Adhesive capsulitis of the shoulder: diagnosis using magnetic resonance arthrography, with arthroscopic findings as the standard

OBJECTIVE: The purpose of this study was to assess the usefulness of magnetic resonance (MR) arthrography of the glenohumeral joint in the diagnosis of adhesive capsulitis. METHODS: MR arthrography of the glenohumeral joint was performed in 16 patients with arthroscopically proven adhesive capsulitis and 11 controls. Thickness of the joint capsule and synovium, filling ratio of the fluid-distended axillary recess to the posterior joint cavity, and a width of the rotator cuff interval were measured by 2 musculoskeletal radiologists. The measurements of those parameters for the patients with adhesive capsulitis and the controls were compared. Interobserver variability for the measurements of each parameter was calculated. RESULTS: The mean thickness of the joint capsule and synovium was 2.97 mm in patients with adhesive capsulitis and 1.86 mm in controls (P < 0.001). The mean filling ratio of the fluid-distended axillary to the posterior joint cavity was 0.51 in patients with adhesive capsulitis and 0.82 in controls (P = 0.004). The mean width of the rotator cuff interval was 7.45 mm in patients with adhesive capsulitis and 8.48 mm in controls (P > 0.05). Intraclass correlation coefficient for interobserver variability showed good agreement (95% CI; 0.72-0.95). CONCLUSIONS: On MR arthrography, thickening of the joint capsule and synovium and diminished filling ratio of the axillary recess to posterior joint cavity appeared to be useful diagnostic criteria for the diagnosis of adhesive capsulitis of the shoulder.     

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: role of MR imaging in differential diagnosis

The purpose of this study was to describe and characterize the MR imaging findings in a group of patients who underwent surgery for adhesive capsulitis. Twenty-four MR imaging studies in 24 consecutive patients with clinical evidence of adhesive capsulitis were performed prior to arthroscopic capsulotomy. There were 17 women and 7 men with a mean age of 53.5 years. Images were scrutinised for changes in the synovium particularly in the rotator interval, around the biceps anchor and axillary pouch. Intravenous gadolinium was given routinely. We also examined a control group of 22 patients who underwent the same MR imaging protocol after referral for rotator cuff pathology. Soft tissue density showing variable enhancement after gadolinium administration was visible in the rotator interval in 22 of 24 studies on MR imaging. Seventeen patients showed soft tissue density partially encasing the biceps anchor. Ten patients showed thickening and gadolinium enhancement of the axillary pouch. Three patients from the study cohort had partial tears of the supraspinatus tendon. All the patients subsequently had surgery which confirmed fibrovascular scar tissue in the rotator interval, around the biceps anchor and a variable degree of synovial inflammation of the glenohumeral capsule. Two patients from a control group with suspected rotator cuff pathology showed abnormal intensity in the rotator interval on MR imaging. Magnetic resonance imaging can identify changes in the shoulder joint that correspond to abnormalities seen at surgery. This may be useful for discriminating adhesive capsulitis from other causes of shoulder pain.     

Extra-articular contrast material leaks into locations unrelated to the injection path in shoulder MR arthrography

Objectives

To evaluate the localisation, frequency and amount of extravasation in patients with extra-articular contrast material leak into locations unrelated to the injection path in shoulder magnetic resonance (MR) arthrography and associated shoulder disorders.

Methods

The sites of extravasation were determined on the shoulder MR arthrography of 40 patients. The extravasations were measured on three vertical planes of the MR arthrography. Sufficient joint distension was assessed according to the transverse diameters of the axillary recess on coronal MR images.

Results

Extravasation of the contrast material occurred through the subscapular recess, the synovium of the biceps, and the axillary recess. In four cases, extravasations were observed in more than one anatomic location. The most common site of extravasation was along the subscapularis muscle. Superior labrum anterior-posterior (SLAP) lesions were found to be most frequently associated with extravasations. The amount of extravasation was significantly higher in patients with adhesive capsulitis compared with the patients with a different diagnosis (p?=?0.022).

Conclusions

The extravasations adjacent to the axillary recess do not always indicate glenohumeral ligament pathology. Massive subscapular extravasations were most frequently associated with adhesive capsulitis and SLAP lesions, and might be considered in the MR arthrography report.

Key Points

? Contrast material extravasation may reduce the diagnostic value of shoulder MR arthrography. ? The extravasations may occur into locations unrelated to the injection path. ? The extravasations adjacent to axillary recess can be misleading for HAGL lesion. ? Massive subscapular extravasations were frequently associated with adhesive capsulitis and SLAP lesions.     

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?p?p?p?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.     

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.     

MR arthrographic findings in tenosynovitis of the long bicipital tendon of the shoulder

 Purpose. To assess the MR arthrographic findings of bicipital tenosynovitis in correlation with arthroscopy. Design and patients. The shoulder MR arthrographies of 500 consecutive patients were retrospectively analyzed for signs of bicipital tenosynovitis and associated pathologies. Forty patients (8%) had MR evidence of bicipital tenosynovitis, but only 17 (3%) with arthroscopic confirmation were included in the study. The MR findings in these patients were compared with those of 10 patients with rotator cuff lesions but arthroscopically normal long biceps tendons. MR arthrography was performed with 10–15 ml of a 250 mmol/l gadoterate meglumine (Gd-DOTA) solution injected under fluoroscopic guidance, and transaxial, oblique coronal and sagittal MR sequences were obtained. Results. All 17 patients showed one or more abnormal findings: signal increase in the tendon with or without fusiform distension was seen in 12, surface irregularities in six, adhesions in 11 and noncommunicating effusions of the tendon sheath in six. Associated abnormalities of the rotator cuff were present in 16 while the seventeenth patient had glenohumeral synovitis without rotator cuff pathology. MR arthrograms correlated with arthroscopic findings in the joint but comparison was not possible in the intertubercular groove portion of the biceps tendon. None of the 10 patients with an arthroscopically normal biceps tendon showed any of the MR findings of bicipital tenosynovitis. Conclusion. Bicipital tenosynovitis is detectable by MR arthrography. In most cases it is an associated finding of rotator cuff abnormalities and likely to have a similar etiology. When lesions of the anterior rotator cuff are recognized, the biceps tendon should be scrutinized for inflammatory changes.     

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.     

Indirect MR arthrography: techniques and applications

Indirect MR arthrography is a relatively new MR technique improving articular and periarticular contrast. It is achieved by injection of paramagnetic MR contrast media intravenously instead of intra-articular injection as in direct MR arthrography. After the injection exercising the joint results in considerable signal intensity increase within the joint cavity. Fat saturated MR sequences then yield arthrographic images. The method is less invasive than direct MR arthrography and first results showed comparable sensitivities and specificities for rotator cuff and glenoid labrum pathology. In this article the technique, established and potential future indications, drawbacks and limitations of the method are reviewed. Received: 26 March 1997; Revision received 31 July 1997; Accepted 1 August 1997     

Evaluation of Rotator Cuff Tendon Tears: Comparison of Multidetector CT Arthrography and 1.5-T MR Arthrography

Purpose: To compare the diagnostic performance of multidetector computed tomographic (CT) arthrography and 1.5-T magnetic resonance (MR) arthrography in the evaluation of rotator cuff lesions, with arthroscopic correlation. Materials and Methods: This study was approved by the institutional ethical committee, and informed consent was obtained from all patients. CT and MR arthrographic images prospectively obtained in 56 consecutive patients, following the same arthrographic procedure, were independently evaluated by two radiologists. Arthroscopy, performed within 1 month of the imaging, was used as the reference standard. Sensitivity and specificity of CT and MR arthrography were compared by using the McNemar test. Interobserver and intertechnique agreement for detecting rotator cuff lesions were measured and compared with κ and Z statistics. The Bland-Altman method was used to determine interobserver and intertechnique agreement for measuring tendon tears. For grading fatty infiltration of rotator cuff muscles, κ and Z statistics were used. Results: There was no statistically significant difference in sensitivity and specificity between CT arthrography and MR arthrography in depiction of rotator cuff lesions. The respective sensitivity and specificity of CT arthrography were 92% and 93%-97% for the supraspinatus, 100% and 77%-79% for the infraspinatus, 75%-88% and 85%-90% for the subscapularis, and 55%-65% and 100% for the biceps tendon. The respective sensitivity and specificity of MR arthrography were 96% and 83%-93% for the supraspinatus, 88%-100% and 81%-83% for the infraspinatus, 75%-88% and 90%-100% for the subscapularis, and 65%-85% and 100% for the biceps tendon. Interobserver agreement was substantial to almost perfect (κ = 0.744-0.964 for CT arthrography; κ = 0.641-0.893 for MR arthrography), and intertechnique agreement was almost perfect (κ > 0.819). CT and MR arthrography both yielded moderate interobserver and intertechnique agreement for measuring rotator cuff tears and grading muscle fatty infiltration. Conclusion: Data suggest that CT and MR arthrography have similar diagnostic performance for the evaluation of rotator cuff tendon tears. ? RSNA, 2012.     

Evaluation of articular cartilage thickness of the humeral head and the glenoid fossa by MR arthrography: anatomic correlation in cadavers

Objective. To evaluate the accuracy of MR arthrography in determining the thickness of articular cartilage of the humeral head and glenoid fossa. Design and patients. MR arthrography of the glenohumeral joint was performed in 17 cadaveric shoulders. Articular cartilage thickness was measured on the MR arthrographic images and corresponding anatomic sections. Results. The correlation coefficients for MR arthrographic measurement versus anatomic measurement of the cartilage thickness were 0.7324 and 0.8757 for humeral head and glenoid fossa, respectively. With regard to the humeral head, there was a tendency to overestimate regions of thin cartilage and underestimate regions of thick cartilage. This tendency was not found in the assessment of glenoid cartilage. The mean of the absolute value of MR-anatomic differences was similar on the glenoid side (0.27 mm) and the humeral side (0.29 mm). The accuracy of measurement was significantly better on the glenoid side (Fisher’s r-to-Z transformation: Z=5.21, P=0.000001). Conclusion. MR arthrography causes a moderate degree of error in the naked-eye measurement of the cartilage of the glenohumeral joint. The accuracy is higher on the glenoid side than on the humeral side.     

Reactive synovitis of the knee joint: MR imaging appearance with arthroscopic correlation

Objective. To evaluate the use of routine MR imaging sequences in detecting and characterizing secondary reactive synovitis of the knee joint using arthroscopy as the standard of reference. Design and patients. Fifty consecutive patients with a history of knee pain who were referred for MR imaging and subsequently underwent arthroscopy of the knee comprised the study group. MR images were evaluated for the presence and appearance of synovitis reflected in synovial thickening and irregularity. Synovial thickening was graded on MR imaging as follows: 0=normal, 1=thin line of increased signal intensity, 2=increased signal intensity with frond-like or hair-like projections and a granular appearance of joint fluid. Standard knee imaging protocols were used. Results. The sensitivity, specificity, and accuracy of MR imaging in detecting synovitis compared with arthroscopy were 88%, 97%, and 95%, respectively. Grade 1 synovitis was best seen on proton-density-weighted images, demonstrating increased signal intensity of the synovium against the relatively low signal intensity of the joint fluid. Grade 2 synovitis was best seen on proton-density images and T2-weighted spin echo and fast spin echo images with fat saturation, demonstrating a granular and linear hair-like appearance of joint fluid. Axial and sagittal imaging planes were most helpful in the diagnosis of synovitis. Conclusion. Routine MR pulse sequences are useful in identifying the presence and extent of synovial abnormalities. The detection of different stages of synovial pathology should become an important part of the evaluation of the post-traumatic patient as treatment may be altered as a result. Received: 17 March 2000 Revision requested: 5 May 2000 Revision received: 8 June 2000 Accepted: 8 June 2000     

