Frozen Shoulder: MR Arthrographic Findings

Additional Effect of Extracorporeal Shockwave Therapy with Lidocaine Injection on Clinical and MRI Findings in Frozen Shoulder: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial

INTRODUCTION

Frozen shoulder is a very common musculoskeletal condition and the evidence related to the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in individuals with frozen shoulder is rare. Therefore, this study aims to compare and investigate the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in a frozen shoulder.

METHODS

Sixty eligible participants with frozen shoulder were included and the active group (n = 30, age 52.12 ± 5.2 years) received a lidocaine injection (1% lidocaine (Xylocaine) and 2cc (80 mg) methylprednisolone acetate) with active ESWT (3.5 bar air pressure and 2000 pulses with an energy flux density (EFD) ¼ 0.16 mJ/mm2) three sessions a week for 4 weeks. The placebo group (n = 30, age 53.56 ± 5.5 years) received lidocaine injection with placebo treatment (a special head that blocked the shock waves) three sessions a week for 4 weeks. Both groups received progressive resistance exercises (PRE) to the shoulder muscles. The primary outcome was pain intensity, measured with the visual analogue scale. The other outcome measures were the thickness of the coracohumeral ligament (CHL) measured by magnetic resonance imaging (MRI), abduction, and lateral rotation range of motion (ROM), functional disability, kinesiophobia, depression status, and quality of life. Participants were assessed at baseline, after 4 weeks, 8 weeks, and at 6-month follow-up.

RESULTS

The post-intervention at 4 weeks showed an improvement of 2.0 (CI 95% 1.71-2.28) in the active group compared to the placebo group. Similar effects were noted after 8 weeks (2.2) (CI 95% 1.91-2.48) and at the 6-month (1.9) (CI 95% 1.61-2.18) follow-up. Similar improvements were also found in the thickness of the CHL ligament (0.6) (CI 95% 0.46-0.73), abduction and lateral rotation (ROM) (- 23.6) (CI 95% - 27.47 to -19.72), (- 18.10) (CI 95% - 19.72 to - 16.47), functional disability (16.2) (CI 95% 14.85-17.54), kinesiophobia (11.0 (CI 95% 10.21-11.98), depression status (4.4) (CI 95% 4.03-4.76) and quality of life (0.9) (CI 95% 0.79-1.00) (p = 0.001) at the 6-month follow-up period, where mean estimates and their confidence intervals all included worthwhile effects. There were no adverse reactions or side effects noted in either the active or placebo groups during and after the treatment.

CONCLUSIONS

The study concluded that the addition of extracorporeal shockwave therapy after intra-articular lidocaine injection improves pain, functional disability, range of motion, kinesiophobia, depression status, and quality of life in people with frozen shoulder.

TRIAL REGISTRATION

https://ctri.nic.in , identifier; CTRI/2020/04/024834 prospectively registered on 24/04/2020.

Diagnostic accuracy of non-contrast MRI in frozen shoulder

INTRODUCTION

Despite being the most used exam today, few studies have evaluated the accuracy of findings on non-contrast magnetic resonance imaging (MRI). The primary objective of the study was to evaluate the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of non-contrast MRI findings in frozen shoulder, isolated and in combination. The secondary objectives were to define the interobserver and intraobserver agreement of the assessments and the odds ratio for frozen shoulder because of the various findings of MRI.

METHODS

A retrospective diagnostic accuracy study comparing non-contrast MRI findings between the frozen shoulder group and the control group. Sensitivity, specificity, positive and negative predictive value, accuracy, odds ratio, interobserver and intraobserver agreement were calculated for each finding and their possible associations.

RESULTS

The hyperintensity on capsule in the axillary recess presented 84% sensitivity, 94% specificity, and 89% accuracy. The obliteration of the subcoracoid fat triangle in the rotator interval had sensitivity 34%, specificity 82% and accuracy 58%. For coracohumeral ligament thickness ≥ 2 mm had specificity 66%, 48% specificity and 57% accuracy. Capsule thickness in the axillary recess ≥ 4 mm resulted in 54% sensitivity, 82% specificity, and 68% accuracy. Regarding interobserver agreement, only the posteroinferior and posterosuperior quadrants showed moderate results, and all the others showed strong reliability. The odds ratio for hyperintensity in the axillary recess was 82.3 for frozen shoulder. The association of these findings increased specificity (95%).

CONCLUSION

The accuracy of non-contrast magnetic resonance imaging is high for diagnosing frozen shoulder, especially when evaluating the hyperintensity of the axillary recess. The exam has high reliability and reproducibility. The presence of an association of signs increases the specificity of the test.

LEVEL OF EVIDENCE

Level III, study of diagnostic test.

Diagnostic performance and interreader agreement of individual and combined non-enhanced and contrast-enhanced MR imaging parameters in adhesive capsulitis of the shoulder

OBJECTIVE

The aims of our study were to analyze agreement among readers with different levels of expertise and diagnostic performance of individual and combined imaging signs for the diagnosis of adhesive capsulitis of the shoulder.

METHODS

In a retrospective study, contrast-enhanced shoulder MRIs of 60 patients with and 120 without clinically diagnosed adhesive capsulitis were evaluated by three readers independently. As non-enhanced imaging signs, readers evaluated signal intensity and thickness of the axillary recess capsule, thickness of the rotator interval capsule and the coracohumeral ligament as well as obliteration of subcoracoid fat. Furthermore, contrast enhancement of axillary recess and rotator interval capsule were evaluated. Data analysis included interreader reliability, ROC analysis, and logistic regression (p < 0.05).

RESULTS

Contrast-enhanced parameters showed substantially higher agreement among readers (ICC 0.79-0.80) than non-enhanced parameters (0.37-0.45). AUCs of contrast-enhanced signs (95.1-96.6%) were significantly higher (p < 0.01) than of non-enhanced imaging signs (61.5-85.9%) when considered individually. Combined evaluation of axillary recess signal intensity and thicknesses of axillary recess or rotator interval-when at least one of two signs was rated positive-increased accuracy compared to individual imaging signs, however not statistically significant.

CONCLUSION

Contrast-enhanced imaging signs show both distinctly higher agreement among readers and distinctly higher diagnostic performance compared to non-enhanced imaging signs based on the imaging protocol used in this study. Combined evaluation of parameters showed a tendency to increase discrimination; however, the effect on diagnosis of ACS was not statistically significant.

[Adhesive capsulitis]

BACKGROUND

Adhesive capsulitis (CA; also called Frozen shoulder) is a common, usually unilateral disease of the shoulder joint primarily affecting middle-aged women. Primary, idiopathic, and secondary forms are distinguished. Painful active and passive movement restriction are the clinically leading symptoms.

COURSE OF THE DISEASE

The disease usually progresses in three successive stages: freezing phase, frozen phase, and thawing phase.

