CASE 58

By: Dr. Subramaniyan Ramanathan MD, Dr. Mahmoud Alheidous and

 Dr.Nizar Al-Nakshabandi. MD, FRCPC.

HISTORY: 55-year-old male with restricted shoulder movements.

What are your findings?

What is the differential diagnosis?

What are the causes?

FINDINGS:

Sagittal T1W MRI shows loss of Subcoracoid fat triangle. Coronal and sagittal PD FS images show the capsulosynovial thickening in the axillary recess with rotator interval synovitis demonstrated on the sagittal images. Associated supraspinatus tendinosis with insertional degenerative bone cysts noted at the humeral head.

DIAGNOSIS:

Adhesive capsulitis shoulder.

PEARLS AND DISCUSSION:

Adhesive capsulitis is a clinical syndrome of pain and severely decreased joint motion (“frozen shoulder”) caused by thickening and contraction of the joint capsule and synovium. The incidence in the general population is thought to be 3-5%. Adhesive capsulitis typically affects women in the 5th to 6th decades of life, although patients with co-morbidities such as diabetes may develop the condition at earlier ages. The incidence in patients with diabetes is reported to be 2 to 4 times higher than in the general population. 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.

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. Capsulosynovial thickening > 4 mm is often seen in the axillary pouch. The Subcoracoid triangle sign is specific sign and refers to obliteration of the fat triangle between the coracohumeral ligament (CHL) and the coracoid process.

FURTHER READING:

1. Connell D, Padmanabhan R, Buchbinder R. Adhesive capsulitis: role of MR imaging in differential diagnosis. European Radiology. 2002 Aug;12(8):2100-6.

2. Manton GL, Schweitzer ME, Weishaupt D et-al. Utility of MR arthrography in the diagnosis of adhesive capsulitis. Skeletal Radiol. 2001;30 (6): 326-30

3. Emig EW, Schweitzer ME, Karasick D et-al. Adhesive capsulitis of the shoulder: MR diagnosis. AJR Am J Roentgenol. 1995;164 (6): 1457-9