Health &Medicine

1. Dr/ ABD ALLAH NAZEER. MD.
Radiological imaging of adhesive capsulitis(Frozen shoulder).

2. 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.

3. Clinical presentation
Adhesive capsulitis presentation can be broken into three distinct stages:
freezing: painful stage
patients may not present during this stage because they think that
eventually, the pain will resolve if self-treated
as the symptoms progress, pain worsens and both active and passive range
of motion (ROM) becomes more restricted
this can eventually result in the patient seeking medical consultation
typically lasts between 3 and 9 months and is characterised by an acute
synovitis of the glenohumeral joint
frozen: transitional stage
most patients will progress to the second stage
during this stage, shoulder pain does not necessarily worsen
because of pain at the end of the range of motion, arm movement may be
limited, causing muscular disuse
can last between 4 to 12 months
the common capsular pattern of limitation has historically been described as
diminishing motions with external shoulder rotation being the most limited,
followed closely by shoulder flexion, and internal rotation
a point is eventually reached in the frozen stage where pain does not occur
at the end of the range of motion

4. thawing stage(Resolution stage).
begins when the range of motion starts to improve
lasts anywhere from 12 to 42 months and is
defined by a gradual return of shoulder mobility
Pathology
Adhesive capsulitis is divided into two main types:
primary or idiopathic
absence of preceding trauma
secondary
major or minor repetitive trauma
shoulder or thoracic surgery
endocrine, e.g. diabetes, hyperthyroidism
rheumatological conditions

5. Radiographic features
Fluoroscopic arthrography
Described features include:
limited injectable fluid capacity of the glenohumeral joint
small dependent axillary fold
small subscapularis bursa
irregularity of the anterior capsular insertion at the
anatomic neck of the humerus
lymphatic filling may be present
Ultrasound
Limitation of movement of the supraspinatus is
considered a sensitive feature. A thickened coracohumeral
ligament (CHL) can also be a suggestive feature of
adhesive capsulitis.

6. MRI/MR arthrography
normal inferior glenohumeral ligament measures <4 mm
and is best seen on coronal oblique images at the mid
glenoid level; in adhesive capsulitis, the axillary recess
may show thickening ≥1.3 cm
joint capsule thickening
abnormal soft tissue thickening within the rotator
interval with signal alteration
abnormal soft tissue encasing the biceps anchor
variable enhancement of the capsule and synovium within
the axillary recess and rotator interval
Other MR arthrography features include:
thickening of the coracohumeral ligament (CHL)
subcoracoid triangle sign

7. Conventional arthrography, anteroposterior view. (a) Normal distension of the axillary
recess (black arrow) and the subscapular recess (thick arrow). (b) Reduced distension
of the axillary recess (black arrow) and subscapular recess associated with medial
leakage of contrast (white arrow) in a patient with adhesive capsulitis.

8. Axillary long-axis view of the inferior glenohumeral ligament with arm in
abduction. (a) Thickening of the inferior capsular profile (calipers, 3.3 mm)
in a shoulder affected by adhesive capsulitis. H humerus (b) In the
contralateral shoulder, the capsule has normal thickness (calipers, 1.5 mm)

9. Coronal oblique T2-
weighted fat-saturated
(a, b) and axial proton
density fat-saturated
(c, d) images. In a healthy
subject (a, c), the capsular
recess has normal signal
intensity (arrows), while
in a patient with adhesive
capsulitis (b, d), clear
signal hyperintensity can
be seen
(arrows). H humerus,
G glenoid, S supraspinatu
s tendon

10. Coronal oblique proton density image in a patient with adhesive capsulitis.
The axillary pouch (arrows) is thickened. G glenoid, H humerus.

11. MR arthrography, coronal oblique T1-weighted fat-saturated image. (a) In a healthy subject,
the axillary pouch is normally distensible (arrow). H humerus, G glenoid. (b). In a patient
with adhesive capsulitis, the axillary pouch is contracted and poorly distended (arrow)

12. MRI scan showing thickened (5mm) inferior capsule (normally 1mm).

13. Left Shoulder. Coronal T2 FS image of a 33-years-old male patient.
Shows thickened GHLI (5,58mm) synovial intraarticular liquid increase.

14. T2-fatsat MRI: Thickening of the capsule in the axillary
recess, and intermediate signal in adjacent soft tissues.

15. Coronal T1 (left) and PD-fat sat (right) MRI. Thickening (left) and intermediate signal
(right) of the joint capsule in the axillary recess in a patient with adhesive capsulitis.

