Utility of MR arthrography in the diagnosis of adhesive capsulitis

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.

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.

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.

Association between subscapularis trigger point and frozen shoulder: A cross sectional study

BACKGROUND

Frozen shoulder (FS) is one of the most common shoulder conditions characterized by pain, restricted range of motion and high morbidity. Though FS is known as adhesive capsulitis, presence of capsular adhesions has been rebutted and the nomenclature adhesive capsulitis is debated. It has been proposed that FS is a condition of cytokine driven capsular, ligamentous fibrosis and contracture. Despite extensive research on it, still it is unclear that how far the capsular contracture contribute to range of motion restriction in FS. Evidence also suggested that myofascial trigger points play a role in restricted range of motion.

OBJECTIVE

To find an association between subscapularis trigger point and frozen shoulder.

STUDY DESIGN

Cross-sectional study.

METHOD

143 Patients were screened for inclusion and exclusion criteria, out of which 100 patients, were selected for the study. Manual palpation was performed to look for subscapularis muscle trigger points via axillary approach on both the affected and unaffected side. Trigger point diagnosing criteria was used to diagnose subscapularis trigger points.

RESULTS

Results have shown that there was an association between subscapularis trigger point and frozen shoulder (X 2 = 32.151 P < 0.0001) on the affected side. We used Phi coefficient to measure the degree of association which denotes (Phi = 0.567 P < 0.0001) strong association between frozen shoulder and subscapularis trigger point on the affected side compared to unaffected side (X 2 9.157; P < 0.002: Phi:0.303: P < 0.002).

CONCLUSION

This study concluded that there appears to be a strong association between subscapularis trigger point and frozen shoulder.

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.

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.

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.

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

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

ACR Appropriateness Criteria® Shoulder Pain-Atraumatic

Shoulder pain is one of the most common reasons for musculoskeletal-related physician visits. Imaging plays an important role in identifying the specific cause of atraumatic shoulder pain. This review is divided into two parts. The first part provides a general discussion of various imaging modalities (radiographs, arthrography, nuclear medicine, ultrasound, CT, and MRI) and their usefulness in evaluating atraumatic shoulder pain. The second part focuses on the most appropriate imaging algorithms for specific shoulder conditions including: rotator cuff disorders, labral tear/instability, bursitis, adhesive capsulitis, biceps tendon abnormalities, postoperative rotator cuff tears, and neurogenic pain. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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.

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.

3D volumetric MR arthrographic assessment of shoulder joint capacity in patients with primary adhesive capsulitis

OBJECTIVE

To evaluate the three-dimensional (3D) volumetric MR arthrographic findings of shoulder joint capacity in patients with primary adhesive capsulitis.

METHODS

Thin-section 3D volumetric MR arthrography sequences of the shoulder joint were obtained in 28 patients with clinically and radiologically proven primary adhesive capsulitis and in 25 controls. Volumetric measurements of the total glenohumeral joint capacity, extra-articular contrast material leakage, and the rotator interval, axillary recess, and biceps tendon sheath capacities were performed for the study and control groups.

RESULTS

Mean volume of the rotator interval was 7.67 ± 2.6 cm³ in the study group, which was significantly lower than in the control group (12.31 ± 2.5 cm³) (p < 0.0001). Mean volume of the bicipital groove was significantly decreased in the patient group compared to the control group (1.67 ± 0.9 cm³ vs 2.88 ± 0.9 cm³) (p ≤ 0.0001). Mean volume of extra articular contrast material extravasation was 9.93 ± 1.7 cm³ in the patient group, which was significantly higher than in the control group (5.1 ± 1.4 cm³) (p = 0.002). Mean total glenohumeral joint volume was 22.52 ± 1.1 cm³ in the patient group and 26.01 ± 1.2 cm³ in the control group (p = 0.003).

CONCLUSION

On 3D volumetric MR arthrographic examination, obliterations in the biceps tendon sheath and rotator interval as well as decreased joint capacity may be useful imaging criteria for diagnosing primary adhesive capsulitis.

ADVANCES IN KNOWLEDGE

In the present study, MR arthrography showed contrast material extravasation in 71% of the patients and showed extra articular contrast material extravasation in 48% of the control subjects. On 3D volumetric MR arthrographic examination, obliterations in the biceps tendon sheath and rotator interval as well as decreased joint capacity may be useful imaging criteria for diagnosing primary adhesive capsulitis.In patients with primary adhesive capsulitis, thin-section 3D volumetric MR arthrography is a useful imaging modality to evaluate both joint capacity and capsular structure.

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.

Is the Frozen Shoulder Classification a Reliable Assessment?

Background

Although a common shoulder disease, there are no accepted classification criteria for frozen shoulder (FS). This study therefore aimed to evaluate the accuracy of the conventionally used FS classification system.

Methods

Primary FS patients (n=168) who visited our clinic from January 2010 to July 2015 were included in the study. After confirming restrictions of the glenohumeral joint motion and absence of history of systemic disease, trauma, shoulder surgery, shoulder muscle weakness, or specific x-ray abnormalities, the Zuckerman and Rokito’s classification was employed for diagnosing primary FS. Following clinical diagnosis, each patient underwent a shoulder magnetic resonance imaging (MRI) and blood tests (lipid profile, glucose, hemoglobin A1c, and thyroid function). Based on the results of the blood tests and MRIs, the patients were reclassified, using the criteria proposed by Zuckerman and Rokito.

