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14 thoughts on “Adhesive Capsulitis? Yes or No? 69M 2 months pain and limited range of motion”
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Thanks for this discussion, I feel the frustration with int rotation.
Won’t normally call without rotator interval findings. Usually would say
something like:
although there is thickening and intermediate signal of the IGHL anterior
band, this may be accentuated by internal rotation and there is no signal
abnormality in the rotator interval to support adh caps.
That way I get words in the report to say I’m thinking about it at least.
That said I’d love to hear how the crowd approaches this — I agree the
capsular thickening seems to stand out.
-Matt O
On Fri, Jun 25, 2021 at 11:18 AM hilary umans <hilary.umans@gmail.com>
wrote:
[gallery]
I would call it. The capsule looks swollen next to the humeral head
insertion. With redundancy due to internal rotation alone the capsule stays
dark no? I’ve called it before without much going on in the rotator
interval in patients who had definite clinical frozen shoulder. Also have
seen various stages where it is swollen near the humeral insertion and
others near the glenoid. Maybe early or healing adhesive capsulitis?
Maybe I’m over thinking it.
Does she have convincing clinical frozen shoulder?
On Fri, Jun 25, 2021 at 1:28 PM Matthew O’Brien < matthewbrennanobrien@gmail.com> wrote:
[gallery]
In an ideal world, external rotation is best… Better to have internal rotation than a scan filled with motion because of patient pain/movement.
My 2 cents….
Best,
Frank
Thanks for this discussion, I feel the frustration with int rotation. Won’t normally call without rotator interval findings. Usually would say something like:
although there is thickening and intermediate signal of the IGHL anterior band, this may be accentuated by internal rotation and there is no signal abnormality in the rotator interval to support adh caps.
That way I get words in the report to say I’m thinking about it at least. That said I’d love to hear how the crowd approaches this — I agree the capsular thickening seems to stand out.
-Matt O
The arm is internally rotated….which is a CONSTANT frustration.I’ve been told by some in this forum that they don’t diagnose adhesive capsulitis with normal rotator interval capsule (Sag T1 looks quite normal in this case).I think anterior axillary capsular thickening and edema is seen best in the “BLO” sequence (top) ….though thickening might be exaggerated by arm rotation.Really no tendinosis…some mild SA/SD bursitis….that’s it. What do you think?
I agree with Phil. Will call it Adhesive capsulitis.
Tarun Pandey M.D, F.R.C.R
I would call it. The capsule looks swollen next to the humeral head insertion. With redundancy due to internal rotation alone the capsule stays dark no? I’ve called it before without much going on in the rotator interval in patients who had definite clinical frozen shoulder. Also have seen various stages where it is swollen near the humeral insertion and others near the glenoid. Maybe early or healing adhesive capsulitis?
Maybe I’m over thinking it.
Does she have convincing clinical frozen shoulder?
Thanks for this discussion, I feel the frustration with int rotation. Won’t normally call without rotator interval findings. Usually would say something like:
although there is thickening and intermediate signal of the IGHL anterior band, this may be accentuated by internal rotation and there is no signal abnormality in the rotator interval to support adh caps.
That way I get words in the report to say I’m thinking about it at least. That said I’d love to hear how the crowd approaches this — I agree the capsular thickening seems to stand out.
-Matt O
<1.jpg>
<2.jpg>
<3.jpg>
The arm is internally rotated….which is a CONSTANT frustration.
I’ve been told by some in this forum that they don’t diagnose adhesive capsulitis with normal rotator interval capsule (Sag T1 looks quite normal in this case).
I think anterior axillary capsular thickening and edema is seen best in the “BLO” sequence (top) ….though thickening might be exaggerated by arm rotation.
Really no tendinosis…some mild SA/SD bursitis….that’s it.
What do you think?
[gallery]
I was genuinely interested to hear everyone’s opinion….but the responses I have received directly have ranged from Definitely adhesive capsulitis, to Definitely not…and every shade of gray in between. I don’t personally understand the wide held opinion that the RI must be involved. We all know that there can be localized and even circumferential adhesive capsulitis.
While it is usually a clinical diagnosis, early on the symptoms and exam findings can be less specific. I think the history of 2 months pain and LROM, without much else either than mild SA/SD bursitis is compelling.
That apparent asymmetric thickening and bright capsular signal at the humeral insertion (as Phil says) seems to support adhesive capsulitis.
I reported “findings suggesting adhesive capsulitis in the proper clinical context”. No cuff pathology. Mild bursitis. It’s up to the clinician to decide what to make of it.
