Adhesive capsulitis of the shoulder joint is a

Transcription

1 dhesive Capsulitis of the Shoulder Joint: Usefulness of Dynami Sonography Kyung Nam Ryu, MD, Sun Wha Lee, MD, Yong Girl Rhee, MD, Jae Hoon Lim, MD We studied the value of dynami sonography in adhesive apsulitis of the shoulder joint in patients with linially suspeted frozen shoulder. The sonographi riterion of adhesive apsulitis was ontinuous limitation of the sliding movement of the supraspinatus tendon against the aromion of the sapula. rthrography was regarded as a gold standard in the diagnosis of adhesive apsulitis against whih the sonographi results were ompared. mong 23 patients with arthrographially doumented adhesive apsulitis, sonographi examination showed limitation of movement of the supraspinatus tendon in 21. This sonographi sign therefore has a sensitivity of 91%, a speifiity of 100%, and an auray of 92% for deteting adhesive apsulitis, making dynami sonography a reliable tehnique for the diagnosis of this ondition. KEY WORDS: dhesive apsulitis; Shoulder joint; Ultrasound. dhesive apsulitis of the shoulder joint is a ommon ause of hroni shoulder pain and disability. Beause of the age group affeted and the absene of trauma, a degenerative ause frequently is favored. Diagnosis of adhesive apsulitis has depended on physial examination and ar thrography. Distention arthrography is a form of therapy for adhesive apsulitis.l Dynami sonography of the shoulder is a reognized tehnique for demonstrating a fluid olletion in the subaromialsubdeltoid bursal system and the integrity of the rotator uff.l. 4 However, beause the role of dynami sonography in the diagnosis of adhesive apsulitis of the shoulder has not been desribed previously, we undertook this study. Reeived Otober 29, 1992, from the Departments of Diagnosti Radiology (K.N.R., S.W.L., J.H.L.) and Orthopedi Surgery (Y.G.R. ), Kyung Hee University Hospital, Seoul, Korea. Revised manusript aepted for publiation Marh 10, ddress orrespondene and reprint requests to Kyung Nam Ryu, MD, Department of Diagnosti Radiology, Kyung Hee Uni versity Hospital, 1, Hoeki-dong, Dongdaemun-ku, Seoul , Korea. MTERILS ND METHODS Between January 1991 and July 1992, 26 patients underwent shoulder sonography followed by arthrography. ll patients were referred by one orthopedi surgeon beause of linial suspiion of frozen shoulder. Sonography was performed by one radiologist (K.N.R.). The group onsisted of 15 men and 11 women, with a mean age of 56 years (range, 20 to 75 years). The sonograms were obtained using a 5 MHz linear phased-array transduer (Ultramark 9, TL, Bothell, W). ll sonograms were interpreted prospetively. Sanning was onduted as follows: while the sonographer is faing the patient or standing behind him or her, the sonographer makes a routine examination of the shoulder, inluding the rotator uff and bieps tendon, imaging with the arm held in a neutral position and also in maximal internal rotation and hyperextension. While holding the patient's elbow joint with one hand and plaing the transduer on the tendon of the supraspinatus musle longitudinally with the other hand, the sonographer observes movement of the supraspinatus tendon as patient's elbow joint is elevated laterally. Normally, when the by the merian Institute of Ultrasound in Mediine /93/$3.50

2 446 DHESIVE CPSULffiS OF SHOULDER B D Figure 1 Shemati diagram of the sliding movement of the supraspinatus musle., Normal supraspinatus musle in the neutral position. The axillary reess (long a"ow) is redundant. Short arrow identifies subaromial bursa; D, deltoid musle; S, supraspinatus tendon. 8, Normal sliding movement in lateral elevation of the arm. The supraspinatus musle slides under the aromion (), and the axillary reess is strethed. C, bnormal shemati diagram in the neutral position. The axillary reess is tight (arrow). D, bnormal shemati diagram in the lateral elevation of the arm. The supraspinatus musle shows inomplete sliding movement under the aromion, The angle between the lateral border of the sapula and the humerus is not inreased. arm is elevated laterally more than 90 degrees, the tendon of the supraspinatus musle.is not observed between the aromion and the humerus beause it has slid beneath (Fig. 1). The sonographi riteria for adhesive apsulitis were (1) ontinuous limitation of sliding movement, and (2) ontinuous visualization of the supraspinatus tendon during lateral elevation of the arm. n anillary finding was a bieps tendon sheath effusion. Double-ontrast arthrography was performed after sonography on the same day. The sonographi results usually were available to the radiologist before