Results

New diagnoses were ascertained including blood test results (16 patients with diabetes, 43 with thyroid abnormalities, and 149 with dyslipidemia), and MRI revealed intra-articular lesions in 81 patients (48.2%). After re-categorization based on the above findings, only 5 patients (3.0%) were classified having primary FS. The remaining 163 patients (97.0%) had either undiagnosed systemic or intrinsic abnormalities (89 patients), whereas 74 patients had both.

Conclusions

These findings demonstrate that most patients clinically diagnosed with primary FS had undiagnosed systemic abnormalities and/or intra-articular pathologies. Therefore, a modification of the Zuckerman and Rokito’s classification system for FS may be required to include the frequent combinations, rather than having a separate representation of systemic abnormalities and intrinsic causes.

Systematic review of quantitative imaging biomarkers for neck and shoulder musculoskeletal disorders

Background

This study systematically summarizes quantitative imaging biomarker research in non-traumatic neck and shoulder musculoskeletal disorders (MSDs). There were two research questions: 1) Are there quantitative imaging biomarkers associated with the presence of neck and shoulder MSDs?, 2) Are there quantitative imaging biomarkers associated with the severity of neck and shoulder MSDs?

Methods

PubMed and SCOPUS were used for the literature search. One hundred and twenty-five studies met primary inclusion criteria. Data were extracted from 49 sufficient quality studies.

Results

Most of the 125 studies were cross-sectional and utilized convenience samples of patients as both cases and controls. Only half controlled for potential confounders via exclusion or in the analysis. Approximately one-third reported response rates. In sufficient quality articles, 82% demonstrated at least one statistically significant association between the MSD(s) and biomarker(s) studied. The literature synthesis suggested that neck muscle size may be decreased in neck pain, and trapezius myalgia and neck/shoulder pain may be associated with reduced vascularity in the trapezius and reduced trapezius oxygen saturation at rest and in response to upper extremity tasks. Reduced vascularity in the supraspinatus tendon may also be a feature in rotator cuff tears. Five of eight studies showed an association between a quantitative imaging marker and MSD severity.

Conclusions

Although research on quantitative imaging biomarkers is still in a nascent stage, some MSD biomarkers were identified. There are limitations in the articles examined, including possible selection bias and inattention to potentially confounding factors. Recommendations for future studies are provided.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1694-y) contains supplementary material, which is available to authorized users.

Correlation of Joint Volume and Passive Range of Motion With Capsulo-Synovial Thickness Measured by Contrast-Enhanced Magnetic Resonance Imaging in Adhesive Capsulitis

BACKGROUND

No study has investigated the relationship between the findings of contrast-enhanced magnetic resonance imaging (CE-MRI) and the joint volume of the shoulder, which has been considered the standard reference for diagnosis of adhesive capsulitis (AC).

OBJECTIVE

To investigate the relationships among the capsulo-synovial thickness measured by CE-MRI, joint volume, and passive range of motion (ROM) in patients with AC.

DESIGN

This was a retrospective study.

SETTING

The study took place at an institutional practice.

PATIENTS

Medical record of 103 patients (46 male and 57 female), who were treated with sonographically guided intra-articular injection with diagnosis of AC and underwent CE-MRI to rule out other concomitant shoulder disease, were retrospectively reviewed.

METHODS

Passive ROM and glenohumeral joint (GHJ) volume were measured before and during sonographically guided injection. The thickness of the enhancing portion of the capsulo-synovium was measured at the axillary recess and rotator interval on CE-MRI.

MAIN OUTCOME MEASUREMENTS

The relationship among the thickness of the enhancing portion on CE-MRI, GHJ volume, and passive ROM was analyzed using the Pearson correlation coefficient.

RESULTS

Capsulo-synovial thickness measured by CE-MRI at the enhancing portion of the axillary recess inversely correlated with GHJ volume (ρ = -0.444, P < .001), whereas at the rotator interval, this finding was not observed. At the axillary recess, the capsulo-synovial thickness inversely correlated with abduction (ρ = -0.400, P < .001), forward elevation (ρ = -0.378, P < .001), and external rotation (ρ = -0.297, P < .01), but at the rotator interval, such statistically significant correlations were not shown.

CONCLUSION

The capsulo-synovial thickness measured by CE-MRI at the enhancing portion of the axillary recess could represent obliterated joint capacity and clinical impairment (restricted passive ROM), which could help in diagnosing AC and in differentiating other shoulder diseases that may mimic this condition.

LEVEL OF EVIDENCE

III.

CT arthrography of adhesive capsulitis of the shoulder: Are MR signs applicable?

OBJECTIVE

To determine if diagnostic signs of adhesive capsulitis (AC) of the shoulder at Magnetic Resonance Imaging (MRI) and arthrography (MRA) are applicable to CT arthrography (CTA).