CLINICAL DIAGNOSIS AND IMAGING

CA is primarily diagnosed clinically, with imaging being used to assess or exclude differential diagnoses. Radiography as part of basic diagnostics allows exclusion of common differential diagnoses such as osteoarthritis of the shoulder or calcific tendinitis. Native magnetic resonance imaging (MRI) and MR arthrography (MRA) reveal pathomorphologies typical of CA. Intravenously administered gadolinium increases the sensitivity of MRI. Sonography may be used as a complementary diagnostic modality or as an alternative in case of contraindications to MRI. Fluoroscopy-guided arthrography has been replaced by MRI because of its invasiveness. Computed tomography (CT) has no role in diagnostics due to its radiation exposure and significantly lower sensitivity and specificity compared to MRI.

TREATMENT

Therapy of CA is stage-adapted and includes conservative measures such as analgesics and physiotherapy and surgical procedures such as arthroscopic arthrolysis. The therapeutic spectrum is supplemented by new, innovative procedures such as transarterial periarticular embolization.

PROGNOSIS

CA is self-limiting and usually persists for 2-3 years. However, the patients may even suffer from pain and limited range of motion beyond this time.

SSR white paper: guidelines for utilization and performance of direct MR arthrography

OBJECTIVE

Direct magnetic resonance arthrography (dMRA) is often considered the most accurate imaging modality for the evaluation of intra-articular structures, but utilization and performance vary widely without consensus. The purpose of this white paper is to develop consensus recommendations on behalf of the Society of Skeletal Radiology (SSR) based on published literature and expert opinion.

MATERIALS AND METHODS

The Standards and Guidelines Committee of the SSR identified guidelines for utilization and performance of dMRA as an important topic for study and invited all SSR members with expertise and interest to volunteer for the white paper panel. This panel was tasked with determining an outline, reviewing the relevant literature, preparing a written document summarizing the issues and controversies, and providing recommendations.

RESULTS

Twelve SSR members with expertise in dMRA formed the ad hoc white paper authorship committee. The published literature on dMRA was reviewed and summarized, focusing on clinical indications, technical considerations, safety, imaging protocols, complications, controversies, and gaps in knowledge. Recommendations for the utilization and performance of dMRA in the shoulder, elbow, wrist, hip, knee, and ankle/foot regions were developed in group consensus.

CONCLUSION

Although direct MR arthrography has been previously used for a wide variety of clinical indications, the authorship panel recommends more selective application of this minimally invasive procedure. At present, direct MR arthrography remains an important procedure in the armamentarium of the musculoskeletal radiologist and is especially valuable when conventional MRI is indeterminant or results are discrepant with clinical evaluation.

Posterior capsule edema in adhesive capsulitis: comparison with established non-contrast MRI findings and multivariable analysis

OBJECTIVES

To evaluate posterior glenohumeral capsule edema compared to other MRI findings in adhesive capsulitis (AC).

METHODS

This study was approved by the local Institutional Review Board and it is HIPAA compliant. A retrospective search identified subjects who received fluoroscopically guided intra-articular corticosteroid injections for AC and had an MRI within 6 months prior to injection. The study group was compared with an age-, sex-, and side-matched control group who underwent the same procedures but did not have AC. MRIs were evaluated for edema of posterior capsule, anterior capsule, axillary pouch, coracohumeral ligament (CHL) and rotator interval (RI), thickness of axillary pouch and CHL, thickness of anterior capsule, RI and subcoracoid fat replacement, and teres minor atrophy and edema. Multivariable analysis was performed.

RESULTS

A total of 57 subjects with AC and 57 matched controls were studied: mean age 52 ± 7 (range 31-71) years, 37 female and 20 male, 22 right and 35 left. Posterior capsule edema was more common in the AC group vs. control group (66.7 vs 17.5%, p < 0.001). Multivariable analysis showed posterior capsule edema, CHL edema, and axillary pouch (glenoid) thickness (optimum cutoff = 4 mm) were significant independent predictors of AC. Simplified analysis using these three variables had an area under the curve of 0.860 (95%CI: 0.792-0.928). With all three variables present, the sensitivity and specificity for AC were 32% and 98%, respectively.

CONCLUSIONS

Posterior joint capsule edema may be helpful to confirm AC. Posterior capsule edema, CHL edema, and axillary pouch (glenoid) thickness produce a strong model for distinguishing AC from controls.

CLINICAL RELEVANCE STATEMENT

Edema involving the posterior shoulder joint capsule is an imaging marker of capsulitis and is useful in differentiating patients with adhesive capsulitis from those without in conjunction with other proven MRI findings.

KEY POINTS

• Posterior capsule edema has a sensitivity of 66.7% and a specificity of 82.5% for the detection of adhesive capsulitis. • Posterior capsule edema, coracohumeral ligament (CHL) edema, and axillary pouch (glenoid) thickness were significant independent predictors of adhesive capsulitis, and combining these variables together produces a very strong model for distinguishing cases from controls (AUC = 0.860). • Optimal cutoff values for CHL, axillary pouch (humeral), axillary pouch (glenoid), and axillary pouch (total) thickness were 2.5, 2.6, 4, and 6.3 mm, respectively.

Recurrence of the frozen shoulder after hydrodilatation, what is the true incidence?

Purpose of the study

To assess the outcome and recurrence rates of frozen shoulder treated by hydrodilatation in an independent hospital setting.

Method

Patients presenting to a shoulder clinic from August 2019 to July 2021 with a diagnosis of frozen shoulder were offered hydrodilatation. Data included primary or secondary frozen shoulder, length of symptoms, and diabetic status. An Oxford Shoulder Score was completed prior to hydrodilatation. Using ultrasound guidance, 40 mg Triamcinolone and local anaesthetic (10-25 mL depending on patient tolerance) were injected into the rotator interval. At a mean of 9 months, patients recorded their tolerance of the procedure, subsequent progress, the need for further treatment, and their current Oxford Shoulder Score.

Results

From 55 shoulders, six patients had a failure to improve and 10 patients had a transient improvement followed by recurrence (29%). 2/21 (9.5%) patients had 25 mL injected compared to 14/34 (41%) who had < = 20 mL (p = 0.012). 14/43 (33%) of primary frozen shoulder patients had a recurrence, compared with 2/12 (16%) secondary frozen shoulder patients, p = 0.019.

Conclusion

Further treatment was indicated in 14/34 (41%) of patients who underwent hydrodilatation in the frozen stage of frozen shoulder and could not tolerate more than 20 mL of injection, and was more commonly required in primary (33%) versus secondary (16%) frozen shoulder.

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.

The incidence of adhesive capsulitis and COVID-19 pandemic effect

Background

There are multiple pieces of evidence in the literature that coronavirus disease 2019 (COVID-19) has a pronounced effect on physiological health. There is little existing literature that has studied the pandemic's impact on adhesive capsulitis (AC) incidence. This study aimed to compare the incidence of primary AC before and during the pandemic.

Methods

A retrospective cohort study was done to establish the incidence of primary AC during the COVID-19 pandemic, from March 2020 to March 2021, the pandemic period, and from March 2019 to March 2020, the control period. During these periods, all patients diagnosed with primary AC were included. Patients were also categorized into three different treatment groups according to corticosteroid injection status (none, 1 injection, and 2 injections). The waiting time for the appointment was calculated as a possible confounding factor. Statistical analysis used the chi-square for categorical variables and the Student t test for continuous variables.