3 RYU ET L 447 Figure 2 Normal sliding movement with synovial hypertrophy in a 20 year old man., rthrogram shows multi foal filling defets with lobulated margins, but evidene of apsular adhesion is absent. 8, Sonogram in neutral position. The entire length of the supraspinatus tendon is seen (arrowheads). D, Deltoid; H, humerus;, aromion. C, Sonogram in lateral elevation of the arm. The supraspinatus tendon is not seen beause of omplete sliding movement under the aromion. 8 arthrography. The ontrast agent used was meglumine diatrizoate (Renografin, Squibb, New Brunswik, NJ). bout 5 ml of ontrast agent was injeted into the joint under fluorosopi guidane, followed by injetion of 5 to 15 ml of room air. fter injetion of ontrast material and air, anteroposterior radiographs were made with internal and external rotation using an axillary projetion. rthrographi riteria of adhesive apsulitis were small subsapular and axillary reesses and irregularity of the apsular insertion. RESULTS In 23 of 26 patients (88% ), adhesive apsulitis was diagnosed on arthrogram. Using arthrography as the gold standard for the diagnosis of adhesive apsulitis, we found sonographi results inluded 21 true positives (Fig. 2), three true negatives, two false negatives, and no false positives. The sensitivity of sonography in deteting adhesive apsulitis was 91%, the speifiity was 100%, and the auray was 92%. ll 21 true positive ases showed variable limitation of sliding movement of the supraspinatus tendon under the aromion. The degree of limitation was variable. Review of the two false negative ases showed that adhesive hanges of the apsule were minimal (Fig. 3). In 5 of 26 patients (19% ), a rotator uff tear was diagnosed on sonogram and arthrogram. In three of five ases of rotator uff tear, assoiated adhesive apsulitis was seen and the sliding movement was ontinuously limited. n effusion of the bieps tendon sheath was doumented in 23 of the 26 patients (88% ). In 21 of these 23 (91% ), adhesive apsulitis was diagnosed. DISCUSSION The shoulder joint is a multiaxial spheroidal joint with an unlimited variety of ombinations of swinging and swiveling movements. The laxity of its artie-

4 448 J Ultrasound Med 12:44~449, DHESIVE CPSULITIS OF SHOULDER 1993 B Figure 3 bnormal sliding movement with adhesive ap sulitis in a 45 year old man., rthrogram shows apsular adhesion. 8, Sonogram in neutral position. The supraspinatus tendon is normal in appearane, C, Sonogram in lateral elevation of the arm. The distaj portion of the supraspinatus tendon is not displaed. Complete sliding movement of the supraspinatus is impossible beause of apsular adhesion. ular apsule and the large head of the humerus in omparison to the shallow glenoid avity give the shoulder a wider range of movement than is possible at any other joint. The axillary reess is an area of laxity of the inferior and medial portion of the joint apsule. When the shoulder joint is ankylosed, the loss of movement in the joint is partly ompensated for by inreased mobility of the sapula, but sliding movement of the supraspinatus tendon is limited. dhesive apsulitis of the shoulder joint prevents normal distention of the glenohumeral joint. Its pathologi basis is unknown. The ondition may be related to apsular thikening, adhesion between the apsule and biipital tendon, and adhesion in the subaromial bursa and beneath the oraoid proess. In view of this, and on the basis of the large number of ases of bieps tendon sheath effusion, we thought that joint effusion reahed the bieps tendon sheath through a persisting hannel as a onsequene of the dereased volume apaity of the shoulder joint. n injury, an operation, or pain may ause limitation of motion of the shoulder joint. When movement is urtailed, the joint apsule tends to ontrat. This ondition may further limit motion and inrease shoulder pain. 1 Usually, the entire joint apsule is involved, abnormalities being deteted initially in the fibrous layer of the apsule, with obliteration of dependent reesses.s Mehanial hanges of the joint apsule in adhesive apsulitis an be demonstrated with shoulder arthrography. But this method is invasive and requires manipulation of the painful shoulder. The main arthrographi abnormality in adhesive apsulitis of the glenohumeral artiulation is a joint of low apaity, evidened by inreased resistane to injetion and a tight feel. Only a small amount of fluid (5 to 8 ml) may be injeted suessfully, and when the hand is released from the plunger, the fluid may quikly return to the syringe. The subsapular and axillary reesses are small or absent. Filling of the biipital tendon sheath is variable; in some ases the tendon sheath appears normal, whereas in others it fills poorly or not at all, or ontrast medium may leak from the sheath. Contrast agent also ommonly leaks elsewhere in the joint, partiularly from the subsapular reess. n additional finding is irregularity of the apsular insertion.t,6 Sonography of the shoulder appears to display

