Multi-modal imaging of adhesive capsulitis of the shoulder

Adhesive capsulitis: the importance of early diagnosis and treatment

BACKGROUND

Adhesive capsulitis (AC), more commonly known as "frozen shoulder", is a painful shoulder condition. The illness progresses through three phases: freezing, frozen and thawing. A gold standard treatment for adhesive capsulitis is not defined. The goal of any treatment is to reduce pain and restore shoulder movement.

OBJECTIVE

Objective of the present study is to evaluate the efficacy of gleno-humeral hydrodistension associated with physical therapy in patients with diagnosed adhesive capsulitis comparing the outcomes in term of pain and range of motion in patients with a phase 1 and a phase 2 disease.

METHOD

Between January 2022 and April 2023, We evaluated 87 patients with adhesive capsulitis, 47 were excluded for others concomitant pathologies, finally 40 patients were enrolled for the study, of whom 23 had capsulitis in stage 1 and 17 in stage 2. Patients were evaluated at baseline and at 2, 4 and 6 months after infiltration recording range of motion in all planes, pain and functionality scores.

RESULTS

A significant improvement was recorded in shoulder range of motion in all planes with the except of extension in both groups. Phase 2 patients were able to regain shoulder range of motion in all planes except internal rotation which was recovered with more difficulty. Pain and functionality scores improved significantly between baseline and follow-up visits.

CONCLUSION

Ultrasound-assisted hydrodistention of the glenohumeral joint combined with targeted exercise has been successful in improving pain relief, reducing disability, and increasing range of motion in subjects with stage 1 and 2 adhesive capsulitis, especially if diagnosed before phase 2 (when the range of motion is completely reduced).

Similar short-term outcomes of ultrasound guided posterior intra-articular and anterior extra-articular corticosteroid injection in the treatment of primary frozen shoulder. A randomized controlled, single-blind study

Frozen shoulder, a condition characterized by the limitation of active and passive shoulder movements, is predominantly managed conservatively. Corticosteroid injection stands as a widely utilized and effective method for treatment. Nevertheless, the optimal approach for administering the injection remains a subject of controversy. We hypothesized that the injection of corticosteroid through anterior into the extra-articular area would yield superior results than the posterior intra-articular injection. This prospective, randomized, single-blind, and single-center clinical study aimed to compare the therapeutic effectiveness of ultrasound (USG)-guided injection techniques in patients with primary frozen shoulder. We continued the study with 54 patients who met the inclusion criteria. We evaluated patients pre-injection and at the first, third, and sixth weeks after injection. Two distinct approaches were employed: (1) Injection through the anterior extra-articular area around the coracohumeral ligament (CHL), and (2) injection through the posterior route into the glenohumeral joint. Evaluation parameters, including Visual Analog Scale (VAS) scores, active range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, were assessed pre-injection and at the first, third, and sixth weeks post injection. No significant differences in the demographic and clinical characteristics, laboratory, or radiological findings were observed between the groups. It was observed that both groups exhibited similar and significant improvement in all measured parameters within their respective groups. Regarding pain scores, a notable decrease in VAS scores was observed in both groups (P = .000). There was no difference between the groups in terms of pre-injection VAS, QuickDASH, and ASES scores and active ROM measurements. The study concluded that there was no significant difference between ultrasound-guided injection of posterior intra-articular injection and anterior extra-articular injection concerning pain, ROM, and functional scores. Both techniques can be considered as viable options in the early stage of the disease. Level I, Therapeutic study.

An approach leveraging radiomics and model checking for the automatic early diagnosis of adhesive capsulitis

Adhesive Capsulitis of the shoulder is a painful pathology limiting shoulder movements, commonly known as "Frozen Shoulder". Since this pathology limits movement, it is important to make an early diagnosis. Diagnosing capsulitis relies on clinical assessment, although diagnostic imaging, such as Magnetic Resonance Imaging, can provide predictive or supportive information for specific characteristic signs. However, its diagnosis is not so simple nor so immediate, indeed it remains a difficult topic for many general radiologists and expert musculoskeletal radiologists. This study aims to investigate whether it is possible to use disease signs within a medical image to automatically diagnose Adhesive Capsulitis. To this purpose, we propose an automatic Model Checking-based approach to quickly diagnose the Adhesive Capsulitis taking as input the radiomic feature values from the medical images. Furthermore, we compare the performance achieved by our method with diagnostic results obtained by professional radiologists with different levels of experience. To the best of our knowledge, this is the first method for the automatic diagnosis of Adhesive Capsulitis of the Shoulder.

Biceps Pulley Lesions: Diagnostic Accuracy of Nonarthrographic Shoulder MRI and the Value of Various Diagnostic Signs

BACKGROUND

There is limited data in the literature regarding the role of nonarthrographic MRI for detecting biceps pulley (BP) lesions.

PURPOSE

To assess the accuracy of nonarthrographic MRI for detecting BP lesions, and to evaluate the diagnostic value of various MRI signs (superior glenohumeral ligament discontinuity/nonvisibility, long head of biceps (LHB) displacement sign or subluxation/dislocation, LHB tendinopathy, and supraspinatus and subscapularis tendon lesions) in detecting such lesions.

STUDY TYPE

Retrospective.

POPULATION

84 patients (32 in BP-lesion group and 52 in BP-intact group-as confirmed by arthroscopy).

FIELD STRENGTH/SEQUENCE

1.5-T, T1-weighted turbo spin echo (TSE), T2-weighted TSE, and proton density-weighted TSE spectral attenuated inversion recovery (SPAIR) sequences.

ASSESSMENT

Three radiologists independently reviewed all MRI data for the presence of BP lesions and various MRI signs. The MRI signs and final MRI diagnoses were tested for accuracy regarding detecting BP lesions using arthroscopy results as the reference standard. Furthermore, the inter-reader agreement (IRA) between radiologists was determined.

STATISTICAL TESTS

Student's t-tests, Chi-squared, and Fisher's exact tests, and 4-fold table test were used. The IRA was calculated using Kappa statistics. A P-value <0.05 was considered statistically significant.

RESULTS

The sensitivity, specificity, and accuracy of nonarthrographic MRI for detecting BP lesions were 65.6%-78.1%, 90.4%-92.3%, and 81%-86.9%, respectively. The highest accuracy was noticed for the LHB displacement sign (84.5%-86.9%), and the highest sensitivity was registered for the LHB tendinopathy sign (87.5%). Furthermore, the highest specificity was observed for the LHB displacement sign and LHB subluxation/dislocation sign (98.1%-100%). The IRA regarding final MRI diagnosis and MRI signs of BP lesions was good to very good (κ = 0.76-0.98).

DATA CONCLUSION

Nonarthrographic shoulder MRI may show good diagnostic accuracy for detecting BP lesions. The LHB displacement sign could serve as the most accurate and specific sign for diagnosis of BP lesions.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

Un-resolving frozen shoulder: Are we really treating it?

Objective

To perform ultrasound examination in un-resolving frozen shoulder disorder, in Pakistani cohort visiting rheumatology clinic.

Methods

This cross sectional study was carried out at Department of Rheumatology, Indus Medical College Tando Mohhamad Khan, from 16th March 2022 to 30th October 2022. Patients diagnosed as unilateral frozen shoulder on clinical grounds and received intra-articular injection (s) in last six months, never been investigated, still persisting with pain and restricted range of shoulder motion were enrolled. After the demographic details and shoulder examination, ultrasound examination of both shoulder joints was performed by senior musculoskeletal radiologist, to know the exact diagnosis.

Results

In 138 cases on ultrasound examination following injuries were noted: rotator cuff tendinopathy (RCT) (61%), adhesive capsulitis (21%), mixed lesion (rotator cuff tendinopathy and adhesive capsulitis) (14%).In age group < 50 years rotator cuff tendinopathy was the major lesion, while in cases >50 years age group: adhesive capsulitis (AC) was predominant lesion (p-0.05).Rotator cuff tendinopathy had significant association with supraspinatus tears (p<0.5).

Conclusion

In Un-resolving frozen shoulder pain, ultrasound examination of involved joint helps in reaching the exact cause which may differ from the existing diagnosis and guides to further management.

The efficacy of platelet-rich plasma injections compared to corticosteroids and physiotherapy in adhesive capsulitis: A systematic review and meta-analysis

Introduction

Adhesive Capsulitis is a common condition of the shoulder with significant morbidity and protracted disease. It is usually characterized by sudden onset with progressive symptoms of pain and loss of function. This systematic review compares platelet rich plasma (PRP) intra-articular injections with corticosteroids (CS) injections and physiotherapy.

Material and methods

A literature search was performed using online databases (Pubmed, Cochrane, EMBASE, Medline and CINAHL) including all the studies performed on humans through April 2023. Prospective comparative studies were included in this review of patients with adhesive capsulitis assessing the use of PRP injections versus corticosteroid injections or physiotherapy. The standardized mean difference (SMD) with 95 % confidence interval in VAS/DASH/SPADI and ROM scores was calculated using a random effects model, comparing PRP to corticosteroids injections and physiotherapy across studies.

Results

A total of 11 studies and 971 patients, with a mean age of 52.1, were included in this analysis with 7 being randomised trials and four cohort studies. The control group was corticosteroid injections in 8 studies and physiotherapy in the other three studies. Overall PRP lead to a statistically significant improved outcome at 3 and 6 months follow up for all outcome parameters. The outcome measures at three months includes VAS 0.73 (0.31, 1.16) SMD, DASH 0.66 (0.36, 0.96) SMD, SPADI 1.50 (0.43, 2.57) SMD, ER 1.47 (0.27, 2.66) SMD and Abduction 1.10 (0.21, 1.98) SMD. Six months assessment similarly favoured PRP with VAS 3.17 (1.26, 5.08) SMD and DASH 2.10 (1.66, 2.55) SMD scores. Furthermore, a subgroup analysis demonstrated that PRP was favourable to corticosteroids as control with significant improvement in pain (VAS) at 3 months 0.65 (0.29, 1.00) and 6 months 3.17 (1.26, 5.08) SMD.

Conclusion

This review demonstrated that intra-articular PRP injections for adhesive capsulitis produces favourable outcomes when compared to corticosteroid injections and physiotherapy. PRP produces improved pain and functional scores as well as range of motion, which is statistically significant from 3 to 6 months post intervention. PRP seems to be a safe and effective alternative non-invasive treatment modality for patients with adhesive capsulitis.

Adhesive capsulitis after COVID-19 vaccine injection: a peculiar case treated with combined bursa distention and glenohumeral capsular hydrodilatation

Frozen shoulder is a common and self-limiting condition affecting the soft tissues of the shoulders, characterized by severe pain, impaired range of motion (ROM) and limitation of daily activities. Its prevalence is 5% and it occurs most commonly in the fifth and sixth decades of life; women are more affected [DePalma in Clin Orthop Relat Res 466:552-560, 2008]. It can be idiopathic or associated with other conditions such as metabolic disorders, diabetes, thyroid diseases, prolonged immobilization, trauma [DePalma in Clin Orthop Relat Res 466:552-560, 2008], or complications after vaccine administration known as SIRVA (Shoulder injury related to vaccine administration). SIRVA is not caused by the vaccine itself but by inappropriate vaccination techniques [Martín Arias et al. in Vaccine 35:4870-4876, 2017]. The natural history of the frozen shoulder is a progression through three stages based on clinical and arthroscopic presentations: freezing, frozen and thawing [DePalma in Clin Orthop Relat Res 466:552-560, 2008; Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. The onset is characterized by disabling pain, that worsens at night; it is induced by inflammation and hypervascularity and lasts from 10 to 36 weeks [Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. The second stage is predominated by stiffness and severe reduction of ROM. This phase typically lasts from 9 to 12 months [Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. Eventually, a recovery phase occurs, with a gradual recovery of the ROM that can last between 12 and 42 months. Ultrasound is an emerging diagnostic tool that contributes to differential diagnosis and treatment [Zappia et al. in Insights Imaging 7:365-371, 2016; Ricci et al. in J Ultrasound Med 39:633-635, 2020]: signs of adhesive capsulitis consist of thickening of the inferior recess of the glenohumeral joint capsule, thickening of the coracohumeral ligament and soft tissue structures in the rotator cuff interval, with hypervascularity. An unspecific sign is increased fluid in the tendon sheath of the long head of the biceps [Martín Arias et al. in Vaccine 35:4870-4876, 2017; Tandon et al. in J Ultrasound 20:227-236, 2017].

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.

Shoulder ultrasound imaging in the post-stroke population: a systematic review and meta-analysis

OBJECTIVE

Post-stroke shoulder pain is a serious challenge for stroke survivors. The aim of this meta-analysis was to review the literature to confirm information on structural changes in post-stroke shoulders detected by ultrasound examination.

METHODS

PubMed, Embase, Web of Science and ClinicalTrials.gov were searched until 7 December 2022, for studies describing shoulder sonographic findings in stroke patients. Two independent authors selected the studies, extracted the data, and performed the critical appraisal.

RESULTS

A total of 23 clinical studies were included. The most prevalent pathologies in hemiplegic shoulders pertained to the biceps long head tendon (41.4%), followed by the supraspinatus tendon (33.2%), subdeltoid bursa (29.3%), acromioclavicular joint (15.0%), and subscapularis tendon (9.2%). The common pathological findings encompassed bicipital peritendinous effusion (39.2%), biceps tendinopathy (35.5%), subdeltoid bursitis (29.3%) and supraspinatus tendinopathy (24.6%). Biceps long head tendon and supraspinatus tendon abnormalities were observed significantly more in the hemiplegic (vs contralateral) shoulders, with odds ratios of 3.814 (95% confidence interval 2.044-7.117) and 2.101 (95% confidence interval 1.257-3.512), respectively. No correlation was observed between motor function and shoulder pathology.

CONCLUSION

Ultrasonography enabled the identification of common shoulder pathologies after stroke. Further research is needed to establish the association between these changes and the clinical course of stroke patients.

Ultrasound-Guided Infiltrative Treatment Associated with Early Rehabilitation in Adhesive Capsulitis Developed in Post-COVID-19 Syndrome

Background and Objectives: Post-COVID-19 syndrome is commonly used to describe signs and symptoms that continue or develop after acute COVID-19 for more than 12 weeks. The study aimed to evaluate a treatment strategy in patients with adhesive capsulitis (phase 1) developed in post-COVID-19 syndrome. Materials and Methods: The method used was an interventional pilot study in which 16 vaccinated patients presenting with the clinical and ultrasound features of adhesive capsulitis (phase 1) developed during post-COVID-19 syndrome were treated with infiltrative hydrodistension therapy under ultrasound guidance associated with early rehabilitation treatment. Results: Sixteen patients with post-COVID-19 syndrome treated with ultrasound-guided infiltration and early rehabilitation treatment showed an important improvement in active joint ROM after 10 weeks, especially in shoulder elevation and abduction movements. The VAS mean score before the treatment was 6.9 ± 1.66. After 10 weeks of treatment, the VAS score was 1 ± 0.63. Conclusions: The study demonstrated that the management of adhesive capsulitis (phase 1) developed in post-COVID-19 syndrome, as conducted by physiotherapists in a primary care setting using hydrodistension and a rehabilitation protocol, represented an effective treatment strategy.

Ultrasound-guided hydrodistension for adhesive capsulitis: a longitudinal study on the effect of diabetes on treatment outcomes

OBJECTIVE

The effect of diabetes on adhesive capsulitis (AC) and its impact on the outcomes of ultrasound (US)-guided hydrodistension of the glenohumeral joint are still unclear. We aimed to identify predictors of US-guided hydrodistension outcomes, while assessing the performance of the method in diabetic compared to non-diabetic patients.

MATERIALS AND METHODS

A total of 135 patients with AC who underwent US-guided hydrodistension were prospectively included. Demographics and factors linked to chronic inflammation and diabetes were recorded and patients were followed-up for 6 months. Functionality and pain were evaluated with the Disabilities of the Arm, Shoulder and Hand (DASH) and the Visual Analogue Scale (VAS) score. Statistical analysis was performed with Mann-Whitney U test, linear, and binary logistic regression.

RESULTS

Diabetes was identified in 25/135 patients (18.5%). Diabetic patients had worse DASH and VAS score at presentation (P < 0.0001) and presented with a higher grade of AC (P < 0.0001) and lower range of motion (P < 0.01) compared to non-diabetics. Higher DASH (P = 0.025) and VAS scores (P = 0.039) at presentation were linked to worse functionality at 6 months. Presence and duration of diabetes, and the number of hydrodistension repeats, correlated with worse VAS and DASH scores at 6 months. The number of procedure repeats was the only independent predictor of complete pain resolution at 6 months (OR 0.418, P = 003).

CONCLUSION

Diabetes is linked to more severe AC at presentation and worse outcomes in patients undergoing US-guided hydrodistension. In resistant cases, repeating the intervention is independently linked to worse outcomes for at least 6 months post-intervention.

Current concepts in the diagnosis and treatment of adhesive capsulitis: role of diagnostic imaging and ultrasound-guided interventional procedures

Adhesive capsulitis is a common cause of painful shoulder, characterized by pain and restricted range of motion of the glenohumeral joint. With a well-known clinical presentation, and an increasing understanding of its clinical and radiologic features, early diagnosis of adhesive capsulitis is becoming a reality. Although often treated conservatively, for refractory cases arthroscopic release and open capsulotomy have been the only therapeutic option for a long time. Therefore, in the last years, a particular effort was put into the development of novel minimal-invasive techniques capable of pain relief and functional range improvement of the glenohumeral joint. The purpose of this literature review is to report the main updates on diagnosis and treatment for adhesive capsulitis with a focus on imaging diagnosis techniques and novel minimally invasive ultrasound-guided treatments. Results showed that ultrasound-guided procedures come with a high success rate in terms of pain reduction and improved range of motion, thus making the ultrasound a unique tool capable of giving the operator real-time diagnostic information confirming the clinical suspicion, and subsequently performing an interventional procedure.

Trends in Practice Among Shoulder Specialists in the Management of Frozen Shoulder: A Consensus Survey

Background:

The management of frozen shoulder (FS) differs depending on experience level and variation between scientific guidelines and actual practice.

Purpose:

To determine the current trends and practices in the management of FS among shoulder specialists and compare them with senior shoulder specialists.

Study Design:

Consensus statement.

Methods:

A team of 15 senior shoulder specialists (faculty group) prepared a questionnaire comprising 26 questions regarding the definition, terminology, clinical signs, investigations, management, and prognosis of FS. The questionnaire was mailed to all the registered shoulder specialists of Shoulder and Elbow Society, India (SESI) (specialist group; n = 230), as well as to the faculty group (n = 15). The responses of the 2 groups were compared, and levels of consensus were determined: strong (>75%), broad (60%-74.9%), inconclusive (40%-59.9%), or disagreement (<40%).

Result:

Overall, 142 of the 230 participants in the specialist group and all 15 participants in the faculty group responded to the survey. Both groups strongly agreed that plain radiographs are required to rule out a secondary cause of FS, routine magnetic resonance imaging is not indicated to confirm FS, nonsteroidal anti-inflammatory drugs should be administered at bedtime, steroid injection (triamcinolone or methylprednisolone) is the next best option if analgesics fail to provide pain relief, passive physical therapy should be avoided in the freezing phase, <10% of patients would require any surgical intervention, and patients with diabetes and thyroid dysfunction tend to fare poorly. There was broad agreement that routine thyroid dysfunction screening is unnecessary for women, a single 40-mg steroid injection via intra-articular route is preferred, and arthroscopic capsular release (ACR) results in a better outcome than manipulation under anesthesia (MUA). Agreement was inconclusive regarding the use of combined random blood sugar (RBS) and glycosylated hemoglobin versus lone RBS to screen for diabetes in patients with FS, preference of ACR versus MUA to treat resistant FS, and the timing of surgical intervention. There was disagreement over the most appropriate term for FS, the preferred physical therapy modality for pain relief, the most important movement restriction for early diagnosis of FS, and complications seen after MUA.

Conclusion:

This survey summarized the trend in prevalent practices regarding FS among the shoulder specialists and senior shoulder surgeons of SESI.

Glenohumeral Hydrodistension for Postoperative Stiffness After Arthroscopic Primary Rotator Cuff Repair

Background:

Postoperative stiffness is a known complication after rotator cuff repair (RCR). Glenohumeral hydrodistension (GH) has been a treatment modality for shoulder pathology but has not been used to treat postoperative stiffness after RCR.

Purpose/Hypothesis:

The purpose of this study was to identify the risk factors for postoperative stiffness after RCR and review outcomes after treatment with GH. Our hypotheses were that stiffness would be associated with diabetes and hyperlipidemia and correlated with the tendons involved and that patients with stiffness who underwent GH would have significant improvement in range of motion (ROM).

Study Design:

Case series; Level of evidence, 4.

Methods:

Included were 388 shoulders of patients who underwent primary RCR by a single surgeon between 2015 and 2019. Shoulders with revision RCRs were excluded. Patient characteristics, medical comorbidities, and perioperative details were collected. A total of 40 shoulders with postoperative stiffness (10.3%) received GH injectate of a 21-mL mixture (15 mL of sterile water, 5 mL of 0.5% ropivacaine, and 1 mL of triamcinolone [10 mg/mL]). The primary outcome measure was ROM in forward flexion, internal rotation, external rotation, and abduction. Statistical tests were performed using analysis of variance.

Results:

Patients with diabetes had significantly decreased internal rotation at final follow-up after RCR as compared with patients without diabetes. GH to treat stiffness was performed most commonly between 1 and 4 months after RCR (60%), and patients who received GH saw statistically significant improvements in forward flexion, external rotation, and abduction after the procedure. Patients with hyperlipidemia had the most benefit after GH. Among those undergoing concomitant procedures, significantly more patients who had open subpectoral biceps tenodesis underwent GH. Patients who underwent subscapularis repair or concomitant subacromial decompression had significant improvement in ROM after GH. Only 1 patient who received GH underwent secondary surgery for resistant postoperative stiffness.

Conclusion:

Patients with diabetes had increased stiffness. Patients with a history of hyperlipidemia or concomitant open subpectoral biceps tenodesis were more likely to undergo GH for postoperative stiffness. Patients who underwent subscapularis repair demonstrated the most improvement in ROM after GH. After primary RCR, GH can increase ROM and is a useful adjunct for patients with stiffness to limit secondary surgery.

Evaluation of the tissue thickness of the supraspinatus and biceps long head tendons using ultrasound among elderly patients with unilateral adhesive capsulitis in the freezing phase

[Purpose] This study aimed to clarify the changes in the tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and evaluate the treatment effects in the freezing phase of adhesive capsulitis. [Participants and Methods] Thirty-two elderly patients with unilateral shoulder pain underwent ultrasound of the supraspinatus and biceps long-head tendons, pain evaluation, and orthopedic testing. Both the supraspinatus and biceps long-head tendons were classified as normal, abnormal, and other groups. Participants with negative orthopedic test results were assigned the “normal group”. Participants with positive orthopedic test results and resting and night pain were assigned the “abnormal group”. Differences in tissue thickness were calculated from the differences between the symptomatic and non-symptomatic sides. [Results] The thickness of the supraspinatus and biceps long-head tendons was significantly higher in the abnormal than in the normal group. [Conclusion] This study clarified the changes in tissue thickness of the abnormal supraspinatus and biceps long-head tendons among elderly patients to select the treatment targets and assess the treatment effects in the freezing phase of adhesive capsulitis. The study results suggest the usefulness of ultrasound for selecting the treatment targets for analgesia and assessing the treatment efficacy in cases of adhesive-capsulitis freezing phase.

Ultrasound Features of Adhesive Capsulitis

Introduction

Adhesive capsulitis (AC), which is characterised by shoulder pain and a limited range of motion (ROM), is usually diagnosed on the basis of clinical suspicion, with imaging only being used to exclude other causes of similar symptoms. The aim of this study was to identify and describe the typical ultrasound (US) features of AC in a group of patients with shoulder pain and stiffness.

Methods

This was a cross-sectional study of 1486 patients with AC in which two experienced US specialists examined the axillary pouch (AP), the coracohumeral ligament (CHL), the superior glenohumeral ligament (SGHL), and the long head of the biceps tendon (LHBT), and dynamically visualised the infraspinatus tendon during passive external rotation (PER) during a US evaluation of shoulder ROM.

Results

AC was confirmed in 106 patients (7.1%). Thickening of the AP of more than 4 mm was observed in 93.4% of the patients, whereas 6.6% showed AP thickening of less than 4 mm but more than 60% of the thickening in the contralateral shoulder. Effusion within the LHBT sheath was detected in 71% of the patients, and thickening of the CHL or SGHL in 88%. The dynamic study of the infraspinatus tendon showed reduced sliding with folding towards the joint capsule in 73% of cases, thus changing the tendon’s profile from flat to concave during PER. The reduced tendon sliding was associated with a bouncing movement that returned the tendon to its baseline resting position in 41.5% of cases.

Conclusions

We believe a sufficiently experienced US specialist can confirm a clinical diagnosis of AC by carrying out a comparative study of APs, evaluating the thickness of the CHL and SGHL, and detecting reduced sliding of the infraspinatus tendon.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00413-w.

Current updates in image-guided musculoskeletal interventions

Image-guided musculoskeletal interventions are frequently done in clinical practice. Even then, the literature regarding their effectiveness is relatively scarce. Image guidance adds value over the conventional landmark-based approach and should be preferred. We hereby try to list the commonly performed procedures along with the current practice guidelines regarding their clinical indications and periprocedural care.

MR Imaging Biomarkers for Clinical Impairment and Disease Progression in Patients with Shoulder Adhesive Capsulitis: A Prospective Study

BACKGROUND

MRI diagnostic criteria of shoulder adhesive capsulitis (AC) are nowadays widely used, but there is little information available on the association between MRI findings and clinical impairment.

PURPOSE

To determine the correlation of MRI findings with the Constant-Murley Score (CMS), pain duration and symptoms at the one-year follow-up in AC patients.

MATERIALS AND METHODS

This monocentric prospective study included 132 patients with a clinical diagnosis of shoulder AC who underwent shoulder MRI. Mean patient age was 54.1 ± 9.3 years, and there were 55 men and 77 women. A radiologist examined all patients and completed the CMS just prior to MRI. Pain duration was assessed along with the signal intensity and measured the maximal thickness of the inferior glenohumeral ligament (IGHL) by two radiologists. Medical record analysis was performed in a sub-group of 49 patients to assess prognosis approximately one year after the MRI examination. Linear regression analysis with the Pearson test and the Fisher exact test were used to determine the association between MRI findings and clinical impairment.

RESULTS

There was a significant difference in mean pain duration score (3.8 ± 1.2 versus 3.2 ± 0.9 and 3.8 ± 1.2 versus 3.2 ± 0.9, respectively, for readers 1 and 2) and in mean mobility scores (15.7 ± 8 points versus 19.6 ± 10.1 points and 15.8 ± 8.2 points versus 19.4 ± 10 points, respectively, for readers 1 and 2) in patients with a high IGHL signal compared to those with a low IGHL signal (p < 0.05). IGHL was thicker in patients with clinical improvement at one-year follow-up compared to those presenting clinical stability or worsening (p < 0.05).

CONCLUSIONS

In patients with shoulder AC, the degree of signal intensity at the IGHL was inversely related to shoulder pain duration and range of motion, and a thickened IGHL indicated a favorable outcome at one-year follow-up.

Comparison of ultrasound-guided platelet-rich plasma injection and conventional physical therapy for management of adhesive capsulitis: a randomized trial

OBJECTIVE

We evaluated the effect of ultrasound (US)-guided injection of platelet-rich plasma (PRP) into the shoulder joint in patients with adhesive capsulitis (AC) and compared its effect with that of conventional physiotherapy (CPT).

METHODS

Sixty-four subjects with AC were included and randomly allocated into two groups, as follows: PRP (n=32; intra-articular [IA] PRP [4 mL] was injected); and CPT (n=32; short wave diathermy and exercise therapy were performed at three sessions/week for 6 weeks). Treatment outcomes evaluated therapeutic effectiveness before and at 1, 3, and 6 weeks after PRP injection and CPT initiation.

RESULTS

Subjects in both groups showed a significant decrease in the visual analogue scale score for pain and shoulder and hand scores, and they a significant increase in shoulder passive range of motion at all evaluation time points. There was no significant difference in the measured outcomes between the two groups. However, there was less acetaminophen consumption after IA PRP injection compared with that after CPT.

CONCLUSIONS

IA PRP injection is a useful option for treating patients with AC, particularly those who have low therapeutic compliance for exercise therapy or have contraindications for corticosteroid injection or oral pain reduction medication.

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.

The presence of gastroesophageal reflux disease increases the risk of developing postoperative shoulder stiffness after arthroscopic rotator cuff repair

BACKGROUND

Postoperative shoulder stiffness (SS) after arthroscopic rotator cuff (RC) repair has been reported with a variable incidence, and numerous preoperative risk factors have been described. This prospective study aimed to document the incidence of postoperative SS and to evaluate the role of preoperative risk factors in the development of this complication, with a special focus on the role of gastroesophageal reflux disease (GERD).

METHODS

Preoperative risk factors for SS were prospectively evaluated in 237 consecutive patients undergoing arthroscopic single-row RC repair. The presence of GERD was evaluated with the GerdQ diagnostic tool. Postoperative SS was diagnosed according to the criteria described by Brislin et al in 2007.

RESULTS

The incidence of postoperative SS was 8.02%. The presence of GERD was significantly associated with the development of postoperative SS (odds ratio [OR], 5.265; 95% confidence interval [CI], 1.657-1.731; P = .005). Older age (OR, 0.896; 95% CI, 0.847-0.949; P < .001), male sex (OR, 0.126; 95% CI, 0.0252-0.632; P = .012), and number of pregnancies (OR, 0.47; 95% CI, 0.228-0.967; P = .040) emerged as protective factors.

CONCLUSIONS

The presence of GERD significantly influences the development of postoperative SS after arthroscopic single-row RC repair. An underlying aspecific proinflammatory condition, characterized by increased expression of tumor necrosis factor α and transforming growth factor β, and disorders in retinoid metabolism are hypotheses that could explain this previously unknown association. The documented incidence of postoperative SS falls within previously reported ranges, with women being significantly more affected than men.

Is adhesive capsulitis of the shoulder a form of complex regional pain syndrome type I?

[No Abstract Available].

