Ultrasound Findings of Adhesive Capsulitis

A common complaint found in a sports medicine office is shoulder pain. It is difficult to differentiate rotator cuff impingement and the early stages of adhesive capsulitis. Both conditions present with shoulder pain and a decrease in shoulder range of motion is sometimes not present on initial examination. The loss of motion typically occurs in the later stages of adhesive capsulitis (3). Adhesive capsulitis is characterized by glenohumeral capsular inflammation and fibrosis (1).

Stages of adhesive capsulitis (1)

Diagnosis is typically made with a thorough clinical exam (4). However, radiology studies are used to help assist in diagnosing adhesive capsulitis. Standard radiographs are performed and they are usually not diagnostic for adhesive capsulitis (2). In certain cases, a decrease in bone mineral density can be seen (2). An MRI can be used to visualize capsular thickening, thickening of the coracohumeral ligament, and enhancement of the rotator interval (1).

Ultrasound has been studied as a way to assist in diagnosing adhesive capsulitis. Measuring the thickness of the coracohumeral ligament has been found to aid in diagnosis of adhesive capsulitis (1). The image below shows the positioning and measurement of the ultrasound of the coracohumeral ligament (1). This view shows the coracohumeral ligament in an oblique axial view (4). An abnormal thickness is estimated to be greater than 2.2mm (1). One of the issues with using the coracohumeral ligament in diagnosis is that it can be missed in up to 30% of affected patients (5). This can be due to patients with limitations in their motion being unable to get their arm in the correct position needed to visualize the ligament.

Coracohumeral ligament thickening (1)

The rotator cuff interval should also be evaluated with ultrasound. The image below shows how to evaluate for thickness of the rotator cuff interval (1). An increase in blood flow to the rotator cuff interval can also be seen with adhesive capsulitis (5).

Ultrasound image of the rotator cuff interval (1)

Thickness of the inferior glenohumeral capsule within the axillary recess can also be measured to assist in the diagnosis of adhesive capsulitis (1). A thickness greater than 4mm is thought to be diagnostic of an adhesive capsulitis (6). The ultrasound probe is placed in the axilla and the patient’s shoulder is placed in maximal abduction (6).

Ultrasound image of axillary recess (1)

Imaging for an effusion of the long head of the biceps tendon sheath can also be performed (1). However, the use of this technique has not been replicated and is not considered a diagnostic test (5).

Long head of the bicep ultrasound (1)

Other ultrasound findings that are still being studied are assessing the glide of the rotator cuff tendons and also measuring the elasticity of the coracohumeral ligament (5).

Adhesive capsulitis symptoms can be similar to other shoulder pathologies in the early phases of the condition. The range of motion restrictions become more pronounced in later stages. As a result, ultrasound can be performed in office to assist in diagnosis. Many different measurements have been studied and the one most easily replicated is measuring the thickness of the coracohumeral ligament.

By Gregory Rubin, DO
rubinsportsmed.com

– More Frozen Shoulder @ Wiki Sports Medicine: https://wikism.org/Adhesive_Capsulitis

References

1)      Do, Jong Geol, et al. “Correlation of Ultrasound Findings With Clinical Stages and Impairment in Adhesive Capsulitis of the Shoulder.” Orthopaedic Journal of Sports Medicine, vol. 9, no. 5, May 2021, p. 23259671211003675. PubMed Central, https://doi.org/10.1177/23259671211003675

2)      Brue, S., Valentin, A., Forssblad, M. et al. Idiopathic adhesive capsulitis of the shoulder: a review. Knee Surg Sports Traumatol Arthr 15, 1048–1054 (2007). https://doi.org/10.1007/s00167-007-0291-2

3)      Neviaser, Andrew, Neviaser, Robert. Adhesive Capsulitis of the Shoulder. J Am Acad Orthop Surg. 2011;19(9):536-542. Cited in: Your Journals@Ovid Full Text at http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=yrovftm&NEWS=N&AN=00124635-201109000-00004. Accessed March 24, 2024.

4)      Homsi, C., Bordalo-Rodrigues, M., da Silva, J.J. et al. Ultrasound in adhesive capsulitis of the shoulder: is assessment of the coracohumeral ligament a valuable diagnostic tool?. Skeletal Radiol 35, 673–678 (2006). https://doi.org/10.1007/s00256-006-0136-y

5)      Shrestha-Taylor, Sumi, et al. “Ultrasound Features for the Diagnosis of Adhesive Capsulitis/Frozen Shoulder: A Systematic Review.” Ultrasound in Medicine & Biology, vol. 48, no. 12, Dec. 2022, pp. 2379–97. PubMed, https://doi.org/10.1016/j.ultrasmedbio.2022.07.003.

6)      Michelin, P., Delarue, Y., Duparc, F. et al. Thickening of the inferior glenohumeral capsule: an ultrasound sign for shoulder capsular contracture. Eur Radiol 23, 2802–2806 (2013). https://doi.org/10.1007/s00330-013-2874-2

 

7)      Stella, S.M., Gualtierotti, R., Ciampi, B. et al. Ultrasound Features of Adhesive Capsulitis. Rheumatol Ther 9, 481–495 (2022). https://doi.org/10.1007/s40744-021-00413-w