16. MR arthrography, (a) coronal oblique and (b) axial T1-weighted fat-saturated
image in a patient with adhesive capsulitis. Leakage of contrast agent can be seen
on the anterior inferior margin of the scapula (arrow). H humerus, G glenoid

17. Oblique coronal PDFS image of a 45-year-
old woman after recent trauma. There is
thickening and edema of the axillary
recess(white arrow).
Oblique coronal T1 weighted image of a 57-year-
old man with clinically proven adhesive capsulitis.
There is thickening of the axillary recess, which is
only mildly hyperintense (white arrows).

18. Adhesive capsulitis of the shoulder.

19. Adhesive Capsulitis.

20. Adhesive capsulitis.

21. MRI findings are subtle in frozen shoulder. To be certain, frozen shoulder is a
clinical diagnosis, and there are no specific direct signs that are pathognomonic
for frozen shoulder. Described direct signs suggestive of frozen shoulder include:
Thickening of the glenohumeral joint capsule along the axillary pouch
Thickening of the coracohumeral ligament
Obliteration of the subcoracoid fat triangle
Rotator interval synovitis.

22. MRI shows- poor definition of coracohumeral ligament with abnormal intermediate
amorphous signal (with hypointense foci on all sequences) surrounding the ligament
with ill definition of superior glenohumeral ligament & rotator interval with mild free
fluid in the shoulder joint – likely suggesting adhesive capsulitis.

23. Inferior glenohumeral ligament and the
inferior joint capsule (yellow block arrow) in
the axillary recess shows diffuse thickening.
Diffuse thickening of the coracohumeral ligament
(white arrow) extending up to the rotator cuff
interval and is hyperintense on the T2 images.

24. (2a) 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.
(2b) The coronal T2-weighted fat-suppressed image demonstrates an abnormally thickened
inferior glenohumeral ligament (arrow).
(2a)
(2b)

25. Adhesive capsulitis is a self-limited clinical syndrome characterized
by painful, gradual loss of active and passive glenohumeral motion.

26. Sagittal oblique T1-weighted
image (TR/TE = 550 ms/15 ms) (1A)
shows thickened CHL (arrows).
C = inferior margin for the coracoid
process. Sagittal oblique (1B),
oblique coronal (1C), and
transverse (1D) fat-suppressed,
proton density weighted, spin-echo
image (TR/TE = 3000 ms/34 ms)
show high-signal intensity soft
tissue in the rotator cuff interval
for the same patient (arrows).
Coronal oblique (1E) and
transverse (1F) fat-suppressed,
proton density, weighted spin-echo
image (TR/TE = 3000 ms/34 ms)
demonstrate a thickened inferior
glenohumeral ligament (axillary
recess) for the same patient
(arrows).

27. Magnetic Resonance Imaging, Arthrography, and Ultrasonography Reflect Clinical
Impairment in Patients With Idiopathic Adhesive Capsulitis of the Shoulder.

28. Oblique sagittal PDFS image of a 69-year-
old man. There is thickening of the CHL,
and fibrovascular tissue with mild edema
in the rotator cuff interval(white arrow).
Fibrovascular changes are visible around
CHL and around SGHL. Axial PDFS images
(A,B) through the rotator cuff interval
shows extensive fibrovascular tissue
around the biceps tendon (white arrow).

29. Sagittal oblique T2-weighted image in a patient
with adhesive capsulitis. The coracohumeral
ligament (arrows) is markedly thickened.
MR arthrography, sagittal oblique T1-
weighted image. In a patient with adhesive
capsulitis for 15 weeks, the fat triangle
(arrowheads) signal is considerably reduced.

30. Oblique sagittal PD weighted image shows
obliteration and fibrosis in subcoracoid space.
Oblique sagittal oblique PD weighted
image shows thickened CHL (arrow) in a
57-year-old man with adhesive capsulitis.

31. 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.
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.

32. Sagittal oblique T1 MRI. Thickened coracohumeral
ligament (arrows) in a patient with frozen shoulder.

33. T1 sagittal oblique MRI (left): Almost complete obliteration of subcoracoid fat (arrow);
T2 fat-sat sagittal oblique MRI (right): intermediate signal scar in the rotator interval.

34. Adhesive capsulitis with frozen Shoulder.

35. Thank You.