Is ultrasonographic evaluation of rotator interval useful in diagnosis of adhesive capsulitis of shoulder?
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1 Is ultrasonographic evaluation rotator interval useful in diagnosis adhesive capsulitis shoulder? Poster No.: C-2230 Congress: ECR 2011 Type: Scientific Paper Authors: Y. C. Yoon, J. M. Seo, H. S. Kim, K. J. Park; Seoul/KR Keywords: Musculoskeletal st tissue, Ultrasound, Inflammation DOI: /ecr2011/C-2230 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form scientific presentations. References to any names, marks, products, or services third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation the third party, information, product or service. ECR is not responsible for the content these pages and does not make any representations regarding the content or accuracy material in this file. As per copyright regulations, any unauthorised use the material or parts there as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version presentations. Page 1 10
2 Purpose Several studies about shoulder ultrasonography for adhesive capsulitis were published. Among those studies, some reported that hypoechoic st tissue around the biceps long head tendon on ultrasonography are related to diagnose adhesive capsulitis. The purpose this presentation is to evaluate the usefulness abnormal findings in rotator interval with ultrasonography in diagnosing the adhesive capsulitis. Methods and Materials Fig.: Figure 1. Measurements Capsular Thickness and Height ratio Page 2 10
3 Fig.: Table 1. Subjective grading capsular thickening at RI Between September 2007 and December 2009, total 398 patients took shoulder ultrasonography at our institute, and the total number cases is 446 shoulders. The inclusion criteria for patient group on this study are patients who suffer from, one painful stiff shoulder for at least 4 weeks, forward elevation less than one-hundred degree and external rotation to side less than forty five degree and no rotator cuff tear on ultrasonography nor abnormal X-ray finding. The exclusion criteria are patients with suboptimal image and other medical diseases such as brain infarctions and quadriplegia. which may prevent us from evaluating the range shoulder motion. According to the reference standard we applied in this study, we finally selected fifty-eight shoulder US fifty-four patents. The patient group consists 30 shoulders. And control group, 28 shoulders showing full range motion without long-lasting pain. The average interval day between physical examination and shoulder US each group are 11.4 days and 14.0 days, respectively. All shoulder ultragraphies were performed by one musculoskeletal radiologist with linear transducer 9-12 MHz. All the images include transverse scan rotator interval with the patient's fist held by the side as routine protocol providing optimal images rotator interval. Page 3 10
4 Two radiologists analyzed shoulder ultrasonographic images retrospectively.they measured and graded capsular thickening, st tissue in the rotator interval and height ratio individually. How observers graded capsular thickening at rotator interval are described in Table 1. In Figure 1, letter A represents capsular thickness and letter B stands for BLHT thickness. Capsular Thickness to Height ratio (Height ratio) is calculated by following formula. Height ratio = B / (A+B+C) For statistical analysis, we used Kappa statistics for interobserver agreement, Mann- Whitney U test to evaluate differences in subjective grading capsular thickening, presence or absence abnormal st tissue in RI and T-test to evaluate difference in measurements. Results Page 4 10
5 Fig.: Figure 3. Control group Left) subjective grading (3,3), hypoechoic st tissue (1,1), capsular thickness (3.7, 3.1), height ratio (0.33, 0.39) Right) subjective grading (0,0), hypoechoic st tissue (0,0), capsular thickness (2.9, 0.8), height ratio (0.34, 0.48) We found similar results with the patient group. The patients in the control group show that there is no consistency between the subjective grading score and presence hypoechoic st tissue. Fig.: Figure 2. Patients group Left) subjective grading (3,3), hypoechoic st tissue (1,1), capsular thickness (4, 2.2), height ratio (0.29, 0.34) Right) subjective grading (0, 0), hypoechoic st tissue (0, 0), capsular thickness (1.4, 0.8), height ratio (0.37, 0.44) In the left image, the capsular thickness is larger than the thickness biceps long head tendon. Each observer graded it 3. Another patient in the same group showed a different result from ultrasonography. In the right image, each observer graded it zero because smaller capsular thickness than the half thickness biceps long head tendon. Therefore, we discovered that even patients in the same patient group can show big differences in subjective grading score and presence hypoechoic st tissue in rotator interval. Page 5 10