Results

There were 69 patients diagnosed with primary AC out of 704 new referrals during the pandemic. One year earlier, a total of 73 patients were diagnosed with primary AC out of 1148 new referrals. Representing a relative increase of 3.5% (P = .086) in the incidence of primary AC. No significant differences were found between the control and the pandemic groups in regard to the distribution of patients per treatment group (P = .13), age (P = .49), sex (P = .21), laterality (P = .54), diabetic disease (P = .45), and thyroid disease (P = .62).

Conclusion

There was a nonstatistically significant increase in the incidence of primary AC during the COVID-19 pandemic. No other significant differences were found. Further research is still needed to evaluate the relationship between the COVID-19 pandemic and AC.

The S2e Guideline on Shoulder Stiffness

The clinical picture of "frozen shoulder" is still poorly understood. In order to present the current state of knowledge on aetiology, diagnosis, and treatment, and to provide recommendations for the professional groups involved, a working group was formed by the DGOU and the DVSE to create a German language, evidence-based guideline, which was published in 2022 by the AWMF. The following summarises the development and the most important results.

What is the most predictive magnetic resonance imaging finding of rotator cuff tear concomitant with shoulder stiffness?

Background

Common magnetic resonance imaging (MRI) findings in adhesive capsulitis are not often evident in rotator cuff tear concomitant with shoulder stiffness. This study aimed to determine the most predictive MRI finding of rotator cuff tear with shoulder stiffness to differentiate from that without stiffness.

Materials and methods

The data of patients who underwent arthroscopic rotator cuff repair between January 2014 and October 2019 were retrospectively reviewed. Stiffness was defined as forward flexion <120°, external rotation at side <30°, and internal rotation at back 

Results

Anterior capsular thickness, glenoid capsular thickness in the axillary recess, and anterior and axillary capsular hyperintensities were significantly more dominant in the stiff group (all P < .05) than in the control group. Anterior capsular thickness and anterior capsular abnormal hyperintensity could be used to differentiate between the stiff and control groups (P < .05). Anterior capsular thickness showed high diagnostic performance with an area under the receiver operating characteristic curve of 0.993. The cut-off value for stiffness was 3.07 mm (sensitivity, 96.1%; specificity, 100%).

Conclusion

Anterior capsular thickening and abnormal hyperintensity were the most predictive MRI findings for stiffness in patients with rotator cuff tear and stiffness to differentiate from patients with rotator cuff tear without stiffness.

Collapse

Key Words

• Adhesive capsulitis
• Anterior capsular abnormal hyperintensity
• Anterior capsular thickness
• Magnetic resonance imaging
• Rotator cuff tear
• Stiff shoulder

Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Ji Young Yoon Department of Orthopaedic Surgery, National Police Hospital, Seoul, Republic of Korea
HeeSoo Han Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
Myoung Yeol Shin Department of Orthopaedic Surgery, National Police Hospital, Seoul, Republic of Korea
Hyeon Jang Jeong Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
Yusuhn Kang Department of Radiology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
Young Dae Jeon Department of Orthopaedic Surgery, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
Ji Un Kim Department of Orthopaedic Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
Joo Han Oh Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea

Collapse

A Modified Arthroscopic Outside-in Shoulder Release Approach for Severe Shoulder Stiffness

OBJECTIVE

Arthroscopic release is effective for patients with shoulder stiffness, but the traditional inside-out procedure cannot effectively alleviate the mobility of some severe stiff shoulder and even cause itrogenic injuries sometimes. The aim of this study is to evaluate the clinical efficacy and advantages of a modified outside-in shoulder release approach for severe shoulder stiffness.

METHODS

Included in this retrospective study were 15 patients (five male and 10 female) with severe shoulder stiffness who underwent modified outside-in shoulder release surgery at our hospital between June 2019 and March 2021. Of them, 10 patients had a primary frozen shoulder and five had secondary shoulder stiffness, involving the right shoulder in six cases and the left shoulder in nine cases. The mean age of the 15 patients was 56.7 (34-69) years. The patients were instructed to exercise passively from second-day post-operation and enhance the rehabilitation exercise gradually. All patients received a range of motion (ROM) examination before and after surgery. The American Shoulder and Elbow Surgeon's Score (ASES), Constant Score (CS), and Visual Analog Scale (VAS) score for pain were recorded. All data were tested by normal distribution first and then by paired T test, otherwise by Wilcoxon rank sum test.

RESULTS

The mean follow-up period was 18.2 (12-33) months. Compared with the preoperative value, the mean ASES score at the final follow-up improved from 38.4 ± 7.37 to 88.13 ± 6.33 points; the mean CS score from 43.27 ± 6.71 to 78.74 ± 6.93 points; the mean VAS score from 5.07 ± 1.03 to 0.81 ± 0.83 points; forward flexion from 81.93° ± 11.45° to 156.73° ± 9.12°; abduction from 65.93° ± 16.82° to 144.80° ± 8.83°; neutral external rotation from 13.53° ± 10.38° to 51.20° ± 4.77°; internal rotation from the buttock to waist (L3), all showing a significant difference (P < 0.0001). No serious complication was observed in any patient during the postoperative follow-up periods.

CONCLUSION

The present study has demonstrated that the modified arthroscopic outside-in shoulder release approach can improve ROM of patients and alleviate pain effectively, proving it to be an appropriate surgical option for the treatment of severe shoulder stiffness.

Vitamin C as a Potential Prophylactic Measure Against Frozen Shoulder in an In Vivo Shoulder Contracture Animal Model

BACKGROUND

Frozen shoulder is a common, painful, and movement-restricting condition. Although primary frozen shoulder is idiopathic, secondary frozen shoulder can occur after trauma or surgery. Prophylactic and therapeutic options are often unsatisfactory. Vitamin C (ascorbic acid) is a potent physiological antioxidant and likely inhibits the activation of nuclear factor κB, which plays a decisive role in inflammatory reactions.

HYPOTHESIS

Because of its anti-inflammatory effects, vitamin C may be valuable in the prevention of secondary frozen shoulder.

STUDY DESIGN

Controlled laboratory study.

METHODS

An in vivo shoulder contracture model was conducted by fixation of the right proximal limb of Sprague-Dawley rats. A treatment group (n = 8) receiving vitamin C orally was compared with a control group (n = 9) without vitamin C. The primary outcome was capsular thickness at the shoulder joint measured on magnetic resonance imaging (MRI) examination. Further histological examination was performed but was not statistically analyzed because of variability of the cutting plane through the glenoid.

RESULTS

Vitamin C treatment resulted in less thickening of the axillary fold of the operated shoulder at 2 of the 3 locations measured on MRI compared with untreated controls (insertion to the glenoid, P = .074; insertion to the humerus, P = .006; middle of the axillary recess, P = .008). The observed structural changes in histological examination corroborated the significant changes obtained from the MRI measurements.

