and the adjacent soft tissues. Nevertheless, sonography can show anatomic details of this region and be used to assess several pathologic conditions. The aims of this pictorial essay are to briefly review the anatomy of the coracoid process region, describe examination technique and normal sonographic appearances, and present the sonographic findings of the main disorders affecting this region.

Adhesive Capsulitis in Eight Dogs: Diagnosis and Management

OBJECTIVE

To describe clinical and diagnostic findings as well as management of adhesive capsulitis in dogs.

BACKGROUND

Adhesive capsulitis, also known as frozen shoulder, is a syndrome defined by loss of range of motion of the shoulder and may be the end-stage manifestation of several primary conditions.

EVIDENTIARY VALUE

This is a case series report of eight dogs with chronic forelimb lameness diagnosed with adhesive capsulitis.

METHODS

Medical records (June 1, 2010-September 1, 2015) including, physical examination findings, radiographic findings, magnetic resonance imaging (MRI) findings, arthroscopy findings, and treatment plans were reviewed.

RESULTS

All dogs presented with a chronic, grade III-VI/VI forelimb lameness. On orthopedic examination, all dogs had moderate to significant discomfort on shoulder extension and flexion and severe restriction of range of motion. Six of the eight dogs had evidence of bone remodeling and sclerosis in the affected shoulder on radiographs. Six of the dogs had an initial diagnostic ultrasound performed, which revealed evidence of fibrous scar tissue. Five dogs had MRI performed that revealed moderate shoulder effusion and enhancement of the synovial lining of the shoulder. Arthroscopy was performed in five of the eight patients. Three were noted to have significant contracture, adhesions, and fibrous scar tissue of the joint capsule. Severe inflammation was noted throughout the synovium of two patients. All eight patients tried conservative management consisting of oral medications and rehabilitation therapy. Five of the eight patients received extracorporeal shockwave therapy. Three patients received regenerative medicine treatment in the affected supraspinatus and shoulder. Regardless of the treatment elected, none of the dogs were reported to have significant improvement.

CONCLUSION

Adhesive capsulitis is an uncommon cause of chronic forelimb lameness. Further investigation is needed to describe the etiology and pathogenesis of adhesive capsulitis in dogs to evaluate the effectiveness of both non-surgical and surgical treatment modalities, establish treatment protocols, and evaluate short- and long-term clinical outcome of patients.

APPLICATION

Adhesive capsulitis should be considered in patients with chronic forelimb lameness and moderate to significant discomfort and restriction on shoulder range of motion.

Ultrasonographic Measurement of the Thickness of Axillary Recess Capsule in Healthy Volunteers

Objective

To evaluate the inter-rater and intra-rater reliability of ultrasonographic measurements of axillary recess (AR) thickness in healthy individuals, and to analyze the factors affecting the thickness of the AR capsule.

Methods

We recruited 20 healthy individuals (10 male, 10 female) with a mean age of 37 years (standard deviation ±10). Two physiatrists (an experienced and a novice rater) independently investigated the AR thickness in three rounds. The AR thickness was measured for each individual at three shoulder abduction angles (50°, 70°, and 90°). Intra-class correlation (ICC) coefficients were used to assess the reproducibility of each measurement.

Results

Excellent intra-rater reliability coefficients were observed at the three shoulder abduction angles, in the analysis of both raters. The inter-rater reliability coefficient was also was excellent in both studies. There were significant differences in the AR thickness, according to the angle of shoulder abduction. The AR was thicker at 50° than at 70° and 90° (all p<0.001), and the AR was thicker at 70° than at 90° (p<0.001). Height (r=0.62, p=0.003) and body mass index (r=0.52, p=0.019) were positively correlated with AR thickness. Males had a thicker AR capsule than females at all three angles (all p<0.001).

Conclusion

Ultrasonographic measurements of AR thickness in healthy individuals demonstrate excellent intra-rater and inter-rater reliability. AR thickness may depend on anthropometric variables and position of the shoulder.

Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers

Introduction

The goal of this study was to investigate the efficacy of diagnosing shoulder dislocation using a single-view, posterior approach point-of-care ultrasound (POCUS) performed by undergraduate research students, and to establish the range of measured distance that discriminates dislocated shoulder from normal.

Methods

We enrolled a prospective, convenience sample of adult patients presenting to the emergency department with acute shoulder pain following injury. Patients underwent ultrasonographic evaluation of possible shoulder dislocation comprising a single transverse view of the posterior shoulder and assessment of the relative positioning of the glenoid fossa and the humeral head. The sonographic measurement of the distance between these two anatomic structures was termed the Glenohumeral Separation Distance (GhSD). A positive GhSD represented a posterior position of the glenoid rim relative to the humeral head and a negative GhSD value represented an anterior position of the glenoid rim relative to the humeral head. We compared ultrasound (US) findings to conventional radiography to determine the optimum GhSD cutoff for the diagnosis of shoulder dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of the derived US method were calculated.

