EBM Adhesive Capsulitis

The concept is simple: “Capsulitis” – capsule inflammation. “Adhesive” – may refer to decreased range of motion of the shoulder, or may refer to intra-articular adhesions, but the end result is still the same – decreased range of motion and pain. The majority of routine joint MRs and ultrasounds are obtained without intra-articular contrast. So, we won’t be able to look for abnormal enhancement of joint capsule. However, we will be able to look for capsule thickening. Here come some interesting questions:

  • “What is normal shoulder joint capsule thickness?”
  • “Does it change with age?”
  • “Is joint capsule thickness inversely related to the amount of joint fluid?”
  • “How much does joint capsule thickness change with humeral rotation?”

Below is the summary of what has been published about ultrasound of shoulder adhesive capsulitis as of May 2019. Notice how much the measurements vary for superior glenohumeral ligament between studies, even when the humerus was externally rotated.

Study MethodnGround TruthMajor FindingsBlindedICC/KappaNotesPublication
Measured CHL121 – asx360 – painful17 – adh capsulitis by arthroscopyArthroscopy, clinical sxsCHL = 1.34 vs 1.39 vs 3 mm in thicknessNot specifiedSingle sonographer, 20yrs experienceHomsi C, Bordalo-Rodrigues M, da Silva JJ, Stump XM. Ultrasound in adhesive capsulitis of the shoulder: is assessment of the coracohumeral ligament a valuable diagnostic tool? Skeletal Radiol. 2006 Sep;35(9):673-8. Epub 2006 May 25. PubMed PMID: 16724200.
Measured CHL, evaluated rotator interval30 age and sex matched controls30 – painful30 adh capsulitis by clinical and MRIMRI0.38(0.09) vs 0.53(0.18) vs 1.2 (0.35) mm, 0.7 mm cut off for best ROC, 90% hypoechoic soft tissue in AC group, 10% increased vascularity in AC groupBlinded0.961 for CHLTwo independent msk radiologists with more than 10 yrs experience, arm was externally rotated, proposed 0.7 as cutoffTandon A, Dewan S, Bhatt S, Jain AK, Kumari R. Sonography in diagnosis of adhesive capsulitis of the shoulder: a case-control study. J Ultrasound. 2017 Aug 21;20(3):227-236. doi: 10.1007/s40477-017-0262-5. eCollection 2017 Sep. PubMed PMID: 28900523; PubMed Central PMCID: PMC5573706.
Measured IGHL on symtomatic shoulder and compared to contralateral shoulder20 contralateral asx shoulder20 symptomatic shouldersExpert opinion after ultrasound and few MRIIGHL = 1.3 mm vs 4 mmNot specifiedSingle radiologist, 6 years experienceMichelin P, Delarue Y, Duparc F, Dacher JN. Thickening of the inferior glenohumeral capsule: an ultrasound sign for shoulder capsular contracture. Eur Radiol. 2013 Oct;23(10):2802-6. doi: 10.1007/s00330-013-2874-2. Epub 2013 May 8. PubMed PMID: 23652851.
US of rotator interval10 asx100 rotator cuff tears30 adh capsulitisClinical diagnosis26/30 hypoechoic soft tissue and increased Doppler in rot interval, 0 in control and 92/100 in RC group had tendinosisNot specifiedExperienced sonographer and radiologistLee JC, Sykes C, Saifuddin A, Connell D. Adhesive capsulitis: sonographic changes in the rotator cuff interval with arthroscopic correlation. Skeletal Radiol. 2005 Sep;34(9):522-7. Epub 2005 Jul 6. PubMed PMID: 15999280.
Compared gliding of supraspinatus tendon (abn vs nl) to capsule distention after injecting up to 25 cc of contrast67 – non specific pain and decr ROMMR positive by CH and capsule measurements47 restricted, 20 non-restricted. 10.7 (3.31) ml vs 22.0 (6.29) ml, 40/47 vs 2/20 MR positiveNot specifiedTwo radiologists with 10 and 5 yrs of experience, typos, check statisticsKim I, Yi JH, Lee J, Bae JH, Lim JK, Yoon JP, Jeon IH. Limited subacromial gliding of the supraspinatus tendon during dynamic ultrasonography can predict a decrease in capacity and MR arthrographic features of the shoulder joint. Eur radiol. 2012 Nov;22(11):2365-70. doi: 10.1007/s00330-012-2513-3. Epub 2012 Aug 17. PubMed PMID: 22898934.
Measured CHL, evaluated elasticity30 asx (32-2- CHL not seen)20 clinically sxs (22-2 CHL not seen)2.0(1.7-2.1)mm vs 3.1 (2.4-3.4) mm; elastic modulus in ext rot: 243.7 (203.2-307.8) vs 285.3 (233.1-317.8)Not specifiedRe-evaluated in 3 daysShoulder externally rotated, one physiatrist with 8 yrs experience, tables include comparison of both sides in each groupWu CH, Chen WS, Wang TG. Elasticity of the Coracohumeral Ligament in Patients with Adhesive Capsulitis of the Shoulder. Radiology. 2016 Feb;278(2):458-64. doi: 10.1148/radiol.2015150888. Epub 2015 Aug 31. PubMed PMID: 26323030.