CONCLUSION

Prophylactic vitamin C seemed to reduce the thickening of the axillary recess in secondary frozen shoulder in this preclinical study.

CLINICAL RELEVANCE

Vitamin C may be helpful as a noninvasive therapeutic measure to prevent secondary frozen shoulder (eg, within the context of surgery in the shoulder region or immobilization) or to treat primary frozen shoulder at an early stage. Further studies are required to evaluate the effect of this treatment in humans and the necessary dosage in humans.

Preemptive middle glenohumeral ligament release in arthroscopic rotator cuff repair does not reduce the postoperative stiffness: a retrospective comparative study

BACKGROUND

This study aimed to evaluate the efficacy of preemptive middle glenohumeral ligament (MGHL) release in arthroscopic rotator cuff repair (ARCR) to reduce postoperative stiffness.

METHODS

Patients who underwent ARCR were enrolled and allocated into two groups retrospectively: the preemptive MGHL release group (n = 44) and the preemptive MGHL non-release group (n = 42). Clinical outcomes were assessed and compared between the two groups, including the range of motion, Japanese Orthopedic Association Shoulder Score, Constant Shoulder Score, and the University of California, Los Angeles Score preoperatively and 3 months, 6 months, and 12 months postoperatively and complications. The integrity of the repaired tendon was assessed at the 12-month follow-up using magnetic resonance imaging.

RESULTS

There were no significant differences between the groups in all range of motion and all functional scores at any of the assessed time points. There was also no significant difference in the healing failure rate 2.3% in the preemptive MGHL group and 2.4% in the preemptive MGHL non-release group (p = .97), and postoperative stiffness was 2.3% in the preemptive MGHL group and 7.1% in the preemptive MGHL non-release group (p = .28). There was no postoperative instability in both group.

CONCLUSION

ARCR effectively facilitates the recovery of range of motion and function in patients with a rotator cuff tear. However, preemptive MGHL release could not be an effective method to reduce postoperative stiffness.

Imaging for patients presenting with a painful shoulder

Shoulder pain is a common cause of musculoskeletal presentation in primary care, where both traumatic and atraumatic pathologies can also lead to emergency department attendances. This article discusses common acute and chronic presentations of a painful shoulder, looking at the typical history of patients presenting with a painful shoulder, examination findings and the most appropriate imaging modalities to consider. Strengths and weaknesses of each imaging modality are discussed along with their role in aiding diagnosis, as well as management of the various pathologies encountered in primary and secondary care.

ACR Appropriateness Criteria® Chronic Shoulder Pain: 2022 Update

Chronic shoulder pain is an extremely common presenting complaint. Potential pain generators include the rotator cuff tendons, biceps tendon, labrum, glenohumeral articular cartilage, acromioclavicular joint, bones, suprascapular and axillary nerves, and the joint capsule/synovium. Radiographs are typically the initial imaging study obtained in patients with chronic shoulder pain. Further imaging may often be required, with modality chosen based on patient symptoms and physical examination findings, which may lead the clinician to suspect a specific pain generator. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Influence of joint volume on range of motion after arthroscopic rotator cuff repair

BACKGROUND

Capsular contracture is a well-known etiology in the primary stiff shoulder; thus capsular contracture and resultant decreased joint volume could lead to postoperative stiffness, which is a commonly reported morbidity after arthroscopic rotator cuff repair (ARCR). The purpose of this study was (1) to quantify the joint volume (total joint volume and each quadrant compartmental volume) using computed tomography arthrography (CTA) and (2) to demonstrate the relationship between joint volume and postoperative range of motion (ROM) after ARCR.

MATERIALS AND METHODS

Eighty-three patients (60 ± 5.11 years, men = 26, women = 57) who had undergone ARCR between January 2015 to December 2020 due to small to medium full-thickness tear and followed by CTA 6 months postoperatively were retrospectively reviewed. An image reconstruction program (3D Slicer, version 4.11.2 software) was used to calculate the joint volume (total joint volume and quadrant compartment joint volumes; anteroinferior, anterosuperior, posterosuperior and posteroinferior). For shoulder ROM, data including scaption (Sc), external rotation on side (ERs), external rotation at 90° (ER90), and internal rotation on back (IRb) were collected 6 months postoperatively. An evaluation of the correlation between joint volume and each shoulder motion was performed.

RESULTS

There were moderate correlations between the total joint volume and each motion (Sc: Pearson coefficient, 0.32, p = 0.0047; ERs: Pearson coefficient, 0.24, p = 0.0296; ER90: Pearson coefficient, 0.33, p = 0.0023; IRb: Pearson coefficient, 0.23, p = 0.0336). Among the quadrant compartments, the anteroinferior (Sc: Pearson coefficient, 0.26, p = 0.0199; ERs: Pearson coefficient, 0.23, p = 0.0336; ER90: Pearson coefficient, 0.25, p = 0.0246; IRb: Pearson coefficient, 0.26, p = 0.0168) and posterosuperior (Sc: Pearson coefficient, 0.24, p = 0.029; ER90: Pearson coefficient, 0.29, p = 0.008; IRb: Pearson coefficient, 0.22, p = 0.0491) and posteroinferior (Sc: Pearson coefficient, 0.30, p = 0.0064; ER90: Pearson coefficient, 0.29, p = 0.0072) showed moderate correlations with each shoulder motion.

CONCLUSION

Total joint volume, anteroinferior compartment joint volume, posterosuperior compartment joint volume and posteroinferior compartment joint volume were related to postoperative ROM after ARCR. Perioperative methods to increase the joint volume, especially the anteroinferior, posterosuperior and posteroinferior parts of the capsule may prevent postoperative stiffness after ARCR.

LEVEL OF EVIDENCE

Level III; Retrospective Case-Control Study.

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.

Effectiveness of ultrasound-guided fascia hydrorelease on the coracohumeral ligament in patients with global limitation of the shoulder range of motion: a pilot study

We conducted a prospective single-arm interventional study of the treatment efficacy of ultrasound-guided fascia hydrorelease (US-FHR) on the coracohumeral ligament (CHL) of patients with global limitation of shoulder range of motion (ROM) without local inflammation. The primary outcome was the change in passive ROM (pROM) of external rotation (ER) after first US-FHR. Secondary outcomes included the change in pROM of other directions from baseline, the pain visual analogue scale (pVAS) at the timepoints after each procedure (first, second US-FHR and rehabilitation) as well as the change in the Shoulder Pain and Disability Index (SPADI) from the first to the second visit. Eleven patients underwent US-FHR. The pROM of ER after the 1st US-FHR changed by a median of 7.1° (p < 0.01). There was a statistically significant improvement in the pROM of flexion, extension, abduction, external rotation, and internal rotation from baseline to each timepoints. The pVAS at rest showed no significant improvement, although the pVAS at maximal ER showed a trend towards improvement. The SPADI score decreased by a median of 13.4 (p < 0.01). No adverse events were observed. US-FHR on the CHL with or without rehabilitation might be an effective, less invasive treatment for patients with global limitation of shoulder ROM.

Shear Wave Elastography of the Coracohumeral Ligament With Frozen Shoulder in Different Stages

OBJECTIVES

To study the shear wave elastography (SWE) of the coracohumeral ligament (CHL) in different stages of frozen shoulder and to analyze its correlation with the visual analogue scale (VAS) score and shoulder range of motion (ROM).

METHODS

Sixty-four patients with frozen shoulder were divided into three stages: stage I (freezing phase), stage II (frozen phase), and stage III (thawing phase). The SWE of the CHL of the affected and healthy sides was measured and compared in the different stages. The VAS score and ROM of the affected side were evaluated, and their correlation with the SWE of the CHL was analyzed in the different stages.

RESULTS

In stage I frozen shoulder, the SWE of the CHL on the affected side was lower than that on the healthy side, while in stages II and III, the SWE on the affected side was higher (P = .001 for all). The SWE of the CHL of the affected side was different across the three stages; the SWE in stages II and III higher than that in stage I (P < .01), while the difference between stages II and III was not significant (P > .05). The SWE of the CHL of the affected side was negatively correlated with the VAS score but not with forward flexion (Ff), external rotation (Er) or internal rotation (Ir) in stage I; in stages II and III, it was positively correlated with the VAS score and negatively correlated with Ff, Er, and Ir.

CONCLUSIONS

The CHL stiffness of the affected side and its correlation with the shoulder VAS score and ROM are different for different stages of frozen shoulder.

Clinical Significance of Shear Wave Ultrasound Elastography in Patients With Idiopathic Adhesive Capsulitis: Can It Be Used Instead of Magnetic Resonance Imaging as an Early Indicator?

ABSTRACT

The aim of this study was to evaluate the elasticity of the supraspinatus (SSp) and infraspinatus (ISp) tendons and coracohumeral ligament (CHL), as well as the thickness of CHL in patients diagnosed with adhesive capsulitis (AC) using ultrasound (US) and 2D shear wave elastography (2D-SWE), determining their contributions to diagnosis and stage differentiation.This prospective case-control study was conducted between January 2020 and May 2021. In all cases, the ultrasound examinations were performed using the virtual touch quantification and expressed as shear wave velocity (SWV) in meters per second. After US examinations, magnetic resonance imaging (MRI) was planned for all cases.The measurements made in US and MRI revealed that CHL thicknesses and SWV values of CHL and SSp and ISp tendons were statistically substantially higher in the patient group. The diagnostic performance of 2D-SWE in predicting AC was evaluated using receiver operating characteristics curve analysis. When the cutoff value of the mean SWE for CHL was taken as 4.67 m/s, the sensitivity of SWE was found to be 90.2% and the specificity 85.7%.Our study results suggest that CHL thickness on B-mode US, as well as SWV values of CHL and SSp and ISp tendons in 2D-SWE examination, can be used as a useful tool for AC diagnosis without the need for MRI, a costly and time-consuming examination.

Effect of proprioceptive neuromuscular facilitation technique on the treatment of frozen shoulder: a pilot randomized controlled trial

Background and objectives

Frozen shoulder is a common painful disease of the shoulder joint characterized by structural changes in the shoulder joint, restricting both active and passive shoulder joint activities. Proprioceptive neuromuscular facilitation (PNF) effectively improved and maintained the range of motion; however, it is not clear whether it can improve the shoulder joint structure in patients with frozen shoulder. This pilot study used magnetic resonance imaging (MRI) observation to assess the improvement of the local structure of the shoulder joint upon PNF treatment to elucidate a target based on structure for the treatment of frozen shoulder.

Materials and methods

Forty-eight patients with frozen shoulder were randomly divided into the traditional manual therapy group and the PNF technique group. Changes in the thicknesses of the coracohumeral ligament (CHL) and capsule in axillary recess (CAR) of the shoulder joint were observed via MRI upon admission and at 4 weeks after treatment. A visual analog scale (VAS) and passive shoulder range of motion (ROM) at abduction, anteflexion and external rotation position were used to evaluate the improvement of shoulder joint pain and function in the initial, mid-term, and discharge of the two groups of patients.

Results

The primary outcome results shown that the PNF joint mobilization significantly reduced the thickness of the CHL (p = 0.0217) and CAR (p = 0.0133). Compared with simple joint mobilization, The mid-term and discharge rehabilitation assessment results showed that PNF has a better effect on shoulder pain. At the mid-term evaluation, the ROM of the PNF group was significantly better than that of the Control group in the three directions (p < 0.05).

Conclusion

As an adjunctive therapy, PNF can improve the shoulder joint structure of patients with frozen shoulder and is an effective treatment strategy for frozen shoulder.

MR imaging detection of adhesive capsulitis of the shoulder: impact of intravenous contrast administration and reader's experience on diagnostic performance

OBJECTIVE

Correct identification of adhesive capsulitis of the shoulder (ACS) has an important impact on adequate therapy. The aim of our study was to investigate the influence of intravenous contrast administration and of reader's experience on sensitivity and specificity of MRI in diagnosing ACS.

MATERIALS AND METHODS

A total of 180 patients were included in a retrospective study: 60 subjects with at least 4 of 5 clinical signs of adhesive capsulitis of the shoulder and 120 patients with other shoulder diseases who underwent contrast-enhanced MRI. In a first session, only non-enhanced images and in a second session also contrast-enhanced (CE) series were independently evaluated by three radiologists with various levels of professional experience. Readers were blinded to all clinical information and had to rate the shoulder MRIs for absence or presence of adhesive capsulitis. Data analysis included McNemar's test, t test, and U test (p < .05).

RESULTS

Using non-enhanced MRI, readers achieved a mean sensitivity of 63.9% and a mean specificity of 86.4%. By additional use of CE sequences, the mean sensitivity (85.5%) and the sensitivity for each reader increased significantly (p = .046, p < .01, p < .001, p = .045) while the improvement in mean specificity was not significant. Reader's experience had a positive effect on sensitivity and specificity, which was in part but not consistently significant.

CONCLUSION

The addition of CE sequences can significantly increase the sensitivity of MRI in the diagnosis of ACS. Reader's experience has shown to be another important factor for the diagnostic outcome.

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.

Superior humeral head migration might be a radiological aid in diagnosing patients with adhesive capsulitis of the shoulder

Background

The diagnosis of adhesive capsulitis (AC) of the shoulder might be challenging, as it is a diagnosis of exclusion and mainly based on the clinical examination. The purpose of the present study was to investigate the validity and reliability of 4 commonly reported radiological parameters suggesting a superior humeral head migration on anteroposterior (a/p) shoulder radiograph in identifying patients with AC.

Methods

The a/p shoulder radiographs of 100 patients with AC and 100 control subjects were retrospectively reviewed. A disruption of the normal scapulohumeral arch (≥2 mm), the acromiohumeral interval (AHI), the inferior glenohumeral distance (IGHD), and the upward migration index (UMI) were measured.

Results

A disruption of the scapulohumeral arch was observed in 80% in the AC and 20% in the control group. The mean AHI was 9.3 ± 1.3 mm and 11.0 ± 1.7 mm (P < .001), the mean IGHD was 3.9 ± 3.0 mm and 0.9 ± 1.9 mm (P < .001), and the mean UMI was 1.37 ± 0.1 and 1.44 ± 0.1 (P < .001) in patients with AC and control subjects, respectively. The scapulohumeral arch's disruption demonstrated the best test characteristics with a sensitivity and specificity of 80% in detecting patients with an AC. Patients with a disruption of the scapulohumeral arch had 16 times increased odds of having an AC.

Conclusion

Measuring the superior humeral head migration might be a simple and clinically relevant tool in diagnosing an AC of the shoulder and could be reliably used by clinicians adjacent to the clinical examination without any additional cost. Especially a disruption of the scapulohumeral arch on the a/p shoulder radiograph should raise concerns of AC in the absence of a massive rotator cuff tear.

[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.

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.

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.

The Comma Sign: The Coracohumeral Ligament and Superior Glenohumeral Ligament Exhibit Similar Quantitative Characteristics With Terminal Confluence at the Subscapularis Insertion

Purpose

The purpose of this morphologic cadaveric study was to quantitatively define the composition of the previously described comma tissue along with its relation to the subscapularis tendon insertion.

Methods

Fresh frozen cadaveric shoulder specimens were included for analysis. The coracohumeral ligament (CHL) was exposed at its origin along the base of the coracoid process and freed laterally along its course to the lesser tuberosity adjacent to the bicipital groove. The superior glenohumeral ligament (SGHL) was identified and traced along its course deep to the CHL within the rotator interval with insertion onto the superior aspect of the lesser tuberosity. The midpoint diameters of the SGHL and CHL and their composite insertional diameters on the subscapularis tendon insertion and lesser tuberosity were measured with digital calipers. The mean diameter was determined from 3 measurements taken of each ligament.

Results

Eight specimens were included. With the use of digital calipers, the mean midpoint diameters of the SGHL and CHL were identified as 5.99 mm (range, 5.25-6.91 mm) and 5.13 mm (range, 4.28-5.72 mm), respectively. The composite insertional diameter of the SGHL and CHL on both the lesser tuberosity and humeral insertion of the subscapularis tendon was 9.93 mm (range, 6.69-12.05 mm). At its insertion, the SGHL and CHL comprised 54% and 46% of the comma tissue, respectively. Additionally, all specimens were identified as showing a confluence of the SGHL and CHL composite insertion with the subscapularis tendon at the point of its humeral head insertion.

Conclusions

The comma tissue is a pivotal structure for the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of the midpoint diameter, insertional diameter, and composite distribution of the CHL and SGHL provided by this morphologic cadaveric analysis may aid surgeons in their efforts to restore the native anatomy.

Clinical Relevance

Subscapularis tendon tears have often been under-addressed during rotator cuff repair. The comma tissue has been described as an anatomic structure that can aid in the identification, mobilization, and repair of retracted subscapularis tendon tears. Therefore, quantitative knowledge of this important arthroscopic landmark may aid surgeons in their efforts to restore the native anatomy.

Elasticity of the coracohumeral ligament in patients with frozen shoulder following rotator interval injection: a case series

Aim of the study: To evaluate changes in the elasticity of the coracohumeral ligament in patients with adhesive capsulitis of the shoulder treated with ultrasound-guided rotator interval injections. Methods: Shear wave elastography was used to evaluate elasticity of the coracohumeral ligament in symptomatic and asymptomatic shoulders in the shoulder-neutral position and 30° external rotation. A total of 24 shoulders were assessed. Symptomatic shoulders were treated with targeted steroid injection via the rotator interval and manipulation under local anaesthetic block. Follow-up assessment of the elasticity of the coracohumeral ligament was obtained at 10 weeks post-injection. Results: In all subjects, the coracohumeral ligament elastic modulus was larger at 30° external rotation than in the neutral position. In patients with adhesive capsulitis, the coracohumeral ligament thickness and elastic modulus was significantly greater in the symptomatic shoulder in the neutral position and 30° ER. Treated patients had an excellent response with improved Oxford Shoulder Score and reduced visual analogue scale pain scores. Median Oxford Shoulder Score was 13.5 pre-injection and 34 at 10 weeks post-injection. Median visual analogue scale pain scores measured 8.5 pre-injection, 3.5 at 1 day, 2 at 1 week, and 2.5 at 10 weeks. Improved Oxford Shoulder Score and visual analogue scale pain score was associated with a trend to normalisation of the elastic modus of the coracohumeral ligament. Conclusion: In patients with adhesive capsulitis of the shoulder, shear wave elastography demonstrated the coracohumeral ligament is stiffer in the symptomatic shoulder than in the unaffected shoulder. Treatment with the ultrasound-guided rotator interval injection is associated with improved Oxford Shoulder Score, reduced visual analogue scale pain scores, and reduced stiffness in the coracohumeral ligament.

Sonographically Guided Percutaneous Sectioning of the Coracohumeral Ligament for the Treatment of Refractory Adhesive Capsulitis: Proof of Concept

INTRODUCTION

Treatment options are limited for nonsurgical chronic refractory cases of adhesive capsulitis. We describe a novel percutaneous tenotomy technique for coracohumeral ligament interruption with cadaveric validation.

OBJECTIVE

The objective of this study was to describe and validate a novel technique for percutaneous interruption of the coracohumeral ligament.

DESIGN

Cadaveric study.

SETTING

Academic tertiary care center.

METHODS

Eight cadavers underwent ultrasound (US)-guided percutaneous incision of the coracohumeral (CHL) ligament. Performance of the procedure requires that the practitioner make oscillatory motions with a needle that uses ultrasound energy to cut through tissue. Each pass removes a pinhead-sized amount of tissue. The number of passes and the cutting time are recorded during the procedure. As a standard for this procedure does not exist, the authors created their own based on the preclinical information presented here. Postprocedure dissection was performed to assess the extent of CHL interruption and injury to surrounding tissue.

RESULTS

The average resection time was seven minutes, requiring 500 passes. The technique described in this paper completely interrupted the CHL in all subjects. Cadaveric analysis demonstrated interruption of the CHL with respect to control shoulders requiring an average of seven minutes of cutting time and ∼500 micro-perforations.

CONCLUSION

US-guided percutaneous CHL ligament sectioning is possible with a commercially available ultrasonic probe.

Adhesion of the Long Head of the Biceps Tendon: A Case Series

Purpose

To present the clinical and imaging findings and results of treatment in patients with intra-articular long head of the biceps tendon (LHBT) adhesion to the undersurface of the rotator cuff found incidentally during shoulder arthroscopy.

Methods

Patients with intra-articular LHBT adhesion to the undersurface of the rotator cuff found incidentally during arthroscopy were included with a minimal 2-year follow-up. Demographic data, images, and physical examinations were recorded. LHBT release, tenotomy, or tenodesis were performed according to the patient’s age and surgeon’s preference.

Results

Twelve patients were included in the study. All of them presented with chronic anterior shoulder pain and positive Speed and O’Brien tests. The average age was 46.8 ± 17 years (range 20-79 years) and the pain sustained from 6 to 96 (average 25.5 ± 28.6) months. Before the operation, 6 patients had a positive Jobe’s test, 1 had a positive lift-off test, and all had positive O’Brien and Speed tests and tenderness over the LHBT. Three release, 4 tenotomy, and 5 LHBT tenodesis were done in addition to other procedures if needed. All range of motion except external rotation, pain visual analog score, and functional outcome scores showed significant improvement at 6 months after surgery. There were no significant differences in range of motion and functional scores between 6 months and 12 months postoperatively. No difference was found in LHBT scores at 6 and 12 months after the operation. Magnetic resonance imaging revealed thickened coracohumeral ligament overlying the LHBT.

Conclusions

Patients who had intra-articular LHBT adhesion to the undersurface of the rotator cuff and underwent release of the adhesion around LHBT, tenotomy, or tenodesis all had good clinical outcomes. The lesion was observed in 2.2% of all shoulder arthroscopies. Although difficult to diagnose before surgery, surgeons should be aware of this unusual condition in patients with chronic and insidious anterior shoulder pain.

Level of Evidence

Level IV, Therapeutic case series.

Arthroscopic bursectomy less effective in the degenerative shoulder with chronic subacromial pain

Background

Varying results after surgery in patients with subacromial pain syndrome (SAPS) have raised the question on whether there is a subgroup of patients that can benefit from surgery. Therefore, we aimed to identify preoperative and peroperative factors associated with a favorable patient-reported outcome after arthroscopic bursectomy in patients with SAPS.

Methods

Patients with chronic SAPS who underwent arthroscopic bursectomy after failed conservative management were included (n = 94). Patients were evaluated at the baseline, and 2 weeks, 8 weeks, 6 months, and 1 year after surgery. The primary outcome was the Western Ontario Rotator Cuff index (WORC) score one year after surgery. The secondary outcome measure was a visual analog scale for pain. Mixed model analyses were used to identify prognostic factors.

Results

The mean WORC (mean difference 39%, 95% confidence interval (CI) 32.8-45.3, P < .001) and visual analog scale pain scores (mean difference 41 mm points, 95% CI 3.37-4.88, P < .001) significantly improved one year after surgery. Nineteen patients (20%) developed a postoperative frozen shoulder. A longer duration of preoperative complaints and the peroperative identification of degenerative glenoid cartilage were associated with significantly worse WORC scores, with -0.086% per month (95% CI -0.156 to -0.016, P = .016) and -20% (95% CI -39.4 to -1.26, P = .037), respectively.

Conclusion

We identified demographic and clinical factors that predict the course after arthroscopic subacromial bursectomy. We found that arthroscopic bursectomy is less effective in patients with SAPS with a degenerative shoulder. This finding suggests that an improved treatment effect of arthroscopic subacromial bursectomy can be expected in patients with chronic SAPS if intra-articular pathologies such as glenohumeral osteoarthritis are sufficiently excluded.

Mid-Term Results of Transcatheter Arterial Embolization for Adhesive Capsulitis Resistant to Conservative Treatment

PURPOSE

To evaluate the mid-term clinical outcomes of transcatheter arterial embolization (TAE) for adhesive capsulitis (AC) resistant to medical treatments.

MATERIALS AND METHODS

This is a prospective analysis performed between February 2016 and February 2020. Inclusion criteria for TAE were shoulder pain, restriction of movement and no response to conservative treatment for at least 3 months. Demographic variables, risk factors, technical aspects, adverse events, changes by visual analogue scale (VAS) for pain and physical examination before and after TAE were assessed.

RESULTS

This study included 40 patients with AC (35 women and 5 men; mean age 50 ± 9 years old). Abnormal vessels were observed in 31/40 (77.5%) procedures. As embolic agent, imipenem/cilastatin was used. The mean follow-up was 21.2 ± 10.5 months. Significant differences were obtained in terms of pain reduction before and 6 months after TAE with the median visual analogue scale (VAS) of 8 vs. 0.5, P = 0.0001. Substantial differences were found regarding mobility in flexion and abduction before and 6 months after embolization, respectively (79.5° ± 18.5° vs. 133° ± 24.5°, P = 0.0001; 72.4° ± 18.8° vs. 129.7° ± 27.9°, P = 0.0001). No complications occurred. Complete recovery was obtained in 37/40 (92.5%) patients and partial recovery in 2/40 (5%). No clinical recurrence appeared.

CONCLUSIONS

Clinical results of transcatheter arterial embolization with imipenem/cilastatin are effective and stable in the mid-term follow-up for patients presenting with AC resistant to conservative treatments.

Frozen shoulder: overview of clinical presentation and review of the current evidence base for management strategies

Adhesive capsulitis of the shoulder (ACS) is a condition with significant clinical and economic implications. The etiology of adhesive capsulitis is not clearly understood and there remains lack of consensus in clinical management for this condition. It can occur as a primary idiopathic condition or secondary to medical conditions or trauma. The hallmarks of ACS are pain and stiffness, caused by formation of adhesive or scar tissue in the glenohumeral joint. Management strategies vary depending on stage of presentation, patient factors and clinician preferences, and can range from conservative options to surgical intervention. The aim of this review is to summarize the pathophysiology and clinical presentation of ACS and to discuss the evidence base for various management strategies employed today.

Frozen shoulder (FS) is a relatively common condition characterized by pain and stiffness of the shoulder joint. The exact cause of primary FS is unknown and in some patients the condition can persist for several years. Treatment strategies vary depending on stage of presentation, patient factors and clinician preferences. This review gives a summary of the clinical presentation of FS and an overview of the current evidence for both surgical and conservative treatment options for the condition.

The relationship between high-signal intensity changes in the glenohumeral joint capsule on MRI and clinical shoulder symptoms

Background/objective

High-signal intensity changes in the glenohumeral joint capsule on T2-and proton density-weighted magnetic resonance imaging are known as characteristic finding that is often observed in patients with frozen shoulder. We investigated the associations between high-signal intensity changes in the joint capsule on magnetic resonance imaging and the presence of rotator cuff tears and shoulder symptoms in patients with shoulder pain.

Methods

The medical records of 230 patients with shoulder pain who underwent magnetic resonance imaging at our hospital were reviewed. Patients were divided into three groups according to the presence and/or degree of rotator cuff tears (none, partial, or complete). The frequency of high-signal intensity changes in the joint capsule and its relationship with shoulder symptoms and the severity of rotator cuff tears were assessed. By quantitatively evaluating the intensity on MRI, the ratio between the joint capsule and the long head of the biceps (HSIC ratio) was calculated and compared with 15 healthy subjects.