Sometimes when it’s not very convincing I have used the term “capsulitis” instead of adhesive capsulitis(something I picked from attendings I worked with during fellowship). The “adhesive” part, clinicians can figure out.
Saeed Ahmed, MD
I think you handled it great. Not much downside as the patient may get treated with a steroid as the “big gun” treatment which could help any other cause of his symptoms if adhesive capsulitis is not there. Upside is that the patient gets treated appropriately if the disease is indeed present.
Good point Saeed. There are certainly cases of capsulitis that are secondary to other causes. Like rotator cuff disease!
Completely agreed with Dr. Ahmed, I do the same. Especially if there is no
clear clinical history of range of motion limitation.
Atul
Em sex., 25 de jun. de 2021 às 19:00, Saeed Ahmed <saeedahmed207@gmail.com>
escreveu:
A rare Reply All….apologies in advance for the long-winded response
In early stage adhesive capsulitis, ROM can be preserved or minimally
diminished.
I’ve seen what looked like flagrant adhesive capsulitis, which I diagnosed
with confidence as there was no other imaging abnormality.
The orthopedist called to inform me that there was normal ROM.
I suggested he get back to me in another month. 3 weeks later, the patient
returned with severe limited range of motion.
I suppose we can diagnose capsulitis and leave off the word “adhesive”…:
and that will allow us to be right regardless of physical exam findings.
But that’s all it accomplishes.
At the end of the day, it’s about helping the referrer help the
patient….Right????
No matter what we see has to be put in the context of history and exam
findings….regardless of whether we say “clinical correlation is
recommended”….which is implicit and really (appropriately) annoys a lot of
referrers.
I think the majority of us agree that the capsule looks abnormal
independent of effects of internal arm rotation….that was my
question—-thank you all for your responses.
Some of us are insistent that the rotator interval must be involved to
diagnose adhesive capsulitis, but many of us have seen adhesive capsulitis
(with concordant clinical findings) isolated to the axillary capsule at the
time of our MRI.
The BLO plane is perpendicular to the anterior axillary capsule so I think
it shows the pathology especially well.
On Sat, Jun 26, 2021 at 9:29 AM Atul K. Taneja, M.D., Ph.D. < tanejamsk@gmail.com> wrote:the
Hello,
Below is my experience as a clinical Radiologist seeing patients every week.
1. Middle aged Patients do not come for MRI from the referring unless they have some restriction of motion. I order MRI for them in my clinic for the same esp. if they have abduction and forward elevation limitations. Insurance co also do not approve the scan unless there is restricted motion or instability. So almost all have some adhesive capsulitis clinically. So it’s a moot point if radiologist is trying to decide mild adhesive capsulitis/capsulitis.
2. Among radiologic findings – either and/or IGL thickening (sometimes MGL) and edema and thickening of RI (incl SGL) is enough. Other ancillary signs you can use- differential pooling of fluid in the posterior recess, Subscapularis recess and biceps tendon sheath. More subtle sign includes thickening of the inferior band of the lat bundle of CHL- Best seen on the sag view on In-phase T2 dixon map along the under surface of supraspinatus from the joint side. This thickening progresses in a triangular shape towards the coracoid process with partial and then complete effacement of the sub-coracoid fat plane. So, there is a whole spectrum of findings. You can also see increased vascularity on color doppler if did US- orient plane in oblique angle towards heart axis at biceps groove on top of the anterior shoulder
3. Thus, adhesive capsulitis can be divided based on radiology in three grades but my impression is always listed as “findings that can be seen with adhesive capsulitis” as clinically most have it and it’s a clinical diagnosis.
Mild, moderate, severe as below-
a-mild- IGL findings plus some intra-or periligamentous edema
B- mod- IGL plus partial effacement of RI plus/minus posterior capsular edema
C- severe- IGL plus complete effacement of RI plus/minus posterior capsular edema
Now the big q is what should you suggest if someone near/dear has it..
– over the door pulley exercises- u can get for 8$ on Amazon
Here is the link for pulley I give to my patients for calcific tendinosis and adhesive capsulitis.
-Shoulder-Pulley-Over/dp/B01EI6PNJY/ref=asc_df_B01EI6PNJY/?tag=hyprod-20&linkCode=df0&hvadid=312407792390&hvpos=&hvnetw=g&hvrand=368235102601385226&hvpone=&hvptwo=&hvqmt=&hvdev=m&hvdvcmdl=&hvlocint=&hvlocphy=9026801&hvtargid=pla-569511793104&psc=1
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Associate Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines Blvd., Dallas, Texas 75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
EXTERNAL MAIL
Completely agreed with Dr. Ahmed, I do the same. Especially if there is no clear clinical history of range of motion limitation.