Magnetic resonance imaging of the shoulder

The aim of this article is to review the use of magnetic resonance imaging (MRI) for the evaluation of shoulder pain, which is a common clinical complaint of the musculoskeletal system. MRI is an essential auxiliary tool to evaluate these patients because of its high resolution and high sensitivity in depicting the soft tissues. This article will review the imaging technique, normal imaging anatomy, and most common imaging findings of disorders of tendons, labrum, and ligaments of the shoulder. It will also discuss common systemic diseases that manifest in the shoulder as well as disorders of the acromioclavicular joint and bursae. New advances and research in MRI have provided additional potential uses for evaluating shoulder derangements.

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.

Ultrasound-Guided Percutaneous Tenotomy of the Long Head of Biceps Tendon in Patients with Symptomatic Complete Rotator Cuff Tear: In Vivo Non-contRolled Prospective Study

Background: We prospectively tested technical feasibility and clinical outcome of percutaneous ultrasound-guided tenotomy of long head of biceps tendon (LHBT). Methods: We included 11 patients (6 women; age: 73 ± 8.6 years) with symptomatic full-thickness rotator cuff tear and intact LHBT, in whom surgical repair was not possible/refused. After ultrasound-guided injection of local anesthetic, the LHBT was cut with a scalpel under continuous ultrasound monitoring until it became no longer visible. Pain was recorded before and at least six months after procedure. An eight-item questionnaire was administered to patients at follow-up. Results: A median of 4 tendon cuts were needed to ensure complete tenotomy. Mean procedure duration was 65 ± 5.7 s. Mean length of skin incision was 5.8 ± 0.6 mm. Pre-tenotomy VAS score was 8.2 ± 0.7, post-tenotomy VAS was 2.8 ± 0.6 (p < 0.001). At follow-up, 5/11 patients were very satisfied, 5/11 satisfied and 1/11 neutral. One patient experienced cramping and very minimal pain in the biceps. Six patients had still moderate shoulder pain, 1/11 minimal pain, 2/11 very minimal pain, while 2/11 had no pain. No patients had weakness in elbow flexion nor limits of daily activities due to LHBT. One patient showed Popeye deformity. All patients would undergo ultrasound-guided tenotomy again. Conclusion: ultrasound-guided percutaneous LHBT tenotomy is technically feasible and effective.

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.

Usefulness of intravenous contrast-enhanced MRI for diagnosis of adhesive capsulitis

OBJECTIVES

We aimed to compare the reliability and performance of MRI measures enhanced with intravenous (IV) injection of gadolinium contrast versus non-enhanced MRI measures for the diagnosis of adhesive capsulitis (AC). We also aimed to examine the association between MRI findings and clinical features in patients with AC.

METHODS

MRI of 42 patients with a clinical diagnosis of AC confirmed by arthrography and that of 42 patients in a control group were retrospectively studied by 2 blinded readers. Reliability and performance of MRI findings were compared between IV contrast-enhanced measures and non-enhanced MRI measures in T2-weighted fat-saturated and T1-weighted images. MRI findings were correlated with clinical stage, etiology, and pain.

RESULTS

Sensitivity (97.6%) and specificity (97.6%) of axillary-recess capsule signal enhancement for AC diagnosis were significantly superior (p = 0.02) to hyperintense signals on T2-weighted fat-suppressed images (sensitivity 90.5%, specificity 92.7%). Measures of the intensity signal in the area of the rotator interval were less performant for AC diagnosis but could be improved with joint capsule enhancement. Moreover, we found very high specificity (100%) of enhancement of the coracohumeral ligament signal for AC diagnosis. The early stage of adhesive capsulitis was positively correlated with joint capsule enhancement in the rotator interval. Secondary etiology of capsulitis was correlated with joint capsule hyperintensity signals of the rotator interval on T2-weighted fat-suppressed images.

CONCLUSION

IV contrast injection with MRI can be helpful for AC diagnosis in difficult cases. The stage of AC seems related to joint capsule enhancement in the rotator interval.

KEY POINTS

• IV gadolinium-enhanced MRI can improve the analysis of signal changes in the shoulder synovium and capsule of the shoulder that are related to adhesive capsulitis. • As an original finding, we observed that coracohumeral ligament enhancement had a 100% specificity for the diagnosis of adhesive capsulitis. • The intensity of enhanced signals in the rotator interval seems to be related to the early stage of frozen shoulder.

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.

Treatment of Adhesive Capsulitis of the Shoulder

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

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.

Routine X-rays for suspected frozen shoulder offer little over diagnosis based on history and clinical examination alone

INTRODUCTION

Frozen shoulder is a common condition, and current guidelines state that it is a diagnosis of exclusion. Along with a history and clinical examination, routine X-ray is mandated, to rule out any "masquerading" pathology such as fracture, dislocation, metastatic lesions or severe osteoarthritis. Despite the certainty of the guidelines there is a lack of evidence to support the use of routine X-rays in this situation.

METHODS

A retrospective review was performed of all X-rays obtained in the diagnosis of frozen shoulder between February 2014 and August 2017 in an integrated musculoskeletal interface service. Results were screened and the prevalence of masquerading pathology was determined.

RESULTS

A total of 350 shoulder X-rays that had been performed for patients with a provisional diagnosis of frozen shoulder were reviewed. Of these, 213 were from female patients (60.9%), the mean age was 57.7 (standard deviation 10.4) years and 342 (97.7%) did not have any concerning features. Six (1.7%) had severe osteoarthritis, one (0.3%) had a fracture and one (0.3%) had a lucency. All eight patients with masquerading pathology had findings from the history and clinical examination which would have warranted an X-ray, regardless of a differential diagnosis of frozen shoulder.

CONCLUSIONS

The findings of this retrospective review of a large number of X-rays do not support the requirement of a routine X-ray to rule out masquerading pathology to confirm the diagnosis. The data suggest that it is unnecessary for patients without a relevant clinical history suggestive of serious or masquerading pathology to undergo routine imaging.

Computed Tomography Arthrography Findings of Idiopathic Adhesive Capsulitis of the Hip: An Analog of Adhesive Capsulitis of the Shoulder

Objective

To identify useful imaging findings for the diagnosis of idiopathic adhesive capsulitis of the hip (ACH) on computed tomography arthrography (CTA).