Results

High-signal intensity changes were diagnosed in 165 (72%) patients, and it was significantly associated with night pain and range of motion limitation (p < 0.01). High-signal intensity changes were present in 66 patients (70%) with no rotator cuff tears, in 69 (71%) with partial rotator cuff tears, and in 36 (80%) with complete rotator cuff tears, without differences in their occurrence (p = 0.60), but were significantly associated with night pain in all the groups (p < 0.01) without differences in tear severity (p = 0.63). The ratio in the high-signal intensity changes (HSIC) positive group was approximately six times higher than that in the HSIC-negative and control groups (P < 0.01). Multivariate logistic regression analysis revealed that night pain is significantly associated with high-signal intensity changes (p < 0.01).

Conclusion

Shoulder pain is a common and reliable clinical finding in patients with high–signal intensity changes, regardless of the presence and/or degree of rotator cuff tears, Such changes may indicate night pain and range of motion limitation in patients.

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.

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.

Contrast-enhanced Magnetic Resonance Imaging Revealing the Joint Capsule Pathology of a Refractory Frozen Shoulder

Background:

Frozen shoulder (FS) is clinically diagnosed on the basis of patients’ medical history and physical examination. Its confirmation is based on joint capsule and coracohumeral ligament thickening, subcoracoid fat obliteration, and joint capsule contrast enhancement on magnetic resonance imaging (MRI). We performed bilateral contrast-enhanced MRI (CE-MRI) in FS patients to compare the outcomes with those of their unaffected contralateral counterparts.

Methods:

Ten patients (3 men, 7 women, median age: 54.5 years) with unilateral FS, requiring arthroscopic capsular release after failed conservative treatment, were included. The median forward elevation, abduction, external rotation, and internal rotation of the 10 patients were 100°, 60°, 7.5°, and the buttock, respectively. The median visual analog scale score was 5.3, and American Shoulder and Elbow Surgeons (ASES) score was 42. Bilateral CE-MRI was simultaneously performed on the day before surgery, and MRI findings were compared between FS and contralateral healthy shoulders (controls).

Results:

Significant axillary pouch enhancement and rotator interval were observed in all FS, but not in the unaffected comparable sides (p=0.002, respectively). The thickness of the axillary pouch (FS: 4.8 mm, C: 4.4 mm, p=0.58), coracohumeral ligament (FS: 3.9 mm, C: 4.1 mm, p=0.33), and subcoracoid fat obliteration (p=1.00) were not significantly different between FS and controls.

Conclusion:

CE-MRI aids in the clinical diagnosis of FS. However, axillary pouch joint capsule and coracohumeral ligament thickening or subcoracoid fat obliteration differences were not characteristic findings when contralateral shoulders were compared.

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.

Optimal Cut-Off Value of the Coracohumeral Ligament Area as a Morphological Parameter to Confirm Frozen Shoulder

BACKGROUND

Thickened coracohumeral ligament (CHL) is one of the important morphological changes of frozen shoulder (FS). Previous research reported that coracohumeral ligament thickness (CHLT) is correlated with anterior glenohumeral instability, rotator interval and eventually FS. However, thickness may change depending on the cutting angle, and measurement point. To reduce measurement mistakes, we devised a new imaging criteria, called the coracohumeral ligament area (CHLA).

METHODS

CHL data were collected and analyzed from 52 patients with FS, and from 51 control subjects (no evidence of FS). Shoulder magnetic resonance imaging was performed in all subjects. We investigated the CHLT and CHLA at the maximal thickened view of the CHL using our picture archiving and communications system. The CHLA was measured as the whole area of the CHL including the most hypertrophied part of the MR images on the oblique sagittal plane. The CHLT was measured at the thickest point of the CHL.

RESULTS

The average CHLA was 40.88 ± 12.53 mm² in the control group and 67.47 ± 19.88 mm² in the FS group. The mean CHLT was 2.84 ± 0.67 mm in the control group and 4.01 ± 1.11 mm in the FS group. FS patients had significantly higher CHLA (P < 0.01) and CHLT (P < 0.01) than the control group. The receiver operator characteristic analysis showed that the most suitable cut-off score of the CHLA was 50.01 mm², with 76.9% sensitivity, 76.5% specificity, and area under the curve (AUC) of 0.87. The most suitable cut-off value of the CHLT was 3.30 mm, with 71.2% sensitivity, 70.6% specificity, and AUC of 0.81.

CONCLUSION

The significantly positive correlation between the CHLA, CHLT and FS was found. We also demonstrate that the CHLA has statistically equivalent power to CHLT. Thus, for diagnosis of FS, the treating physician can refer to CHLA as well as CHLT.

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.

Postoperative MR Imaging in Shoulder Instability and Intra-articular Damage

MR imaging of the postoperative shoulder after instability surgery is challenging. The radiologist must be familiar with surgical procedures, altered anatomy, and expected postoperative findings for correct interpretation of normal findings versus a true pathology. Artifacts from metallic hardware or abrasions further complicate MR image interpretation, but are reduced with metal artifact reduction techniques. This article focuses on capsulolabral surgery, bone block transfers, and humeral bone loss procedures in patients with shoulder instability and their postoperative imaging evaluation. Surgical procedures and common complications are explained, and normal and pathologic postoperative imaging findings are presented.

MRI Findings Predictive of Shoulder Stiffness in Patients With Full-Thickness Rotator Cuff Tears

OBJECTIVE. The objective of our study was to evaluate the relationship between stiff shoulder in patients with a full-thickness rotator cuff tear and MRI findings, especially joint capsule abnormality. MATERIALS AND METHODS. This study included 106 patients with small to large (≤ 5 cm) full-thickness rotator cuff tears. Joint capsule edema and thickness in the axillary recess, obliteration of the subcoracoid fat triangle, fatty degeneration of the torn rotator cuff muscle, and degree of retraction were assessed by two radiologists. The size and location of tears were determined by MRI findings and operative report. Associations between MRI findings and preoperative passive range of motion (ROM) were assessed by simple and multiple linear regression analyses and proportional odds logistic regression analysis. RESULTS. There was a significant, negative linear correlation between limited ROM at forward elevation and thickness of the joint capsule in the glenoid portion of the axillary recess (p = 0.018), external rotation and joint capsule edema in the humeral portion of the axillary recess (p = 0.011), and internal rotation and joint capsule edema in the glenoid portion of the axillary recess (p = 0.007). Male sex (p = 0.041) and posterosuperior rotator cuff tear (p = 0.030) were independent predictors of shoulder ROM on external rotation. Degree of fatty degeneration (p = 0.003) was another independent predictor of shoulder ROM on internal rotation. CONCLUSION. MRI findings-especially joint capsule edema and thickness at the axillary recess-can be useful in predicting shoulder stiffness in patients with rotator cuff tear.

Capsular Injury and Inflammation

The capsular and ligamentous structures of the glenohumeral joint are important for stability of the shoulder. These structures are best evaluated by MR imaging. Familiarity with normal and abnormal appearance of the capsular structures of the shoulder is important to ensure that important pathology is not overlooked. Injury to the capsular structures can occur in the setting of trauma and most commonly involves the inferior glenohumeral ligament and axillary pouch. Adhesive capsulitis is a common inflammatory condition with characteristic imaging features that should be considered in the absence of alternative diagnoses.