METHODS

22 shoulder CTAs with AC were retrospectively reviewed for features described in MR literature. The control group was composed of 83 shoulder CTA divided into four subgroups 1) normal (N = 20), 2) omarthrosis (N = 19), 3) labral injury (N = 23), and 4) rotator cuff tear (N = 21). Two musculoskeletal radiologists assessed the rotator interval (RI) for obliteration, increased width and thickening of coracohumeral ligament (CHL). The width and capsule thickness of the axillary recess were measured.

RESULTS

The width of the axillary recess was significantly decreased in the AC group (4.6 ± 2.6 mm versus 9.9 ± 4.6 mm, p ≤ 0.0001; sensitivity and specificity of 84% and 80%). Thickness of the medial and lateral walls of the axillary capsule was significantly increased in the AC group (5.9 ± 1.3 mm versus 3.7 ± 1.1 mm, p ≤ 0.0001 and 5.7 ± 1 mm versus 3.5 ± 1.3 mm, p ≤ 0.0001, respectively). CHL thickness was significantly increased in the AC group (4.1 ± 1 mm (p ≤ 0.001)) in comparison to others groups. Obliteration of the RI was statistically significantly more frequent in patients with AC (72.7% (16/22) vs. 12% (10/83), p < 0.0001). Width of the RI did not differ significantly between patients and controls (p ≥ 0.428).

CONCLUSION

Decreased axillary width, and thickened axillary capsule are MR signs of AC applicable to CTA. Evaluation of rotator interval seems useful and reproducible only for obliteration.

Spectrum of Benign Articular and Periarticular Findings at FDG PET/CT

Whole-body fluorine 18 fluorodeoxyglucose (FDG) positron-emission tomography (PET)/computed tomography (CT) is performed primarily for oncologic indications; however, FDG uptake is not specific for malignancy. Herein we focus on causes of increased FDG uptake in and around joints, as lesions in these locations are commonly benign. A combination of primary intra-articular processes and osseous processes that may occur near the joint space will be discussed. Causes of intra-articular and periarticular increased FDG activity can be broadly divided into infectious, inflammatory, degenerative, and benign neoplastic categories. A familiarity with the full range of these processes is important to avoid misinterpretation, in turn decreasing unnecessary follow-up studies, procedures, and treatments. Differentiation from malignancy is often possible on the basis of a different level of FDG activity, divergent response to therapy, or differing changes over time, in comparison with a patient's known primary cancer. Recognizing an intra-articular lesion location can also be critical, as intra-articular metastases are rare. In some cases, benign FDG-avid articular and periarticular entities have a specific appearance at FDG PET/CT and a correct diagnosis may be made without any additional workup. In most other cases, comparison with prior studies and/or additional imaging can afford an accurate diagnosis. This review is meant to introduce the reader to a spectrum of benign FDG-avid articular and periarticular processes that may be encountered at oncologic FDG PET/CT to increase confidence and diagnostic accuracy. (©)RSNA, 2016.

Clinical correlation of metabolic parameters on 18F-FDG PET/CT in idiopathic frozen shoulder

Objective

Because positron emission tomography/computed tomography (PET/CT) using fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) can be used to visualize inflammation of the musculoskeletal system, it may help elucidate the pathophysiology of frozen shoulder (FS). The purpose of this study was to characterize the uptake pattern on ¹⁸F-FDG PET/CT in patients with idiopathic FS and to determine if there is a correlation between its metabolic parameters and clinical findings.

Methods

¹⁸F-FDG PET/CT was conducted to 35 patients with unilateral idiopathic FS. Clinical data including pain, functional scores, and passive range of motion (ROM) were collected. Maximum standardized uptake values (SUVmax) were measured at the four regions of interest (ROIs): rotator interval (RI), anterior joint capsule (AJC), axillary recess (AR), and posterior joint capsule (PJC) from the attenuation-corrected axial images.

Results

Mean SUVmax values for four ROIs of the affected shoulder were significantly higher than those of the unaffected shoulder. Mean SUVmax values of RI and AR were significantly higher than those of AJC and PJC and mean SUVmax of AJC was significantly higher than that of PJC in the affected side. Three recognizable patterns of increased uptake were noted: (1) AR dominant type (15 patients); (2) RI dominant type (9 patients); (3) both RI and AR dominant type (11 patients). The SUVmax of AR showed negative correlation with abduction and forward flexion. The SUVmax of RI showed negative correlation with external rotation and internal rotation. The SUVmax of AJC showed negative correlation with all ROMs. However, there was no significant correlation between the SUVmax of PJC and any ROM.

Conclusion

Our study demonstrates that the anterior–inferior capsular portion, including RI and AR, is the main pathologic site of idiopathic FS and reveals significant correlations between ROM and metabolic parameters on ¹⁸F-FDG PET/CT. These results imply that AR and RI lesions are related to elevational limitations and rotational limitations, respectively.

Ultrasonographic measurement of the axillary recess thickness in an asymptomatic shoulder

Purpose

The purpose of this study was to measure the axillary recess (AR) thickness in an asymptomatic shoulder by using ultrasonography (US) and to analyze the factors affecting it.

