Coracohumeral Ligament Research Articles

The Pericoracoid Tissue Release in Children With Brachial Plexus Birth Injury

In brachial plexus birth injury (BPBI), children with upper trunk injuries have multidirectional movement deficits, including global abduction and hand-to-neck, hand-to-abdomen, and hand-to-spine movements. The aim of this study was to evaluate the results of pericoracoid tissue release and postoperative structured physiotherapy as a first-step intervention to reduce the multidirectional movement deficit in children with BPBI. Thirty-four children with BPBI underwent pericoracoid tissue release, including coracohumeral and coracoacromial ligament release, pectoralis minor release, and coracoid process osteotomy. Patients were followed up with regular physiotherapy and a home exercise program for 1 year after surgery. Before surgery and at 3 and 12 months after surgery, upper-extremity function was measured using the modified Mallet classification and Active Movement Scale, passive shoulder and elbow joint movements were measured using goniometry, and the difference in the distance between the treatment table and the acromion was measured. There was an improvement in all movement tasks evaluated with modified Mallet classification, and there was increased shoulder flexion, abduction, and external and internal rotation movements as evaluated with Active Movement Scale. Increased passive joint movements were noted in abduction, external rotation, and internal rotation movements with the arm next to the body and with the limb in 90° abduction. There was a decrease in the distance difference between the acromion and the treatment table between both sides. Pericoracoid tissue release provided multidirectional improvement in shoulder joint movements in children with BPBI. Therapeutic IV.

Outcomes of Arthroscopic Coracohumeral Ligament Release in Patients with Frozen Shoulder

Outcomes of Arthroscopic Coracohumeral Ligament Release in Patients with Frozen Shoulder

Similar short-term outcomes of ultrasound guided posterior intra-articular and anterior extra-articular corticosteroid injection in the treatment of primary frozen shoulder. A randomized controlled, single-blind study.

Frozen shoulder, a condition characterized by the limitation of active and passive shoulder movements, is predominantly managed conservatively. Corticosteroid injection stands as a widely utilized and effective method for treatment. Nevertheless, the optimal approach for administering the injection remains a subject of controversy. We hypothesized that the injection of corticosteroid through anterior into the extra-articular area would yield superior results than the posterior intra-articular injection. This prospective, randomized, single-blind, and single-center clinical study aimed to compare the therapeutic effectiveness of ultrasound (USG)-guided injection techniques in patients with primary frozen shoulder. We continued the study with 54 patients who met the inclusion criteria. We evaluated patients pre-injection and at the first, third, and sixth weeks after injection. Two distinct approaches were employed: (1) Injection through the anterior extra-articular area around the coracohumeral ligament (CHL), and (2) injection through the posterior route into the glenohumeral joint. Evaluation parameters, including Visual Analog Scale (VAS) scores, active range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, were assessed pre-injection and at the first, third, and sixth weeks post injection. No significant differences in the demographic and clinical characteristics, laboratory, or radiological findings were observed between the groups. It was observed that both groups exhibited similar and significant improvement in all measured parameters within their respective groups. Regarding pain scores, a notable decrease in VAS scores was observed in both groups (P = .000). There was no difference between the groups in terms of pre-injection VAS, QuickDASH, and ASES scores and active ROM measurements. The study concluded that there was no significant difference between ultrasound-guided injection of posterior intra-articular injection and anterior extra-articular injection concerning pain, ROM, and functional scores. Both techniques can be considered as viable options in the early stage of the disease. Level I, Therapeutic study.

The effect of preemptive middle glenohumeral ligament release, following release of the rotator interval and coracohumeral ligament, in arthroscopic rotator cuff repair of small- to medium-sized tears to prevent postoperative stiffness: a retrospective comparative study