Materials and Methods

Twenty-eight consecutive patients (29 hips; 7 males; mean age, 45.7 years; age range, 17–67 years) with ACH from October 2009 to March 2017 and 29 age- and sex-matched control patients from 2014 to 2016 were enrolled. All CTA images were evaluated by 2 radiologists independently for joint distensibility (anterior-posterior [AP] and superior-inferior [SI] joint cavity filling ratios), the presence of contrast filling around the ligamentum teres, and extracapsular contrast leakage. Fisher's exact test, Mann-Whitney U test, analysis of variance, and receiver operating characteristic curves were used for statistical analysis. P value less than 0.05 was considered to indicate statistical significance.

Results

The anterior joint cavity was significantly more obliterated in the ACH group (mean size, 3.7–4.0 mm) than in the control group (mean size, 4.8–5.0 mm; p < 0.05). The AP filling ratio was also significantly lower in the ACH group (0.6 vs. 1.1; p < 0.05) and decreased more as the ACH stage increased (mean anterior joint cavity size: 1.15 mm in stage 3 vs. 4.68 mm in stage 1; p < 0.05). Extracapsular contrast leakage was more common in the ACH group (27–28 vs. 20–21; p = 0.041 and 0.025, respectively).

Conclusion

On CTA, the anterior joint cavity may have earlier and more marked obliteration than joint cavities on other sides, and may be accompanied by extracapsular contrast leakage in ACH. These CTA findings may be helpful in the diagnosis of ACH.

Rotator cable and rotator interval: anatomy, biomechanics and clinical importance

The rotator cable and rotator interval are among the most recent topics of interest in current shoulder literature. Most of the research has been published in the last two decades and our understanding about the importance of these anatomical structures has improved with biomechanical studies, which changed the pre- and intra-operative approaches of shoulder surgeons to rotator cuff tears in symptomatic patients.

The rotator cable is a thick fibrous bundle that carries the applied forces to the rotator cuff like a ‘suspension bridge’. Tears including this weight-bearing bridge result in more symptoms. On the other hand, the rotator interval is more like a protective cover consisting of multiple layers of ligaments and the capsule rather than a single anatomical formation like the rotator cable.

Advances in our knowledge about the rotator interval demonstrate that even basic anatomical structures often have greater importance than we may have understood. Misdiagnosis of these two important structures may lead to persistent symptoms.

Furthermore, some distinct rotator cuff tear patterns can be associated with concomitant rotator interval injuries because of the anatomical proximity of these two anatomical regions. We summarize these two important structures from the aspect of anatomy, biomechanics, radiology and clinical importance in a review of the literature.

Cite this article: EFORT Open Rev 2019;4:56-62. DOI: 10.1302/2058-5241.4.170071.

Determination of magnetic resonance imaging criteria for diagnosis of adhesive capsulitis

The objective of this study was to identify optimal magnetic resonance imaging (MRI) parameters and their cutoff values for diagnosing adhesive capsulitis (AC). One hundred shoulder MRI images with stage 2 AC (AC group) and 100 MRI images without AC (control group) were randomly reviewed by two experienced shoulder specialists. They were asked whether MRI findings were compatible with AC and measurement of MRI parameters. Sensitivity, specificity, and accuracy were calculated. Correlation between MRI parameters and the range of motions was also analyzed. The mean capsular thickness in the axillary recess (AR) (5.9 mm in the AC group vs. 3.6 mm in the control group) on coronal oblique T2-weighted images and the rotator interval (RI) (7.2 mm vs. 4.8 mm, respectively) on oblique sagittal proton-density images were significantly greater in the AC group than in the control group, whereas the width of RI showed no significant difference between two groups. The highest diagnostic cutoff values were 4.5 mm for the AR and 6 mm for the RI, with sensitivity (91% and 88%, respectively), specificity (90% and 90%), and accuracy (90% and 89%). Capsular thickness in the AR and RI was significantly correlated with external rotation (P = 0.047) and internal rotation (P = 0.023). On conventional MRI, capsular thickness greater than 4.5 mm in the AR or 6 mm in the RI can be an optimal criterion for diagnosing AC. Capsular thickness in the AR and RI was correlated with the range of rotational motion.

Analytical Observational Study of Frozen Shoulder among Patients with Diabetes Mellitus

Purpose  This study aims to identify the prevalence of frozen shoulder (FS) among diabetic patients and its relation to demographic features.

Methods  This observational study of 216 patients randomly included those with diabetes mellitus (DM) attending the Misan Rheumatology and Medical Rehabilitation Department at Al-Sadder Teaching Hospital in Misan Province of Iraq and was conducted during the period from April 2014 to March 2015. Detailed medical histories were taken from patients and scratch test and hemoglobin A _1C were used in diagnostic procedure to confirm diagnosis of FS and DM, respectively.

Results  The occurrence rate of FS was 11.5% among patients, with a higher prevalence in females versus males. The most commonly afflicted age group was 60 to 70 years old at 33.3%. Dominant shoulder was more commonly affected than nondominant one. DM presented in large number of patients with FS with a prevalence of 90.3% of cases. The onset of FS in patients with DM was most common within the chronic phase of the disease at 32.3 and 33.8% for durations of 1 to 5 and 5 to 10 years, respectively.

Conclusion  There is a strong association between DM and FS. Females were more commonly affected than males. Aging increased shoulder disorder distribution with dominant side being mostly affected. Chronic and noncontrolling diabetic patients were more commonly affected.

Level of Evidence  This is a Level III, analytical, observational study.

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.

Efficacy of the Rotational Traction Method in the Assessment of Glenohumeral Cartilage Surface Area in Computed Tomography Arthrography

OBJECTIVE

We aimed to investigate the efficacy of the rotational traction method in expanding the joint space and enabling the assessment of an extended surface area.

METHODS

Sixty patients who underwent computed tomography arthrography were evaluated in the study: 30 with and 30 without the help of rotational traction. The subgroups consisted of patients with adhesive capsulitis, habitual luxation, or labral tears. Areas of obscured joint surface by coalescent cartilages were calculated using computer software, and those belonging to the traction and nontraction groups along with subgroups were compared statistically.

RESULTS

There was a significant difference between the traction and nontraction group regarding the contact surface area (P < 0.001 for both observers). In patients with adhesive capsulitis, the contact surface area was larger compared with the other subgroups (P = 0.002 for observer 1 and P = 0.002 for observer 2). In patients with habitual luxation, the contact surface area was smaller compared with the other subgroups (P = 0.002 for observer 1 and P = 0.001 for observer 2).