Atul
Em sex., 25 de jun. de 2021 às 19:00, Saeed Ahmed <saeedahmed207@gmail.com<mailto:saeedahmed207@gmail.com>> escreveu:
Sometimes when it’s not very convincing I have used the term “capsulitis” instead of adhesive capsulitis(something I picked from attendings I worked with during fellowship). The “adhesive” part, clinicians can figure out.
Saeed Ahmed, MD
I agree with Phil. Will call it Adhesive capsulitis.
Tarun Pandey M.D, F.R.C.R
I would call it. The capsule looks swollen next to the humeral head insertion. With redundancy due to internal rotation alone the capsule stays dark no? I’ve called it before without much going on in the rotator interval in patients who had definite clinical frozen shoulder. Also have seen various stages where it is swollen near the humeral insertion and others near the glenoid. Maybe early or healing adhesive capsulitis?
Maybe I’m over thinking it.
Does she have convincing clinical frozen shoulder?
Thanks for this discussion, I feel the frustration with int rotation. Won’t normally call without rotator interval findings. Usually would say something like:
although there is thickening and intermediate signal of the IGHL anterior band, this may be accentuated by internal rotation and there is no signal abnormality in the rotator interval to support adh caps.
That way I get words in the report to say I’m thinking about it at least. That said I’d love to hear how the crowd approaches this — I agree the capsular thickening seems to stand out.
-Matt O
<1.jpg>
<2.jpg>
<3.jpg>
The arm is internally rotated….which is a CONSTANT frustration.
I’ve been told by some in this forum that they don’t diagnose adhesive capsulitis with normal rotator interval capsule (Sag T1 looks quite normal in this case).
I think anterior axillary capsular thickening and edema is seen best in the “BLO” sequence (top) ….though thickening might be exaggerated by arm rotation.
Really no tendinosis…some mild SA/SD bursitis….that’s it.
What do you think?
Hi,
Don’t you use intravenous contrast media sometimes in these cases when
there is any doubt?
Ciro
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Em sáb., 26 de jun. de 2021 às 10:57, Avneesh Chhabra < Avneesh.Chhabra@utsouthwestern.edu> escreveu:
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Only in cancer patients when looking for mets
You will often find a lot of synovitis and bursitis
But otherwise, it should be a clinical diagnosis
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Associate Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines Blvd., Dallas, Texas 75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
Hi,
Don’t you use intravenous contrast media sometimes in these cases when there is any doubt?
Ciro
[https://ipmcdn.avast.com/images/icons/icon-envelope-tick-round-orange-animated-no-repeat-v1.gif]<http://www.avast.com/sig-email?utm_medium=email&utm_source=link&utm_campaign=sig-email&utm_content=webmail> Livre de vírus. http://www.avast.com<http://www.avast.com/sig-email?utm_medium=email&utm_source=link&utm_campaign=sig-email&utm_content=webmail>.
Em sáb., 26 de jun. de 2021 às 10:57, Avneesh Chhabra <Avneesh.Chhabra@utsouthwestern.edu<mailto:Avneesh.Chhabra@utsouthwestern.edu>> escreveu:
Hello,
Below is my experience as a clinical Radiologist seeing patients every week.
1. Middle aged Patients do not come for MRI from the referring unless they have some restriction of motion. I order MRI for them in my clinic for the same esp. if they have abduction and forward elevation limitations. Insurance co also do not approve the scan unless there is restricted motion or instability. So almost all have some adhesive capsulitis clinically. So it’s a moot point if radiologist is trying to decide mild adhesive capsulitis/capsulitis.
2. Among radiologic findings – either and/or IGL thickening (sometimes MGL) and edema and thickening of RI (incl SGL) is enough. Other ancillary signs you can use- differential pooling of fluid in the posterior recess, Subscapularis recess and biceps tendon sheath. More subtle sign includes thickening of the inferior band of the lat bundle of CHL- Best seen on the sag view on In-phase T2 dixon map along the under surface of supraspinatus from the joint side. This thickening progresses in a triangular shape towards the coracoid process with partial and then complete effacement of the sub-coracoid fat plane. So, there is a whole spectrum of findings. You can also see increased vascularity on color doppler if did US- orient plane in oblique angle towards heart axis at biceps groove on top of the anterior shoulder
3. Thus, adhesive capsulitis can be divided based on radiology in three grades but my impression is always listed as “findings that can be seen with adhesive capsulitis” as clinically most have it and it’s a clinical diagnosis.