BackgroundThis study aimed to evaluate the efficacy of preemptive middle glenohumeral ligament (MGHL) release during arthroscopic rotator cuff repair (ARCR) of small- to medium-sized tears to prevent postoperative stiffness. MethodsPatients who underwent ARCR of small- to medium-sized tears were enrolled and allocated into two groups retrospectively: the preemptive MGHL release group (MGHL+ group, n=34) and preemptive MGHL non-release group (MGHL- group, n=32). The rotator interval and coracohumeral ligament release were performed in all patients with or without MGHL release in both groups. Clinical outcomes including the range of motion (ROM), Constant Shoulder (CS) score, and University of California, Los Angeles (UCLA) score preoperatively and at 3 months, 6 months, and 12 months postoperatively and complications were assessed and compared between the two groups. The integrity of the repaired tendon was assessed at the 12-month follow-up using magnetic resonance imaging. ResultsThe MGHL+ group showed a significantly higher external rotation, CS score, and UCLA score than the MGHL- group at 6 months postoperatively (P=.03, <.001, .01, respectively). The ROM and functional scores were not significantly different between the groups at 3 and 12 months postoperatively (P>.05). The retear rate, postoperative stiffness, and postoperative instability were not significantly different between the groups (all, P>.05). ConclusionsPreemptive MGHL release in ARCR of small- to medium-sized tears could be an effective method to prevent early postoperative shoulder stiffness but does not significantly change the overall clinical outcome after ARCR.

Ultrasonography-guided corticosteroid injection in the coracohumeral ligament in patients with adhesive capsulitis of the shoulder: a double-blinded, sham-controlled randomized study

BackgroundContracture and thickening of the coracohumeral ligament (CHL) occur in patients with adhesive capsulitis. This adversely affects the movement and function of the shoulder joint. There is limited evidence that explores the effectiveness of an isolated steroid injection into CHL in combination with physical therapy. This prospective randomized control trial aimed to evaluate the clinical effects of ultrasound-guided corticosteroid injection compared to a sham injection into the CHL in subjects with adhesive capsulitis. MethodsForty patients (23 males, 52.2 ± 8 years of age) with unilateral adhesive capsulitis (with 5.4 ± 2 months mean duration of symptoms) were randomly assigned to either the experimental or control group. Both groups received ultrasound-guided injections into the CHL. The experimental group (n=20) received corticosteroids and the control group (n=20) received a sham lidocaine injection. All subjects underwent supervised conventional physical therapy three times a week for 3 months. Subjects were evaluated for improvements in pain, range of motion, and disability at 6 and 12 weeks as compared to pre-injection baseline measurements. Data were compared statistically across groups and times at p<0.05. The CHL thickness was compared at baseline across sides using paired t-tests. ResultsThe experimental group showed statistically greater improvements in pain, functional scores, flexion, abduction, internal and external rotation range of motion at 12 weeks compared to the control group. Pain reduction was observed in both groups at 6 and 12 weeks, but the experimental group exhibited significantly greater reductions. The CHL was significantly thicker on the affected side as compared to the unaffected side (p<0.001). Discussion and ConclusionThis study partially supported the hypothesis. Notably, significant improvements in pain, range of motion, and functional scores were observed at 12 weeks in the experimental group. The greater improvements in pain and external rotation may have resulted in lower disability scores in the experimental group. The results emphasize the importance of targeted intervention into the CHL.

Diagnostic Value of Superb Microvascular Imaging of the Rotator Cuff Interval for the Early Diagnosis of Frozen Shoulder.

To explore the early diagnostic value of superb microvascular imaging (SMI) features within the rotator cuff gap for frozen shoulder. This prospective study enrolled patients with acute early-stage frozen shoulder seeking treatment at Zhabei Central Hospital in Jing'an District, Shanghai, between July 2021 and December 2022 were enrolled in this study. Healthy controls were collected in a 1:1 ratio from the same hospital's physical examination center. All participants underwent SMI and power Doppler ultrasound (PDUS) of the rotator cuff gap. The study included 79 patients with frozen shoulder and 77 healthy controls. Compared with the healthy control group, the patient group had a higher proportion of hypoechoic rotator cuff gap (81.0% vs 48.1%, P<0.001), a thicker coracohumeral ligament (2.60±1.01 vs 2.03±0.97, P<0.001), a thicker glenohumeral joint capsule (3.10±0.99 vs 2.46±1.17, P<0.001), and elevated blood grading using SMI (P<0.001) and PDUS (P=0.014). The highest area under the curve (AUC) was observed for SMI blood flow grading (AUC=0.824, 95% CI: 0.755-0.880, P<0.001), resulting in 82% sensitivity and 77% specificity when using a cutoff of 1. SMI blood flow grading was associated with external rotation <30° (P=0.007) and abduction <30° (P=0.013) but not with internal rotation <30° (P=0.630) or flexion <30° (P=0.562). The grading of SMI blood flow may emerge as a valuable predictive indicator for the early stages of frozen shoulder. This simple ultrasound technique holds the potential to enhance the diagnostic process, enabling early initiation of treatment and potentially improving patient outcomes.

