Adhesive Capsulitis Demonstrated on Magnetic Resonance Imaging

by Abe Shaikh, MD; Murali Sundaram, MD

The case:

A 32-year-old diabetic man presented with decreased range of motion in his right shoulder

Magnetic resonance imaging (MRI) of the shoulder demonstrated soft tissue thickening and increased signal intensity in the rotator interval, obscuring the normal fat surrounding the coracohumeral ligament, seen on both coronal and sagittal oblique images (Figure 1). In addition, there was an abnormally thickened inferior glenohumeral ligament (Figure 2). These findings are compatible with adhesive capsulitis, an inflammatory condition of the glenohumeral joint capsule and synovium leading to restricted range of motion. The patient’s symptoms improved slightly with physical therapy and corticosteroid injections. However, after a year of intermittent relief from corticosteroid injections, his range of motion was still limited, and he was scheduled for closed manipulation under anesthesia in an attempt to increase his range of motion.
ttempt to increase his range of motion.

Figure 1: Sagittal oblique T1 (A) and fat-saturated T2 (B), and coronal oblique fat-saturated T2 (C), images of the anterior rotator cuff interval in the right shoulder demonstrate replacement of the normal fat surrounding the coracohumeral ligament (arrow) with high-signal soft tissue thickening. Coracoid process (C), acromion (A), and subscapularis tendon (S) are labeled for orientation. Figure 2: Coronal oblique fat-saturated T2-weighted MRI of the right shoulder demonstrates a thickened inferior glenohumeral ligament (arrows).

Epidemiology

Adhesive capsulitis or “frozen shoulder” affects approximately 2% of the general population.¹ Primary or idiopathic adhesive capsulitis refers to patients who develop the condition in the absence of preceding trauma. Secondary adhesive capsulitis results from injury, repetitive low-level trauma, surgery, or endocrine or rheumatological conditions. The condition typically affects women in the fifth and sixth decades of life, although patients with comorbidities such as diabetes may develop the condition at earlier ages.¹ The incidence in patients with diabetes is reported to be 2 to 4 times higher than in the general population.² Patients with diabetes have a 40% chance of developing adhesive capsulitis during their lifetime.¹ In addition, the incidence of diabetes and the life expectancy of patients with diabetes have both increased in recent years, resulting in an overall increase in the incidence of adhesive capsulitis.

Figure 3: Sagital oblique T1 (A) and coronal oblique T2 (B) images of the right shoulder demonstrate a normal coracohumeral ligament (arrow) surrounded by fat as it traverses the anterior rotator cuff interval. Coracoid process (C), acromion (A), and subscapularis tendon (S) are labeled for orientation.

Role of MRI in Diagnosis

Patients typically demonstrate an insidious onset of pain, followed by gradual loss of motion in the shoulder with preservation of the glenohumeral joint space on radiographs. Most patients have no history of trauma. However, these diagnostic criteria are nonspecific and overlap with clinical features of rotator cuff disease and impingement. Magnetic resonance imaging can help in differentiating adhesive capsulitis from more common shoulder pathology by effectively demonstrating the rotator interval and axillary recess, two sites commonly affected by adhesive capsulitis.

Figure 4: Axillary recess. Coronal oblique T2-weighted image demonstrates a normal inferior glenohumeral ligament (arrow) measuring 4 mm in thickness.

The rotator interval is a triangular space bordered superiorly by the supraspinatus tendon, inferiorly by the superior aspect of the subscapularis tendon, laterally by the long head of the biceps tendon, and medially by the base of the coracoid process. The coracohumeral ligament arises from the coracoid process and passes through the rotator interval before inserting on the greater tuberosity and bicipital sheath.³ Figure 3 demonstrates the normal appearance of the coracohumeral ligament as a curvilinear low-signal structure in the anterior rotator interval surrounded by fat. Compare this to the previous images of our patient showing soft tissue thickening of the rotator interval capsule replacing the fat surrounding the coracohumeral ligament.
In addition to the rotator interval, the axillary recess commonly demonstrates abnormalities in adhesive capsulitis. The normal inferior glenohumeral ligament measures <4 mm and is best seen on coronal oblique images at the mid glenoid level (Figure 4). In adhesive capsulitis, the axillary recess may show thickening up to 1.3 cm or more,⁴ as demonstrated in our patient.

Treatment

Adhesive capsulitis is typically a self-limiting disease that improves over an 18- to 24- month period. Treatment options include physical therapy, corticosteroid injections, closed manipulation under anesthesia, and arthroscopic capsular release with lysis of adhesions.^5,6 In the present case, the patient’s symptoms did not improve with conservative treatment involving physical therapy and corticosteroid injections, and at last follow-up, the patient was scheduled for closed manipulation under anesthesia with the possibility of arthroscopic lysis of adhesions in the future.