Mild, moderate, severe as below-
a-mild- IGL findings plus some intra-or periligamentous edema
B- mod- IGL plus partial effacement of RI plus/minus posterior capsular edema
C- severe- IGL plus complete effacement of RI plus/minus posterior capsular edema
Now the big q is what should you suggest if someone near/dear has it..
– over the door pulley exercises- u can get for 8$ on Amazon
Here is the link for pulley I give to my patients for calcific tendinosis and adhesive capsulitis.
-Shoulder-Pulley-Over/dp/B01EI6PNJY/ref=asc_df_B01EI6PNJY/?tag=hyprod-20&linkCode=df0&hvadid=312407792390&hvpos=&hvnetw=g&hvrand=368235102601385226&hvpone=&hvptwo=&hvqmt=&hvdev=m&hvdvcmdl=&hvlocint=&hvlocphy=9026801&hvtargid=pla-569511793104&psc=1
Best!
AC
Avneesh Chhabra, M.D. M.B.A.
Associate Professor, Radiology & Orthopedic Surgery
Chief, Musculoskeletal Radiology
Department of Radiology
5323 Harry Hines Blvd., Dallas, Texas 75390-9316
Office: 214-648-2122
http://www.utsouthwestern.edu/radiology<http://www.utsouthwestern.edu/education/medical-school/departments/radiology/>
EXTERNAL MAIL
Completely agreed with Dr. Ahmed, I do the same. Especially if there is no clear clinical history of range of motion limitation.
Atul
Em sex., 25 de jun. de 2021 às 19:00, Saeed Ahmed <saeedahmed207@gmail.com<mailto:saeedahmed207@gmail.com>> escreveu:
Sometimes when it’s not very convincing I have used the term “capsulitis” instead of adhesive capsulitis(something I picked from attendings I worked with during fellowship). The “adhesive” part, clinicians can figure out.
Saeed Ahmed, MD
I agree with Phil. Will call it Adhesive capsulitis.
Tarun Pandey M.D, F.R.C.R
I would call it. The capsule looks swollen next to the humeral head insertion. With redundancy due to internal rotation alone the capsule stays dark no? I’ve called it before without much going on in the rotator interval in patients who had definite clinical frozen shoulder. Also have seen various stages where it is swollen near the humeral insertion and others near the glenoid. Maybe early or healing adhesive capsulitis?
Maybe I’m over thinking it.
Does she have convincing clinical frozen shoulder?
Thanks for this discussion, I feel the frustration with int rotation. Won’t normally call without rotator interval findings. Usually would say something like:
although there is thickening and intermediate signal of the IGHL anterior band, this may be accentuated by internal rotation and there is no signal abnormality in the rotator interval to support adh caps.
That way I get words in the report to say I’m thinking about it at least. That said I’d love to hear how the crowd approaches this — I agree the capsular thickening seems to stand out.
-Matt O
<1.jpg>
<2.jpg>
<3.jpg>
The arm is internally rotated….which is a CONSTANT frustration.
I’ve been told by some in this forum that they don’t diagnose adhesive capsulitis with normal rotator interval capsule (Sag T1 looks quite normal in this case).
I think anterior axillary capsular thickening and edema is seen best in the “BLO” sequence (top) ….though thickening might be exaggerated by arm rotation.
Really no tendinosis…some mild SA/SD bursitis….that’s it.
What do you think?
Hi all,
What’s your experience with GH intra-articular steroid in the early phase
of disease when there is little limitation of movement? Do you reckon it
affects progression of disease? I’m attaching a meta-analysis from 2017
showing pain improvement in the short term (< 8 weeks) and ROM improvement in both short and long terms (< 24 weeks according to methodology) when compared to placebo. It has many limitations though, so it would be good to know Ocader's experiences. On another note, I have seen cases of (adhesive) capsulitis where there are also extensive signal changes of rotator cuff tendons, but I don't recall this being part of the disease. Have you seen similar appearances? Is it added RC pathology or part of capsulitis? Should I be thinking of another differential? Thank you all in advance! On Sat, 26 Jun 2021 at 22:11, Avneesh Chhabra < Avneesh.Chhabra@utsouthwestern.edu> wrote: