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.