References

1. Tasto JP, Elias DW. Adhesive capsulitis. Sports Med Arthrosc Rev. 2007; 15(4):216-221.
2. Tighe CB, Oakley WS. The prevalence of a diabetic condition and adhesive capsulitis of the shoulder. South Med. 2008; 101(6):591-595.
3. Lee JC, Guy S, Connell D, Saifuddin A, Lambert S. MRI of the rotator interval of the shoulder. Clinical Radiology. 2007; 62(5):416-423.
4. Sofka CM, Ciavarra GA, Hannafin JA, Cordasco FA, Potter HG. Magnetic resonance imaging of adhesive capsulitis: correlation with clinical staging. HSSJ. 2008; 4(2):164-169.
5. Marx RG, Malizia RW, Kenter K, Wickiwicz TL, Hannafin JA. Intra-articular corticosteroid injection for the treatment of idiopathic adhesive capsulitis of the shoulder. HSSJ. 2007; 3(2):202-207.
6. Bal A, Eksioglu E, Gulec B, Aydog E, Gurcay E, Cakci A. Effectiveness of corticosteroid injection in adhesive capsulitis. Clini Rehab. 2008; 22(6):503-512.

Authors

Drs Shaikh and Sundaram are from the Department of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio.
Drs Shaikh and Sundaram have no relevant financial relationships to disclose.
Correspondence should be addressed to: Abe Shaikh, MD, Department of Radiology – A21, 9500 Euclid Ave, Cleveland, OH 44195.

MRI of adhesive capsulitis of the shoulder

MRI Web Clinic - February 2005 Adhesive Capsulitis by Michael E. Stadnick, M.D. Clinical History: 54-year-old female with decreased range of motion and right shoulder pain increasing over the last 2 months. (A) Sagittal T2-weighted and (B) Coronal fat-suppressed T2-weighted images of the right shoulder are provided. What are the findings? What is your diagnosis? A B Findings A The sagittal T2-weighted image demonstrates a thickened coracohumeral ligament (arrow) and soft tissue thickening in the rotator interval (arrowheads). The short arrow indicates the adjacent long head of the biceps tendon. B The coronal T2-weighted fat-suppressed image (B) demonstrates an abnormally thickened inferior glenohumeral ligament (arrow). Diagnosis Adhesive Capsulitis Discussion Adhesive capsulitis or "frozen shoulder" is an inflammatory condition of the glenohumeral joint synovium and capsule leading to a restricted range of motion. It is most commonly encountered in female patients who are 40 to 60 years of age. Primary or idiopathic adhesive capsulitis is encountered in the absence of preceding trauma. Secondary adhesive capsulitis or post-traumatic arthritis results from antecedent injury, low-level repetitive trauma, surgery, or rheumatologic conditions. Although poorly understood, adhesive capsulitis is felt to begin as an inflammatory hypervascular synovitis, which prompts a progressive fibroblastic response in the adjacent capsule. Capsular thickening and contraction ensue.1 At arthroscopy, synovial inflammation or capsular thickening may be seen. The abnormalities most commonly involve the rotator interval capsule, the biceps tendon root, and the inferior and posterior capsule. The clinical diagnosis of idiopathic adhesive capsulitis relies on the detection of a global decreased range of motion at the glenohumeral joint, absence of previous major trauma, and a normal joint space on plain radiographs.2 However, these diagnostic criteria are nonspecific, as the clinical features of rotator cuff pathology and impingement often mimic those of adhesive capsulitis. MRI effectively demonstrates the rotator interval and the axillary recess, which are sites commonly affected by adhesive capsulitis. The rotator interval lies between the supraspinatus muscle and tendon posterosuperiorly and the subscapularis muscle and tendon anteroinferiorly. The rotator interval capsule is composed of the coracohumeral ligament and the superior glenohumeral ligament. The coracohumeral ligament is readily identified on sagittal and coronal T1-weighted or T2-weighted FSE images as a curvilinear low-signal structure surrounded by fat, lateral to the coracoid process (C and D). The thickness of the capsule of the axillary recess is best demonstrated on coronal images at the mid glenoid level (E). C A sagittal T2-weighted image of the shoulder demonstrates the normal rotator interval. The coracohumeral ligament (arrow), which along with the superior glenohumeral ligament forms the rotator interval capsule, is normally surrounded by fat. The supraspinatus muscle (Sup), subscapularis muscle (Sub), coracoid process (Cor), acromion (Ac) and long head of the biceps (short arrow) are indicated. D A coronal T1-weighted image through the anterior shoulder demonstrates the normal coracohumeral ligament (arrow) arising from the coracoid process (Cor) and extending laterally toward its insertion on the greater and lesser tuberosities of the humerus. The distal clavicle (Cl) is indicated. E A coronal T2-weighted image following an MR arthrogram demonstrates the normal thickness of the inferior glenohumeral ligament (arrow). The MRI findings that suggest adhesive capsulitis include soft tissue thickening in the rotator interval, which may encase the coracohumeral and superior glenohumeral ligaments, and soft tissue thickening adjacent to the biceps anchor (A, F). A thickened inferior glenohumeral ligament greater than 4 mm is often seen in the axillary pouch (B). Loss of definition of the inferior capsule secondary to edema and synovitis may also be demonstrated. IV gadolinium enhancement increases the specificity of the diagnosis by demonstrating enhancement of the rotator interval capsule (G) and enhancement of the capsuloligamentous structures in the axillary recess.3,4 MR Arthrography has also been utilized as a means of making the diagnosis of adhesive capsulitis. However, this procedure is relatively invasive and offers no specific or reproducible signs of adhesive capsulitis.5 F A coronal T2-weighted fat suppressed image through the anterior aspect of the shoulder demonstrates increased signal intensity (asterisk) in the rotator interval region, obscuring the normal fat, suspicious for adhesive capsulitis. The supraspinatus muscle (Sup), subscapularis muscle (Sub), clavicle (Cl), Acromion (Ac) are also indicated. G Post IV gadolinium enhanced sagittal T1-weighted image with fat-suppression demonstrates enhancement in the rotator interval region (arrows), confirming the diagnosis of adhesive capsulitis. The long biceps tendon (short arrow), supraspinatus muscle (Sup), subscapularis (Sub), and Coracoid (Cor) are indicated. The natural history of idiopathic or secondary forms of adhesive capsulitis is quite variable with residual pain and stiffness persisting in some studies up to 7 years.6 Treatment regimens vary greatly, reflecting the complexity of this condition. Supportive treatment, oral and injected medications, physical therapy, the brisement procedure, manipulative therapy, and surgical release are all used in addressing this disorder, depending on the severity and duration of symptoms. Conclusion The MRI changes of adhesive capsulitis are most often observed at the rotator interval and the inferior glenohumeral ligament. Recent evidence indicates that IV gadolinium enhanced MR provides even greater specificity in diagnosing adhesive capsulitis. MRI is therefore an invaluable tool in differentiating adhesive capsulitis from other conditions that may have a similar clinical presentation. References 1 Hannafin JA, DiCarlo ED, Wickiewicz TL, and Warren RF: Adhesive capsulitis: capsular fibroplasias of the Glenohumeral joint. J Shoulder Elbow Surg 3(S):5, 1994. 2 Kessel L: Disorders of the Shoulder. New York: Churchill Livingstone, 1982, p82. 3 Carillon Y, Noel E, Fantino O, Perrin-Faylle O, Tran-Minh VA: Magnetic resonance imaging findings in idiopathic adhesive capsulitis of the shoulder. Rev Rhum Engl Ed. 1999 Apr;66(4):201-6. 4 Connell D, Padmanabhan R, Buchbinder R. Adhesive capsulitis: role of MR imaging in differential diagnosis. European Radiology. 2002 Aug;12(8):2100-6. 5 Manton GL, Schweitzer ME, Weishaupt D, Karasick D. Utility of MR arthrography in the diagnosis of adhesive capsulitis. Skeletal Radiol 2001;30:326-30. 6 Shaffer B, Tibone JE, Kerlan RK: Frozen shoulder: A long-term follow-up. J Bone Joint Surg 74A:738-746, 1992.