5 RYU ET L 449 normal rotator uff anatomy quikly.7-n The value of dynami shoulder sonography with lateral and anterior elevation of the ann is desribed by Farin and olleagues.3 This method was applied to the diagnosis of rotator uff tears. The value of the method lies in its ability to demonstrate fluid olletions in the subaromial-subdeltoid bursal system, with gradual distention of the bursa and lateral pooling of fluid to the subdeltoid portion while the ann is elevated. Two speifi riteria for the sonographi diagnosis of impingement syndrome were (1) fluid olletion in the subaromial-subdeltoid bursa and (2) fluid in the bursal system that gradually distended the bursa and pooled laterally to the subdeltoid portion while the arm was elevated. But, exept for transient limitation during lateral elevation of the ann, limitation of sliding movement of the supraspinatus tendon under the aromion had not been reported in impingement syndrome of the shoulder. In this study, in five patients with rotator uff tears, transient limitation of the sliding movement of the supraspinatus tendon during abdution of the shoulder was seen at the defet of the rotator uff, but hroni limitation did not our. The sonographi riterion of adhesive apsulitis is adhesion of the apsule with dereased joint spae volume and dereased motion of the axillary reess. dhesion and dereased apaity of the axillary reess prevent lateral elevation of the ann. lthough our sonographi riterion for diagnosis of adhesive apsulitis in the shoulder joint is a seondary manifestation, we believe that dynami sonography represents a potential rapid, noninvasive means of diagnosing adhesive apsulitis. The various onditions ausing shoulder pain and inhibition of ative motion related with tendon lesions and aute inflammatory diseases of the glenohumeral joint or subaromial bursa are often observed by sonography. However, in a few onditions assoiated with marked limitation of the range of passive motion, suh as fratures of sapula and humerus, dynami sonography is diffiult. In patients with severe pain and musle spasm due to tendinitis or rotator uff tears, infiltration of loal analgesis may be helpful, allowing demonstration of normal passive motion. large alifiation of the supraspinatus may inhibit passive motion but it is readily identified radiographially. Minimal adhesive hange of joint apsule with redundant axillary reess annot be deteted, and this must be remembered before making the diagnosis of adhesive apsulitis on the basis of sonographi findings. When the patient has severe adhesion of the joint apsule, it is possible to diagnose it linially beause the orthopedi surgeon an observe the pseudomotion of the shoulder joint by the sapular motion in elevating patient's arm laterally. However, when the adhesion of the joint apsule is mild, the pseudomotion of the shoulder joint is not easily observed, and it is impossible to find learly the abnormality of the rotator uff or bieps assoiated with adhesive apsulitis. In suh ases, we think that dynami sonographi examination is most effiient. We believe that dynami sonographi examination with real-time equipment should be used as an initial imaging modality in patients with suspeted adhesive apsulitis of the shoulder joint. REFERENCES 1. Rizk TE, Pinals RS: Frozen shoulder. Semin rthritis Rheum 11:440, ndren L, Lundberg BJ: Treatment of rigid shoulders by joint distention during arthrography. ta Orthop Sand 36:45, Farin PU, Jaroma H, Harju, et at: Shoulder impinge ment syndrome: Sonographi evaluation. Radiology 176:845, Mak L, Matsen F Ill, Kiloyne RF, et at; US evalu ation of the rotator uff. Radiology 157:205, Neviaser JS: dhesive apsulitis of the shoulder: study of the pathologi findings in periarthritis of the shoulder. J Bone Joint Surg 27:211, Reeves 8: rthrographi hanges in frozen and posttraumati stiff shoulder. Pro R So Med 59:827, Middleton WD, Edelstein G, Reinus WR, et al: Ultrasonography of the rotator uff; Tehnique and normal anatomy. J Ultrasound Med 3:549, Middleton WD, Edelstein G, Reinus WR, et al: Sanagraphi detetion of rotator uff tears. JR 144:349, hovuo J, Paavolainen P, Bjorkenhein JM: Ultrasonography in lesions of the rotator uff and bieps tendon. ta Radial 30:253, Vik CW, Bell S: Rotator uff tears: Diagnosis with sonography. IR 154:121, Bretzke C, Crass JR, Craig EV, et al: Ultrasonography of the rotator uff: Normal and pathologi anatomy. Invest Radial 20:311, 1985