MR imaging signs of shoulder adhesive capsulitis: analysis of potential differentials and improved diagnostic criteria.

To evaluate the prevalence of shoulder adhesive capsulitis (AC) signs on MR studies of patients with various common shoulder conditions. MR images of 316 patients were retrospectively evaluated. Patients were divided into three groups: controls (66 patients), clinical AC (63 patients), and study group (187 patients). The final diagnosis of AC was reached clinically. The study group was composed of patients with focal and massive rotator cuff tears, active hydroxyapatite deposition disease, fractures around the shoulder, and post-surgery. The following AC signs were evaluated: inferior glenohumeral ligament (IGHL) thickening; coracohumeral ligament (CHL) thickening; and hyperintensity of the inferior glenohumeral ligament, which was graded in four classes. The IGHL signal intensity was statistically higher in patients with fractures than in controls (P = 0.008). There was no statistically significant difference in IGHL signal between the AC group and patients with massive rotator cuff tears and active hydroxyapatite deposition disease (P > 0.1). IGHL thickness in patients with fractures, massive rotator ruptures, and active hydroxyapatite deposition disease was significantly higher compared to controls (P < 0.02) and significantly lower compared to the AC group (P < 0.0001). Based on these findings, a grading system for fibro-inflammatory capsular changes is proposed. MR AC signs are frequent in patients with shoulder conditions other than AC; however, in these patients, capsular changes are less prominent than in patients with clinical AC.

Anatomy regarding the posterior part of coracohumeral ligament comprehensively including loose connective tissues

Anatomy regarding the posterior part of coracohumeral ligament comprehensively including loose connective tissues

Impact of Coracohumeral Ligament Release on Treatment Outcomes in Patients with Idiopathic Adhesive Capsulitis

Background. The coracohumeral ligament restricts external rotation of the shoulder joint and, along with the upper, middle, and lower glenohumeral ligaments, participates in stabilizing the shoulder joint. There is ongoing debate regarding the division of this anatomical structure in patients with limited external rotation. Objective: to compare the treatment outcomes of patients with idiopathic adhesive capsulitis who underwent coracohumeral ligament release along with selective capsulotomy to those who underwent only partial coracohumeral ligament release. Material and Methods. We treated 85 patients with idiopathic adhesive capsulitis, who were divided into two groups: group 1 underwent selective anterior capsulotomy of the shoulder joint with the division of the middle and lower glenohumeral ligaments, biceps long head tenotomy, subacromial decompression, and partial coracohumeral ligament release; group 2 underwent a similar surgical procedure with complete coracohumeral ligament excision. The average age of the patients was 47.9±19.1 years. The function of the shoulder joint was assessed using the Constant Shoulder Score and VAS scales before surgery and at 3 and 6 months postoperatively. Results. At 3 months postoperatively, group 2 showed a slightly better functional outcome according to the Constant Shoulder Score (12.2±6.9 points) compared to group 1 (18.1±6.4 points, p=0.038). At 6 months postoperatively, group 1 had a mean Constant Shoulder Score of 15.1±7 points, while group 2 had a score of 10.1±6.3 points (p=0.02). Conclusions. Excision of the coracohumeral ligament in patients with idiopathic adhesive capsulitis allows for better functional outcomes according to the Constant Shoulder Score and VAS at both 3 and 6 months postoperatively.

Quantitative evaluation of adhesion severity around subscapularis and its relationship with shoulder range of motion in frozen shoulder and rotator cuff disorder: an observational study using dynamic ultrasonography

BackgroundThis study aimed to evaluate the severity of adhesion between muscles in the shoulder joint using dynamic ultrasonography and to confirm whether adhesions cause range of motion (ROM) restrictions. MethodsTwenty-four shoulders from fifteen frozen shoulder (FS) patients and Twenty-four shoulders from eighteen rotator cuff disorder (RCD) patients were enrolled. We obtained ultrasound video sequences of the subscapularis and deltoid muscles during shoulder external rotation. The mean stretching velocities of the deltoid (VDelt) and subscapularis (VSSC) were subsequently analyzed using a PC. If adhesions occurred between both muscles, the deltoid was stretched more vigorously, and we calculated VDelt/VSSC as adhesion severity. The coracohumeral ligament (CHL) thickness was measured using the same images. Shoulder ROM was measured by using a universal goniometer. ResultsThe intraclass correlation coefficients (1.1) and (2.1) of the adhesion severity measurements were 0.85 and 0.91, respectively. Multiple linear regression analysis revealed that the adhesion severity is a significant predictor for external rotation ROM in the RCD group (R2 = 0.44, F = 10.1, p < 0.01, t = -2.9), while CHL thickness predicts ROM in the FS group (R2 = 0.28, F = 5.5, p = 0.01, t = -3.0). ConclusionThe proposed method is reliable. Muscle adhesion causes ROM restriction of the shoulder joint. The primary cause of shoulder ROM restriction differed between the diagnostic groups.