vascular territories of cerebral arteries

Cerebral Arterial Territory

Vascular territories of the cerebral arteries (adapted and modified with permission from M. Savoiardo (1)

Posterior Inferior Cerebellar Artery (PICA in blue) The PICA territory is on the inferior occipital surface of the cerebellum and is in equilibrium with the territory of the AICA in purple, which is on the lateral side (1). The larger the PICA territory, the smaller the AICA and viceversa. Superior Cerebellar Artery (SCA in grey) The SCA territory is in the superior and tentorial surface of the cerebellum. Branches from vertebral and basilar artery These branches supply the medulla oblongata (in blue) and the pons (in green). Anterior Choroideal artery (AchA in blue)) The territory of the AChA is part of the hippocampus, the posterior limb of the internal capsule and extends upwards to an area lateral to the posterior part of the cella media. Lenticulo-striate arteries The lateral LSA' s (in orange) are deep penetrating arteries of the middle cerebral artery (MCA). Their territory includes most of the basal ganglia. The medial LSA' s (indicated in dark red) arise from the anterior cerebral artery (usually the A1-segment). Heubner's artery is the largest of the medial lenticulostriate arteries and supplies the anteromedial part of the head of the caudate and anteroinferior internal capsule. Anterior cerebral artery (ACA in red) The ACA supplies the medial part of the frontal and the parietal lobe and the anterior portion of the corpus callosum, basal ganglia and internal capsule. Middle cerebral artery (MCA in yellow) The cortical branches of the MCA supply the lateral surface of the hemisphere, except for the medial part of the frontal and the parietal lobe (anterior cerebral artery), and the inferior part of the temporal lobe (posterior cerebral artery). The deep penetrating LSA-branches are discussed above. Posterior cerebral artery (PCA in green) P1 extends from origin of the PCA to the posterior communicating artery, contributing to the circle of Willis. Posterior thalamoperforating arteries branch off the P1 segment and supply blood to the midbrain and thalamus. Cortical branches of the PCA supply the inferomedial part of the temporal lobe, occipital pole, visual cortex, and splenium of the corpus callosum.

subcoracoid and subscapularis space

Drawing shows subcoracoid space in oblique sagittal plane. Note superior subscapularis recess and subcoracoid bursa located anterior to subscapularis muscle. Also note saddlebag appearance of subscapularis recess over subscapularis muscle.