Methods

We recruited 141 patients (52 males; 89 females; age, 57.7±9.9 years) with unilateral shoulder pain and performed US on the unaffected shoulder. Two physiatrists measured the AR thickness of the unaffected shoulder independently. All patients were examined in an upright sitting position with 90° shoulder abduction. The ultrasonographic transducer was placed longitudinally on the mid-axillary line and along the long axis of the humeral shaft. The factors affecting the AR thickness values were analyzed, and intra-class correlation coefficients were used for assessing the reproducibility of each measurement.

Results

The intrarater reliability values for the two physiatrists were 0.98 and 0.96, respectively. The inter-rater reliability of the mean AR thickness measurements was 0.91. The mean AR thickness in all subjects, males, and females was 2.8±0.6 mm, 3.1±0.6 mm, and 2.6±0.5 mm (P<0.01), respectively. No difference between the left and the right sides (males, P=0.086; females, P=0.535) or between the dominant and the non-dominant sides (males, P=0.173; female, P=0.244) was found. The AR thickness correlated positively with the height (r=0.313, P<0.01) and the weight (r=0.319, P<0.01). However, it did not correlate with the body mass index (r=0.152, P=0.077) or the age (r=-0.056, P=0.515).

Conclusion

US measurements of the AR thickness in asymptomatic shoulders demonstrated excellent intrarater and inter-rater reliabilities. The AR thickness showed anatomical variation with sex, height, and weight.

The pathophysiology associated with primary (idiopathic) frozen shoulder: A systematic review

Background

Frozen shoulder is a common yet poorly understood musculoskeletal condition, which for many, is associated with substantial and protracted morbidity. Understanding the pathology associated with this condition may help to improve management. To date this has not been presented in a systematic fashion. As such, the aim of this review was to summarise the pathological changes associated with this primary frozen shoulder.

Methods

Databases: Medline, Embase, CINAHL, AMED, BNI and the Cochrane Library, were searched from inception to 2nd May, 2014. To be included participants must not have undergone any prior intervention. Two reviewers independently conducted the; searches, screening, data extraction and assessment of Risk of Bias using the Cochrane Risk of Bias Assessment Tool for non-Randomised Studies of Interventions (ACROBAT-NRSI). Only English language publications reporting findings in humans were included. The findings were summarised in narrative format.

Results

Thirteen observational studies (involving 417 shoulders) were included in the review. Eight studies reported magnetic resonance imaging or arthrography findings and 5 recorded histological findings. When reported mean ages of the participants ranged from 40.0 to 59.8 years. Duration of symptoms ranged from 0 to 30 months. The majority of studies (n = 7) were assessed to be of moderate risk of bias, two studies at high risk and the remaining four were rated as low risk of bias. Study characteristics were poorly reported and there was widespread variety observed between studies in respect of data collection methods and inclusion criteria employed. Pathological changes in the anterior shoulder joint capsule and related structures were commonly reported. Imaging identified pathological changes occurring in the coracohumeral ligament, axillary fold and rotator interval. Obliteration of the subcoracoid fat triangle also appeared to be pathognomonic. Histological studies were inconclusive but suggested that immune, inflammatory and fibrotic changes where associated with primary frozen shoulder.

Conclusions

This systematic review presents a summary of what is currently known about the tissue pathophysiology of primary frozen shoulder. Further studies that use standardised inclusion and exclusion criteria and investigate changes in naïve tissue at different stages of the condition are required.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Multi-modal imaging of adhesive capsulitis of the shoulder

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

KEY POINTS

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

Proper site of corticosteroid injection for the treatment of idiopathic frozen shoulder: Results from a randomized trial

OBJECTIVE

The objective is to determine whether corticosteroid injection into the subacromial space was not inferior to intra-articular injection in patients with idiopathic frozen shoulder (FS), and whether combined injections had an additive effect.

METHODS

Patients with idiopathic FS (n=126) were randomly assigned to receive ultrasound-guided intra-articular (IA group), subacromial (SA group), or combined IA and subacromial injections (IA+SA group). All groups received a total dose of 40mg triamcinolone acetonide. The outcome measures included the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeon (ASES) shoulder score, subjective shoulder value (SSV), and passive range of motion before and at 3, 6, and 12 weeks after treatment.

RESULTS

There was significant effect of time on all measurements such that all measures improved in all groups (P<0.001) during the 12 weeks after treatment. Group-by-time interactions were significant for ASES (P=0.006), VAS (P<0.001), SSV (P=0.03), and internal rotation (P=0.014). Between-group comparisons revealed a significant improvement in the IA (P<0.001) and IA+SA (P<0.001) groups as compared to the SA group. The IA+SA group demonstrated significant improvement in internal rotation as compared to the IA group (P=0.046).

CONCLUSION

The efficacy of corticosteroid injection into the SA space in idiopathic FS was inferior to IA injection up to 12 weeks; however, combination injections had an additive effect on increasing the internal rotation angle. These results indicate that although the glenohumeral joint is a major site in the pathogenesis of idiopathic FS, the SA space may be a contributing site.