Indirect wrist MR arthrography: the effects of passive motion versus active exercise

Purpose.In the wrist, to determine whether passive motion or active exercise yields a better indirect MR arthrographic effect following intravenous gadolinium administration. Design and patients. Twenty-six consecutive patients were studied by indirect wrist MR arthrography. In half active exercise and in half passive motion was performed. Four regions of interest were studied including the distal radioulnar joint, the radiocarpal joint, the midcarpal joint, and the triangular fibrocartilage. Ranges and means of signal intensity were calculated. Surgical follow-up was performed in 22 patients. Results. The joint fluid intensity was greatest in the distal radioulnar joint. Fluid signal intensity was greater and more consistent in the passive motion group although the results did not achieve statistical significance. Imaging accuracy appeared similar in the two groups and was excellent for the triangular fibrocartilage (100%) and scapholunate ligaments (96%). Conclusion. Active exercise and passive motion yield similar degrees of wrist arthrographic effect, but the effect of passive motion is somewhat more consistent. Preliminary data show good accuracy for internal derangements. Received: 4 June 1999 Revision requested: 6 August 1999 Revision received: 14 September 1999 Accepted: 20 September 1999     

Humeral avulsion of the anterior shoulder stabilizing structures after anterior shoulder dislocation: demonstration by MRI and MR arthrography

 Objective. To demonstrate the MRI findings of an anterior shoulder capsular avulsion from the humerus, with or without subscapularis rupture, after anterior dislocation or severe abduction external rotation injury. Design and patients. We retrospectively reviewed the MRI and MR arthrographic examinations of seven patients who were identified at surgery with avulsion of the anterior shoulder stabilizers from the humerus. MRI was correlated with clinical history and surgical results. Results. MRI findings included: inhomogeneity or frank disruption of the anterior capsule at the humeral insertion (all), fluid intensity anterior to the shoulder (six patients), tear of the subscapularis tendon (six patients), dislocation of the biceps tendon (four patients), and a Hill-Sachs deformity (four patients). MR arthrography additionally found extravasation of contrast through the capsular defect (two patients). Conclusions. Our findings suggest that MRI is helpful for diagnosing humeral avulsion of the anterior glenohumeral capsule, especially when a tear of the subscapularis tendon insertion is present. MR arthrography may be of benefit for diagnosing capsular avulsion without associated subscapularis tendon abnormality.     

Adhesive capsulitis of the wrist: arthrographic diagnosis

Persistent pain and decreased range of motion are disabling complications of wrist trauma. Between 1978 and 1986, in ten patients with persistent pain following trauma, arthrography depicted changes characteristic of adhesive capsulitis. Adhesive capsulitis has been described in the shoulder, hip, and ankle, but little mention has been made of this entity in other joints. Confirmation of this diagnosis requires arthrography, since there are no characteristic findings on plain radiographs. Typical arthrographic findings include decreased capacity, small volar and styloid recesses, and adhesions preventing complete opacification of the joint. The arthrographic diagnosis allows proper institution of appropriate therapy.     

Bizepsprobleme: Ultraschall, Magnetresonanztomographie und MR-Arthrographie

Ultrasound and MR imaging are competitive imaging modalities for the diagnosis of pathologic conditions of the biceps tendon. MR imaging has substantial advantages over ultrasound because biceps tendon lesions are most commonly located in the proximal part where lesions are hidden under the acromion for ultrasound assessment. The value of MR arthrography is substantiated by the capability to assess associated diagnoses which are otherwise difficult to assess. Associated diagnoses include full- and partial thickness tears of supraspinatus and subscapularis tendons, pulley lesions, and adhesive capsulitis (frozen shoulder). Moreover, MR arthrography is the method of choice for the assessment of superior labral anterior posterior (SLAP) lesions.     