Results

A total of 84 patients were enrolled and 19 (22.6%) demonstrated shoulder dislocation on conventional radiography, all of which were anterior. All confirmed dislocations had a negative measurement of the GhSD, while all patients with normal anatomic position had GhSD>0. This value represents an optimum GhSD cutoff of 0 for the diagnosis of (anterior) shoulder dislocation. This method demonstrated a sensitivity of 100% (95% CI [82.4–100]), specificity of 100% (95% CI [94.5–100]), positive predictive value of 100% (95% CI [82.4–100]), and negative predictive value of 100% (95% CI [94.5–100]).

Conclusion

Our study suggests that a single, posterior-approach POCUS can diagnose anterior shoulder dislocation, and that this method can be employed by novice ultrasonographers, such as non-medical trainees, after a brief educational session. Further validation studies are necessary to confirm these findings.

Multi-modal imaging of adhesive capsulitis of the shoulder

Adhesive capsulitis of the shoulder is a clinical condition characterized by progressive limitation of active and passive mobility of the glenohumeral joint, generally associated with high levels of pain. Although the diagnosis of adhesive capsulitis is based mainly on clinical examination, different imaging modalities including arthrography, ultrasound, magnetic resonance, and magnetic resonance arthrography may help to confirm the diagnosis, detecting a number of findings such as capsular and coracohumeral ligament thickening, poor capsular distension, extracapsular contrast leakage, and synovial hypertrophy and scar tissue formation at the rotator interval. Ultrasound can also be used to guide intra- and periarticular procedures for treating patients with adhesive capsulitis.

KEY POINTS

• Diagnosis of adhesive capsulitis is mainly based on clinical findings. • Imaging may be used to exclude articular or rotator cuff pathology. • Thickening of coracohumeral and inferior glenohumeral ligaments are common findings. • Rotator interval fat pad obliteration has 100 % specificity for adhesive capsulitis. • Ultrasound can be used to guide intra- and periarticular treatments.

Targeted ultrasound-guided hydrodilatation via the rotator interval for adhesive capsulitis

OBJECTIVE

To describe and evaluate ultrasound-guided hydrodilatation via the rotator interval for the treatment of adhesive capsulitis.

MATERIALS AND METHODS

Patients referred to our department with adhesive capsulitis were consented for hydrodilatation. Inclusion criteria included a failure to respond to conservative treatment and the absence of full thickness rotator cuff tear. Twenty-one milliliters of a mixture of local anesthetic and steroid was injected into the rotator interval using a 21-gauge needle. Patients were followed up at 2 weeks and 4 months, with documented pain scores from 0 to 10 on a visual analogue scale and the Oxford Shoulder Questionnaire.

RESULTS

Twenty-two patients were suitable for inclusion in the study. Nineteen were female (86 %) and three were male. The mean age was 55 years (range, 32-71 years). The duration of symptoms ranged from 4 weeks to 20 months. At 4 months, 19/22 (86 %) of patients described either complete (7/22) or good (12/22) improvement in their symptoms. The mean pain score was 8.4 prior to the procedure, 3.1 at 48 h and 1.9 at 4 months, and 20/22 (91 %) had a lower pain score after 4 months. There was a statistically significant (p < 0.05) improvement in the Oxford shoulder score, from a mean of 13.6 pre-procedure to 36.5 at 4 months.

CONCLUSIONS

The rotator interval and anterior joint capsule are strongly implicated in the symptomatology of adhesive capsulitis. The novel use of targeted ultrasound-guided hydrodilatation via the rotator interval gives good results in reducing shoulder pain and symptoms in adhesive capsulitis.

Frozen shoulder contracture syndrome - Aetiology, diagnosis and management

Frozen shoulder is a poorly understood condition that typically involves substantial pain, movement restriction, and considerable morbidity. Although function improves overtime, full and pain free range, may not be restored in everyone. Frozen shoulder is also known as adhesive capsulitis, however the evidence for capsular adhesions is refuted and arguably, this term should be abandoned. The aim of this Masterclass is to synthesise evidence to provide a framework for assessment and management for Frozen Shoulder. Although used in the treatment of this condition, manipulation under anaesthetic has been associated with joint damage and may be no more effective than physiotherapy. Capsular release is another surgical procedure that is supported by expert opinion and published case series, but currently high quality research is not available. Recommendations that supervised neglect is preferable to physiotherapy have been based on a quasi-experimental study associated with a high risk of bias. Physiotherapists in the United Kingdom have developed dedicated care pathways that provide; assessment, referral for imaging, education, health screening, ultrasound guided corticosteroid and hydro-distension injections, embedded within physiotherapy rehabilitation. The entire pathway is provided by physiotherapists and evidence exists to support each stage of the pathway. Substantial on-going research is required to better understand; epidemiology, patho-aetiology, assessment, best management, health economics, patient satisfaction and if possible prevention.

Adhesive capsulitis: review of imaging and treatment

Adhesive capsulitis is one of the most common conditions affecting the shoulder; however, early clinical diagnosis can be challenging. Treatment is most effective when commenced prior to the onset of capsular thickening and contracture; consequently, the role of imaging is increasing. The aim of this review is to demonstrate the typical imaging appearances of adhesive capsulitis and to examine some of the evidence regarding each of these imaging modalities. An evaluation of the various management options available to the clinician is also presented.