Metabolic patterns of the shoulder joint on (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in adhesive capsulitis

OBJECTIVE

The purpose of our study was to demonstrate metabolic patterns on (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in patients with adhesive capsulitis (AC).

METHODS

We retrospectively reviewed (18)F-FDG PET/CT performed on 22 shoulders of 21 patients diagnosed with AC: 2 shoulders with stage I, 14 with stage II, and 6 with stage III. A clinical diagnosis of AC was retrospectively made based on clinical examination, clinical course, and imaging. The pattern of radiotracer uptake was analyzed. Standardized uptake values in rotator interval (RI), anterior joint capsule (AJC), axillary recess (AR), and greater tuberosity were measured and compared to those of the contralateral side and the control group consisting of 40 shoulders in 20 subjects without shoulder pain.

RESULTS

Four patterns of uptake were noted: (1) glenoid type I (n = 16), with uptake in RI, AJC, and AR; (2) glenoid type II (n = 2),with uptake in AJC and AR; (3) glenoid type III (n = 2), with uptake in RI and AJC; (4) focal type (n = 2), with uptake in RI or AR. Affected side SUVmax for RI, AJC, and AR was significantly higher compared with the unaffected side and the control group. Two shoulders with stage I AC had patterns similar to the ones with stage II or III.

CONCLUSION

Specific patterns of (18)F-FDG uptake with dominant uptake in RI, AJC, or AR may be related to AC.

An MRI study of symptomatic adhesive capsulitis

Background

Appilication of MR imaging to diagnose Adhesive Capsulitis (AC) has previously been described. However, there is insufficient information available for the MRI analysis of AC. This study is to describe and evaluate the pathomorphology of the shoulder in Asian patients with AC compared to healthy volunteers.

Methodology/Principal Findings

60 Asian patients with clinically diagnosed AC and 60 healthy volunteers without frozen shoulder underwent MRI of the shoulder joint. All subjects who were age- and sex-matched control ones underwent routine MRI scans of the affected shoulder, including axial, oblique coronal, oblique sagittal T1WI SE and coronal oblique T2WI FSE sequences. Significant abnormal findings were observed on MRI, especially at the rotator cuff interval. The coracohumeral ligament (CHL), articular capsule thickness in the rotator cuff interval as well as the fat space under coracoid process were evaluated. MRI showed that patients with adhesive capsulitis had a significantly thickened coracohumeral ligament and articular capsule in the rotator cuff interval compared to the control subjects (4.2 vs. 2.4 mm, 7.2 vs. 4.4 mm; p<0.05). Partial or complete obliteration of the subcoracoid fat triangle was significantly more frequent in patients with adhesive capsulitis compared with control subjects (73% vs. 13%, 26% vs. 1.6%; p<0.001). Synovitis-like abnormality around the long biceps tendon was significantly more common in patients with adhesive capsulitis than in control subjects. With regards to the inter-observer variability, two MR radiologists had an excellent kappa value of 0.86.

Conclusions/Significance

MRI can be used to show characteristic findings in diagnosing AC. Thickening of the CHL and the capsule at the rotator cuff interval and complete obliteration of the fat triangle under the coracoid process have been shown to be the most characteristic MR findings seen with AC.

Correlation between magnetic resonance imaging and clinical impairment in patients with adhesive capsulitis

OBJECTIVE

To determine the relationship between clinical impairment and MRI findings in patients with adhesive capsulitis.

MATERIALS AND METHODS

Contrast-enhanced MRI of 97 patients with a clinical diagnosis of adhesive capsulitis (AC) were retrospectively reviewed. Specific MRI criteria, including thickness and gadolinium enhancement of the joint capsule in the axillary recess and subcoracoid fat obliteration in the rotator interval, were correlated with limited range of motion (ROM) and pain. Other variables considered in this study were rotator cuff pathology, arm dominance, diabetes mellitus, age, and gender. Statistical analysis was performed using logistic and linear regression analysis.

RESULTS

Thickening of the joint capsule in the axillary recess correlated with limited external rotation (p < 0.01), gender (p < 0.01) and arm dominance (p < 0.05). Gadolinium enhancement of the joint capsule in the axillary recess correlated with pain intensity (p < 0.05). Subcoracoid fat obliteration in the rotator interval was not correlated with limited ROM or pain.

CONCLUSIONS

MRI can be a useful technique to assess several clinical impairment measures in patients with adhesive capsulitis. Thickening and gadolinium enhancement of the joint capsule in the axillary recess on MRI are associated with limited ROM and pain.

Limited subacromial gliding of the supraspinatus tendon during dynamic ultrasonography can predict a decrease in capacity and MR arthrographic features of the shoulder joint

OBJECTIVES

The aim of this prospective study was to compare the painful subacromial gliding limitation of the supraspinatus tendon (SGLS) during dynamic ultrasonography, the features of magnetic resonance arthrography (MRA), and the maximum intra-articular injection volume to predict decreased joint capacity of the shoulder joint.