CONCLUSIONS

Expansion of joint distance is important for assessing the joint cartilage. The rotational traction method provides effective separation of the joint space. For this reason, rotational traction can be used effectively in patients in whom the joint cartilage is to be evaluated.

Calcaneal fractures: radiological and CT evaluation and classification systems

Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. Methods: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described. Case reports have not been included. Results: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. Conclusions: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes. (www.actabiomedica.it)

Imaging of metabolic bone disease

Osteoporosis is the most important metabolic bone disease, with a wide distribution among the elderly. It is characterized by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk. Identify bone weakening with an appropriate and accurate use of diagnostic imaging is of critical importance in the diagnosis and follow-up of osteoporotic patients. The aim of this review is to evaluate the detection rates of the different imaging modalities in the evaluation of bone strength, in the assessment of fracture risk and in the management of fragility fractures. (www.actabiomedica.it)

Acute and overuse elbow trauma: radio-orthopaedics overview

The correct management of acute, subacute and overuse-related elbow pathologies represents a challenging diagnostic and therapeutic problem. While major trauma frequently requires a rapid surgical intervention, subluxation and minor trauma allow taking more time for diagnostics and planning the correct elective treatment after careful clinical and radiological investigation. In these conditions, communication between orthopaedic surgeon and radiologist allow to create a detailed radiology report, tailored to the patient's and surgeon's needs and optimal to plan proper management. Imaging technique as X-Ray, CT, US, MRI, CTA and MRA all belong to the radiologist's portfolio in elbow diagnostics. Detailed knowledge of elbow pathology and its classification and of the possibilities and limits of each imaging technique is of crucial importance to reach the correct diagnosis efficiently. The aim of this review is to present the most frequent elbow pathologies and suggest a suitable diagnostic approach for each of them.

Traumatic fractures in adults: missed diagnosis on plain radiographs in the Emergency Department

Radiography remains the imaging standard for fracture detection after trauma. The radiographic diagnosis of most fractures and dislocations poses little difficulty to radiologists: however, occasionally these injuries are quite subtle or even impossible to detect on radiographs. Missed diagnoses of fracture potentially have important consequences for patients, clinicians, and radiologists. Radiologists play a pivot role in the diagnostic assessment of the trauma patients: emergency radiologists who are more practiced at seeking out and discerning traumatic fractures can provide an invaluable service to their clinical colleagues by ensuring that patients do not endure delayed diagnoses. This is a narrative review article aims to highlight the spectrum of fractures in adults potentially missed on plain radiographs, the causes of error in diagnosis of fractures in the emergency setting and the key elements to reduce misdiagnosis of fractures.

Dynamic MRI in the evaluation of the spine: state of the art

INTRODUCTION

Degenerative disease of the spine is a generic term encompassing a wide range of different disease processes, which leads to spinal instability; traumatic/neoplastic events can accelerate this aging process. Therefore, the dynamic nature of the spine and its mobility across multiple segments is difficult to depict with any single imaging modality.

METHODS

A review of PubMed databases for articles published about kMRI in patients with cervical and lumbar spinal desease was performed. We focused on the physiopathological changes in the transition from supine to upright position in spine instability.

DISCUSSION

Until a few years ago, X-ray was the only imaging modality for the spine in the upright position. Of the imaging techniques currently available, MRI provides the greatest range of information and the most accurate delineation of soft-tissue and osseous structures. Conventional MRI examinations of the spine usually are performed in supine position, in functional rest, but the lumbar spine instability is often shown only by upright standing. This can result in negative findings, even in the presence of symptoms. Regardless, the final result is distorted. To overcome this limitation, Kinetic MRI (kMRI) can image patients in a weight-bearing position and in flexed and extended positions, thus revealing abnormalities that are missed by traditional MRI studies.

CONCLUSION

Despite some limitations, the upright MRI can be a complementary investigation to the traditional methods when there are negative results in conventional MRI in symptomatic patients or when surgical therapy is scheduled.

Clinical and instrumental assessment of herniated discs after nucleoplasty: a preliminary study

BACKGROUND AND AIM

The therapy for low back pain boasts different approaches; one of these is nucleoplasty. We wanted to assess the effectiveness of nucleoplasty both by clinical response both by MR imaging evaluation, including even extrusions larger than one third of the spinal canal.

METHODS

Fifty-seven patients were treated with nucleoplasty in our hospital, 11 of these patients accepted both clinical and MRI evaluation after six months from treatment. The clinical evaluation was performed with Visual Analogue Scale (VAS) of pain, scored before and after the procedure. MRI evaluation consisted of analysing some imaging parameters of disc protrusions before and after the treatment.

RESULTS

In 10 out of 11 (91%) patients, VAS was reduced and only 1 out of 11 (9%) had the same pain after procedure. The mean of decrease of VAS score was 64%. In our population 8/11 (72%) patients had a herniation larger than 1/3 of the sagittal diameter of spinal canal and 100% of them had an improvement with a mean VAS reduction value of 75%. With MRI evaluation, the mean percentage of expulsion before and after treatment was respectively 40% and 34%. The expulsion decreased in 7/13 discs, remained equal in 4/13, and increased in 2/13 discs. Among the 9 larger protrusions, 3 didn't change, 6 reduced with a decrease mean value of 13%. Other MRI parameters didn't change significantly.

CONCLUSIONS

Our preliminary experience supports the success of coblation on pain relief, aiming to show progressively that this treatment is suitable even in case of great extrusions, which are generally treated only with surgical approach. It's not clear the usefulness of MRI control yet, even if in most of cases we could have found a certain reduction of expulsion degree.

Scapular fractures: a common diagnostic pitfall

Scapular fractures are one of the most difficult fractures to diagnose on radiographs. Detection can be challenging because of the obscuration by the overlying structures or incomplete imaging due to difficult patient collaboration. Familiarity with imaging characteristics of these abnormalities will allow radiologists to better diagnose and characterize scapular fractures. Three-dimensional computed tomographic scans are considered the gold standard for scapular diagnoses. Treatment strategies differ depending on the type of scapular fractures, but the site and degree of displacement will determine whether surgical intervention should be considered. Complications can occur in fractures that are undiagnosed or improperly evaluated. The purpose of this article is to describe imaging features of traumatic scapular injury, and discuss the role of diagnostic imaging in clinical decision making after shoulder trauma. (www.actabiomedica.it)