6 Fig.: Table 3. Capsular thickness and height ratio Fig.: Table 2. Subjective grading system We did not find the statistical meaningful results as seen in Table 2. Kappa and p-value two grading systems are very high, which means that there are no significant differences between patient group and control group. Similarly in Table 3, the p value each group is high in capsular thickness and height ratio, which means there is no difference between the two groups. We did not find statistically meaningful relationship between AC and shoulder ultrasonographic results. Page 6 10
7 Our study may have potential limitations. First, the number enrolled patients is relatively small, and we did not categorize the enrolled patients by their age or sex. We enrolled symptomatic patients in the control group, so their symptoms may hinder their shoulder motion, which can pose limitations to ultrasonographic evaluation. As for the criteria issue, the criteria for AC has not been established yet, so we adopted a set clinical and plain radiographic criteria as the reference standard for the diagnosis AC. Lastly, in our study, we did not perform the color doppler evaluation, which was used to identify vascularity in the study done by J.C. Lee. The color doppler evaluation was not performed in our study which is considered one ultrasonographic finding AC in other study. Images for this section: Fig. 1: Table 2. Subjective grading system Page 7 10
8 Fig. 2: Table 3. Capsular thickness and height ratio Fig. 3: Figure 2. Patients group Left) subjective grading (3,3), hypoechoic st tissue (1,1), capsular thickness (4, 2.2), height ratio (0.29, 0.34) Right) subjective grading (0, 0), hypoechoic st tissue (0, 0), capsular thickness (1.4, 0.8), height ratio (0.37, 0.44) In the left image, the capsular thickness is larger than the thickness biceps long head Page 8 10
9 tendon. Each observer graded it 3. Another patient in the same group showed a different result from ultrasonography. In the right image, each observer graded it zero because smaller capsular thickness than the half thickness biceps long head tendon. Therefore, we discovered that even patients in the same patient group can show big differences in subjective grading score and presence hypoechoic st tissue in rotator interval. Fig. 4: Figure 3. Control group Left) subjective grading (3,3), hypoechoic st tissue (1,1), capsular thickness (3.7, 3.1), height ratio (0.33, 0.39) Right) subjective grading (0,0), hypoechoic st tissue (0,0), capsular thickness (2.9, 0.8), height ratio (0.34, 0.48) We found similar results with the patient group. The patients in the control group show that there is no consistency between the subjective grading score and presence hypoechoic st tissue. Page 9 10
10 Conclusion We concluded US examination rotator interval in terms capsular thickness, with both subjective grading and measurement, was not useful in diagnosis adhesive capsulitis. References Neviaser RJ. Adhesive capsulitis the shoulder. J Bone Joint Surg. 1945;27: Sarah Walmsley, Darren A. Rivett and Peter G. Osmotherly. Adhesive Capsulitis: Establishing Consensus on Clinical Identifiers for Stage 1 Using the Delphi Technique. Physical Therapy. 2009;89: Min Hee Lee, Joong Mo Ahn, Claus Muhle, Sung Hyun Kim, Ji Seon Park, Seung Ho Kim, Sung Moon Kim, Heung Sik Kang. Adhesive Capsulitis the Shoulder: Diagnosis Using Magnetic Resonance Arthrography, with Arthroscopic Findings as the Standard. J Comput Assist Tomogr 2003;27: Kyung Cheon Kim, Kwang Jin Rhee, Hyun Dae Shin. Adhesive capsulitis the shoulder: Dimensions the rotator interval measured with magnetic resonance arthrography.j Shoulder Elbow Surg. 2009;18: Connell D, Padmanabhan R, Buchbinder R. Adhesive capsulitis: role MR imaging in differential diagnosis.eur Radiol. 2002;12: J. C. Lee, C. Sykes, A. Saifuddin and D. Connell. Adhesive capsulitis: sonographic changes in the rotator cuff interval with arthroscopic correlation. Skeletal Radiology. 2005;34: KM Burbank, JH Stevenson, GR Czarnecki. Chronic Shoulder Pain: Part I. Evaluation and Diagnosis. American Family Physician. 2008;77: Robert C. Manske, Daniel Prohaska. Diagnosis and management adhesive capsulitis. Curr Rev Musculoskelet Med. 2008;1: S. Brue, A. Valentin, M. Forssblad, S. Werner, C. Mikkelsen, G. Cerulli. Idiopathic adhesive capsulitis the shoulder: a review Knee Surg Sports Traumatol Arthrosc. 2007;15: Carolyn M. Ska, Gina A. Ciavarra, Jo A. Hannafin, Frank A. Cordasco, Hollis G. Potter.Magnetic Resonance Imaging Adhesive Capsulitis: Correlation with Clinical Staging. HSSJ. 2008;4: Gefrey L. Manton, Mark E. Schweitzer, Dominik Weishaupt, David Karasick. Utility MR arthrography in the diagnosis adhesive capsulitis. Skeletal Radiol. 2001;30: Personal Information Page 10 10
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