METHODS

Between January 2003 and August 2011, 67 patients prospectively underwent ultrasonography including dynamic examination and MRA. Ultrasonography and ultrasonography-guided injection of contrast medium was performed before MRA, and each SGLSdU was compared with injected contrast volume, which was assumed as the maximum joint capacity and MRA features.

RESULTS

Forty-seven patients (70.1%) were revealed as SGLS-positive, and 20 patients (29.9%) were revealed as SGLS-negative by dynamic ultrasonography. Pearson's correlation coefficient between SGLS and the injection volume was -0.764 (P < 0.001). The value between SGLS and MRA features was 0.711 (P < 0.001). The mean injected volume of the SGLS-positive (22.0 ml) and negative group (10.7 ml) was significantly different (P < 0.001).

CONCLUSIONS

SGLS at ultrasonography correlated well with MRA features and the maximum intra-articular injection volume. This sign could predict the decreased capacity of the shoulder joint, an important feature of adhesive capsulitis, and increase the usefulness of dynamic ultrasonography.

KEY POINTS

• Dynamic ultrasound is increasingly used in the evaluation of the shoulder. • This can assess subacromial gliding limitation of the supraspinatus tendon (SGLS) • SGLS appeared inversely proportional to the maximum volume of intra-articular injection. • Dynamic ultrasonography findings correlated well with MR arthrographic features of adhesive capsulitis.

Biceps pulley: normal anatomy and associated lesions at MR arthrography

The biceps pulley or "sling" is a capsuloligamentous complex that acts to stabilize the long head of the biceps tendon in the bicipital groove. The pulley complex is composed of the superior glenohumeral ligament, the coracohumeral ligament, and the distal attachment of the subscapularis tendon, and is located within the rotator interval between the anterior edge of the supraspinatus tendon and the superior edge of the subscapularis tendon. Because of its superior depiction of the capsular components, direct magnetic resonance arthrography is the imaging modality of choice for demonstrating both the normal anatomy and associated lesions of the biceps pulley. Oblique sagittal images and axial images obtained with a high image matrix are valuable for identifying individual components of the pulley system. Various pathologic processes occur in the biceps pulley as well as the rotator interval. These processes can be traumatic, degenerative, congenital, or secondary to injuries to the surrounding structures. The term hidden lesion refers to an injury of the biceps pulley mechanism and is derived from the difficulty in making clinical and arthroscopic identification. Pathologic conditions associated with pulley lesions include anterosuperior impingement, instability of the biceps tendon, biceps tendinopathy or tendinosis, superior labrum anterior and posterior lesions, and adhesive capsulitis. It is important to be familiar with the normal appearance of the biceps pulley so that abnormalities can be correctly assessed and effectively managed.

Incidence of False Positive Rotator Cuff Pathology in MRIs of Patients with Adhesive Capsulitis

The purpose of this study was to compare the incidence of presumed rotator cuff pathology based on radiologist and surgeon interpretation of preoperative magnetic resonance images (MRIs) with actual rotator cuff pathology found intraoperatively in patients undergoing arthroscopic capsular release for adhesive capsulitis.The medical records of 38 consecutive patients who underwent arthroscopic glenohumeral capsular release for adhesive capsulitis between September 2001 and May 2007 were retrospectively reviewed. Radiologist and surgeon predicted status of the rotator cuff by prospective MRI interpretation was compared to the actual status of the rotator cuff intraoperatively. Radiologists' preoperative MRI interpretations predicted a 57.9% incidence of rotator cuff pathology, while operative findings revealed a true incidence of only 13.2% (P<.0001). Radiologists accurately predicted the absence or presence of a rotator cuff tear in 19 of 38 cases (50%), compared to the surgeon, who correctly interpreted 29 of 38 MRIs (76.3%).Interpretations of shoulder MRIs in patients with adhesive capsulitis may provide misleading information regarding rotator cuff pathology. The actual findings of shoulder MRI scans may lead to the appearance of false rotator cuff pathology in this population, and a high percentage of false positive MRI reports of rotator cuff tears was observed in these patients. If MRI is chosen as a diagnostic adjunct in this patient population, careful consideration should be given to its interpretation to avoid unnecessary or possibly aggravating surgical intervention.

Adhesive capsulitis of the shoulder: dimensions of the rotator interval measured with magnetic resonance arthrography

BACKGROUND

This study was performed to define the dimensions of the rotator interval (RI) in adhesive capsulitis using magnetic resonance (MR) arthrography preoperatively to clarify and evaluate pathology.

METHODS

We performed a retrospective review of a series of 73 shoulders that underwent MR arthrography. The shoulders were grouped according to their diagnosis: group I comprised 47 shoulders without adhesive capsulitis; group II comprised 26 shoulders with adhesive capsulitis. Using MR arthrography, we estimated the height, base, RI area, width, RI index, and RI ratio.

RESULTS

The group II shoulders differed significantly in height, base, RI area, RI index, and RI ratio from the group I shoulders. There were statistically significant differences in RI dimensions between patients with and without adhesive capsulitis of the shoulder.

CONCLUSIONS

Estimating the dimensions of the RI in adhesive capsulitis using MR arthrography may prove to be valuable for assessing patients preoperatively.