Anterolateral ankle impingement: mr arthrographic assessment of the anterolateral recess

PURPOSE: To determine the accuracy of magnetic resonance (MR) arthrography in assessing the anterolateral recess of the ankle. MATERIALS AND METHODS: Thirty-two patients with chronic ankle pain prospectively underwent gadolinium-enhanced MR arthrography of the tibiotalar joint. All underwent clinical examination and were included if anterolateral impingement (n = 13) or a control condition (n = 19; suspected osteochondral defect, intraarticular bodies, instability, osteoarthritis) was diagnosed. MR imaging included transverse and coronal T1-weighted and sagittal T2-weighted imaging sequences. Images were prospectively analyzed by two readers blinded to the clinical diagnosis. The anterolateral gutter contour was assessed. MR arthrographic findings were correlated with subsequent arthroscopic appearances. RESULTS: MR arthrographic assessment of the anterolateral soft tissues had an accuracy of 97%, sensitivity of 96%, specificity of 100%, negative predictive value of 89%, and positive predictive value of 100%. Accuracy was 100% with clinical anterolateral impingement, with an arthroscopically confirmed abnormality in 12 cases and a normal appearance in one. Anterolateral soft-tissue thickening was identified at MR arthrography in 11 control cases, with arthroscopic confirmation in all. The remaining cases had normal appearances, with an arthroscopic soft-tissue abnormality in one case and a normal appearance in seven. CONCLUSION: MR arthrography of the tibiotalar joint is accurate in assessing the anterolateral recess of the ankle.     

Shoulder arthrography as a treatment modality.

Some patients undergoing shoulder arthrography with a stiff and painful joint have a small volume capsule or a frozen shoulder. In certain cases when the rotator cuff is intact, the arthrographic procedure has been therapeutic and joint distention has effected a return to normal function. Four such cases are presented.     

Schultergelenkverletzungen bei Überkopfsportarten

Overhead sport places great demands on the shoulder joint. Shoulder pain in overhead athletes and throwers can in the majority of cases be attributed to lesions resulting from chronic overuse of tendons and capsuloligamentous structures or to sequels of microinstability and secondary impingement. Due to its great impact on therapeutic decisions, imaging in athletes with unclear shoulder pain is a challenge. In this connection, magnetic resonance (MR) arthrography represents the cross-sectional imaging modality of first choice, as it allows depiction and exclusion of pathologic alterations of all relevant joint structures with sufficient confidence. This article reviews the biomechanical and clinical aspects and MR arthrographic features of the most common shoulder pathologies in overhead athletes, including biceps tendinopathy, superior labral anterior-posterior (SLAP) lesions, rotator cuff lesions, as well as extrinsic and intrinsic impingement syndromes.     

Ultrasound in adhesive capsulitis of the shoulder: is assessment of the coracohumeral ligament a valuable diagnostic tool?

Objective To determine the accessibility of the coracohumeral ligament (CHL) by ultrasound (US) and to determine CHL thickness in adhesive capsulitis of the shoulder.Design and patients US examinations were carried out in 498 consecutive shoulders of 306 individuals (194 women and 112 men), mean age 47.4 years (range 15–92 years), in order to identify and measure the maximum thickness of the CHL. The patients were divided into three study groups: asymptomatic shoulders (n=121), painful shoulders (n=360) and shoulders with arthrographic evidence of adhesive capsulitis (n=17). The mean maximal thickness of CHL was compared among the 3 study groups (non-parametric test of Kruskal–Wallis, p<0.05).Results The CHL was visualized in 92 out of 121 shoulders in the asymptomatic group (76.0%), in 227 out of 360 shoulders in the painful shoulder group (63.0%), and in 15 out of 17 shoulders in the adhesive capsulitis group (88.2%). The average thickness of the CHL was significantly greater in adhesive capsulitis (3 mm) than in the asymptomatic (1.34 mm) and painful (1.39 mm) shoulders. No significant difference was found between asymptomatic and painful shoulders.Conclusion CHL depiction can be achieved in a reasonable proportion of shoulders. A thickened CHL is suggestive of adhesive capsulitis. More studies are needed for clinical validation of these data.