Magnetic resonance imaging of adhesive capsulitis: correlation with clinical staging

The purpose of this study was to evaluate non-contrast magnetic resonance imaging (MRI) findings of adhesive capsulitis and correlate them with clinical stages of adhesive capsulitis. This will hopefully define a role for shoulder MR imaging in the diagnosis of adhesive capsulitis as well as in potentially directing appropriate treatment. Forty-seven consecutive non-contrast magnetic resonance imaging examinations of 46 patients with a clinical diagnosis of adhesive capsulitis were retrospectively reviewed and correlated with clinical staging. Specific MRI criteria correlated with the clinical stage of adhesive capsulitis, including the thickness and signal intensity of the joint capsule and synovium as well as the presence and severity of scarring in the rotator interval. Routine MRI of the shoulder without intraarticular administration of gadolinium can be used to diagnose all stages of adhesive capsulitis, including stage 1, where findings may be subtle on clinical examination. We believe that future studies assessing the role of MRI in guiding the initiation of appropriate treatment should be undertaken.

Diagnostic imaging guideline for musculoskeletal complaints in adults-an evidence-based approach-part 2: upper extremity disorders

PURPOSE

To develop evidence-based diagnostic imaging practice guidelines to assist chiropractors and other primary care providers in decision making for the appropriate use of diagnostic imaging for upper extremity disorders.

METHODS

A comprehensive search of the English and French language literature was conducted using a combination of subject headings and keywords. The quality of the citations was assessed using the Quality of diagnostic accuracy studies (QUADAS), the Appraisal of Guidelines Research and Evaluation (AGREE), and the Stroke Prevention and Educational Awareness Diffusion (SPREAD) evaluation tools. The Referral Guidelines for Imaging (radiation protection 118) coordinated by the European Commission served as the initial template. The first draft was sent for an external review. A Delphi panel composed of international experts on the topic of musculoskeletal disorders in chiropractic radiology, clinical sciences, and research was invited to review and propose recommendations on the indications for diagnostic imaging. The guidelines were pilot tested and peer-reviewed by practicing chiropractors and by chiropractic and medical specialists. Recommendations were graded according to the strength of the evidence. Dissemination and implementation strategies are discussed.

RESULTS

Recommendations for diagnostic imaging guidelines of adult upper extremity disorders are provided, supported by over 126 primary and secondary citations. The overall quality of available literature is low, however. On average, 44 Delphi panelists completed 1 of 2 rounds, reaching over 88% agreement on all 32 recommendations. Peer review by specialists reflected high levels of agreement and perceived ease of use of guidelines and implementation feasibility.

CONCLUSIONS

The guidelines are intended to be used in conjunction with sound clinical judgment and experience and should be updated regularly. Future research is needed to validate their content.

Alterations in scapular kinematics in subjects with idiopathic loss of shoulder range of motion

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To determine the effect of idiopathic loss of shoulder range of motion on scapular kinematics.

BACKGROUND

Subjects with idiopathic loss of shoulder range of motion have difficulty performing activities of daily living. Previous investigations have focused on the glenohumeral component of shoulder complex motion.

MATERIALS AND METHODS

Seventeen unilaterally impaired and 17 nonimpaired subjects. The 3-dimensional motion of the humerus, scapula, and trunk were measured withthe Fastrak electromagnetic motion-tracking system during humerus-to-trunk scapular plane elevation. An analysis of variance compared the impaired subjects noninvolved to the nonimpaired subjects' scapulae at 4 scapularplane elevation positions. A repeated-measures analysis of variance compared the impaired subjects' involved and noninvolved scapulae at 3 scapular plane elevation positions, and matched-pairs t test compared peak elevation values.

RESULTS

The between-group ANOVAs demonstrated no difference in anterior tipping, internal rotation, or upward rotation. The repeated-measures ANOVAs demonstrated no difference in anterior tipping or internal rotation and a position-by-side interaction in upward rotation. The involved-side scapulae were more upwardly rotated (7.7 degrees) at peak humerus-to-trunk scapular plane elevation.

DISCUSSION AND CONCLUSION

The impaired subjects' noninvolved scapular kinematics were not significantly different than the nonimpaired subjects, but were significantly different than their involved scapulae. The upward rotation differences may be a substitution pattern used to accomplish functional elevation.

MR Imaging of the Rotator Cuff Interval

The rotator cuff interval is defined as the space between the anterior aspect of the supraspinatus tendon and the superior aspect of the subscapularis tendon. Knowledge of the anatomy, an understanding of the commonly encountered pathology, and an approach for the systematic inspection of the rotator cuff interval is crucial for the accurate characterization and diagnosis of pathology of this region. This article reviews the basic normal anatomy of the rotator cuff interval, imaging considerations unique to this area, and commonly encountered pathology.

Primary synovial osteochondromatosis presenting as constrictive capsulitis

Primary synovial chondromatosis of the joints can present as capsular constriction with peri-articular osteopenia. This rare presentation is highlighted in three cases (two hips and one shoulder). The diagnosis in all the patients was made on arthrography and/or MRI/CT and was confirmed histologically. Synovial chondromatosis should be considered in patients with this presentation. Arthrography is the best imaging modality to confirm the cause (synovial chondromatosis) and effect (constrictive capsulitis).

Adhesive capsulitis of the shoulder: evaluation with MR arthrography

The purpose of this study was to determine the usefulness of magnetic resonance (MR) arthrography for diagnosing adhesive capsulitis. Shoulder MR images of 28 patients with (n=14) and without (n=14) adhesive capsulitis were retrospectively analyzed. MR images were assessed for capsule and synovium thickness as well as the width of the axillary recess on oblique coronal fat-suppressed T1-weighted images and T2-weighted images, respectively. On oblique sagittal fat-suppressed T1-weighted images, the width of the rotator interval and the presence of abnormal tissue in the interval were evaluated. Significant differences were found between the two groups in capsule and synovium thickness on both sides of the recess on oblique coronal T2-weighted images (P=0.000), whereas thickness on the humeral aspect showed no significant difference on oblique coronal fat-suppressed T1-weighted images (P=0.109). On oblique coronal T2-weighted images, a cut-off value of 3-mm thickness gave the highest diagnostic accuracy for adhesive capsulitis with sensitivity, specificity, and accuracy of 79% (11/14), 100% (14/14), and 89% (25/28) at the humeral side and 93% (13/14), 86% (12/14), and 89% (25/28) at the glenoid side, respectively. There were significant differences in rotator interval width, presence of abnormal tissue in the rotator interval, and axillary recess width between the two groups (P<0.05). Thickness of capsule and synovium of the axillary recess greater than 3 mm is a practical MR criterion for diagnosing adhesive capsulitis when measured on oblique coronal T2-weighted MR arthrography images without fat suppression. The presence of abnormal tissue in the rotator interval showed high sensitivity but rather low specificity.

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

OBJECTIVE

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

DESIGN AND PATIENTS

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

RESULTS

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

CONCLUSIONS

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

Magnetic resonance imaging of shoulders with idiopathic adhesive capsulitis: reliability of measures

The magnetic resonance imaging (MRI) findings in idiopathic adhesive capsulitis (AC) were compared with those of contralateral healthy shoulders and the reliability of measures assessed. Twenty-six consecutive patients (26 AC and 14 healthy shoulders) were prospectively assessed. The main measurements were thickness of the joint capsule and synovial membrane in the axillary recess and rotator interval in T1-weighted spin-echo sequence enhanced with intravenous (IV) gadolinium chelate (Gd-chelate). Reliability was studied by use of the intraclass correlation coefficient (ICC). The mean thickness of the axillary recess on the coronal plane was 9.0+/-2.2 mm in AC shoulders and 0.4+/-0.7 mm in healthy shoulders. The mean thickness of the rotator interval on the sagittal plane was 8.4+/-2.8 in AC shoulders and 0.6+/-0.8 mm in healthy shoulders. Interobserver reliability was good for the axillary recess, with ICC values of 0.84 for the coronal plane, and good for the rotator interval, with ICC values of 0.80 for the sagittal plane. MRI with IV Gd-chelate injection can show, with acceptable reliability, signal and thickness abnormalities of the shoulder joint capsule and synovial membrane in AC.

Frozen Shoulder: MR Arthrographic Findings

PURPOSE

To evaluate the magnetic resonance (MR) arthrographic findings in patients with frozen shoulder.

MATERIALS AND METHODS

Preoperative MR arthrograms of 22 patients (six women, 16 men; mean age, 54.7 years) with frozen shoulder treated with arthroscopic capsulotomy were compared with arthrograms of 22 age- and sex-matched control subjects without frozen shoulder. The thickness of the coracohumeral ligament (CHL) and the joint capsule, as well as the volume of the axillary recess, were measured (Mann-Whitney test). Abnormalities in the CHL, subcoracoid fat, superior glenohumeral ligament, superior border of the subscapularis tendon, long biceps tendon, and subscapularis recess were analyzed in consensus by two blinded radiologists (chi(2) test).

RESULTS

Patients with frozen shoulder had a significantly thickened CHL (4.1 mm vs 2.7 mm in controls) and a thickened joint capsule in the rotator cuff interval (7.1 mm vs 4.5 mm; P < .001 for both comparisons, Mann-Whitney test) but not in the axillary recess. The volume of the axillary recess was significantly smaller in patients with frozen shoulder than in control subjects (P = .03, Mann-Whitney test). Thickening of the CHL to 4 mm or more had a specificity of 95% and a sensitivity of 59% for diagnosis of frozen shoulder. Thickening of the capsule in the rotator cuff interval to 7 mm or more had a specificity of 86% and a sensitivity of 64%. Synovitis-like abnormalities at the superior border of the subscapularis tendon were significantly more common in patients with frozen shoulder than in control subjects (P = .014, chi(2) test). Complete obliteration of the fat triangle between the CHL and the coracoid process (subcoracoid triangle sign) was specific (100%) but not sensitive (32%).

CONCLUSION

Thickening of the CHL and the joint capsule in the rotator cuff interval, as well as the subcoracoid triangle sign, are characteristic MR arthrographic findings in frozen shoulder.