Additional Effect of Extracorporeal Shockwave Therapy with Lidocaine Injection on Clinical and MRI Findings in Frozen Shoulder: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial.

Frozen shoulder is a very common musculoskeletal condition and the evidence related to the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in individuals with frozen shoulder is rare. Therefore, this study aims to compare and investigate the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in a frozen shoulder. Sixty eligible participants with frozen shoulder were included and the active group (n = 30, age 52.12 ± 5.2years) received a lidocaine injection (1% lidocaine (Xylocaine) and 2cc (80 mg) methylprednisolone acetate) with active ESWT (3.5 bar air pressure and 2000 pulses with an energy flux density (EFD) ¼ 0.16 mJ/mm2) three sessions a week for 4 weeks. The placebo group (n = 30, age 53.56 ± 5.5years) received lidocaine injection with placebo treatment (a special head that blocked the shock waves) three sessions a week for 4 weeks. Both groups received progressive resistance exercises (PRE) to the shoulder muscles. The primary outcome was pain intensity, measured with the visual analogue scale. The other outcome measures were the thickness of the coracohumeral ligament (CHL) measured by magnetic resonance imaging (MRI), abduction, and lateral rotation range of motion (ROM), functional disability, kinesiophobia, depression status, and quality of life. Participants were assessed at baseline, after 4 weeks, 8 weeks, and at 6-month follow-up. The post-intervention at 4 weeks showed an improvement of 2.0 (CI 95% 1.71-2.28) in the active group compared to the placebo group. Similar effects were noted after 8 weeks (2.2) (CI 95% 1.91-2.48) and at the 6-month (1.9) (CI 95% 1.61-2.18) follow-up. Similar improvements were also found in the thickness of the CHL ligament (0.6) (CI 95% 0.46-0.73), abduction and lateral rotation (ROM) (-23.6) (CI 95% -27.47 to -19.72), (-18.10) (CI 95% -19.72 to -16.47), functional disability (16.2) (CI 95% 14.85-17.54), kinesiophobia (11.0 (CI 95% 10.21-11.98), depression status (4.4) (CI 95% 4.03-4.76) and quality of life (0.9) (CI 95% 0.79-1.00) (p = 0.001) at the 6-month follow-up period, where mean estimates and their confidence intervals all included worthwhile effects. There were no adverse reactions or side effects noted in either the active or placebo groups during and after the treatment. The study concluded that the addition of extracorporeal shockwave therapy after intra-articular lidocaine injection improves pain, functional disability, range of motion, kinesiophobia, depression status, and quality of life in people with frozen shoulder. https://ctri.nic.in , identifier; CTRI/2020/04/024834 prospectively registered on 24/04/2020.

Diagnostic accuracy of non-contrast MRI in frozen shoulder.

Despite being the most used exam today, few studies have evaluated the accuracy of findings on non-contrast magnetic resonance imaging (MRI). The primary objective of the study was to evaluate the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of non-contrast MRI findings in frozen shoulder, isolated and in combination. The secondary objectives were to define the interobserver and intraobserver agreement of the assessments and the odds ratio for frozen shoulder because of the various findings of MRI. A retrospective diagnostic accuracy study comparing non-contrast MRI findings between the frozen shoulder group and the control group. Sensitivity, specificity, positive and negative predictive value, accuracy, odds ratio, interobserver and intraobserver agreement were calculated for each finding and their possible associations. The hyperintensity on capsule in the axillary recess presented 84% sensitivity, 94% specificity, and 89% accuracy. The obliteration of the subcoracoid fat triangle in the rotator interval had sensitivity 34%, specificity 82% and accuracy 58%. For coracohumeral ligament thickness ≥ 2mm had specificity 66%, 48% specificity and 57% accuracy. Capsule thickness in the axillary recess ≥ 4mm resulted in 54% sensitivity, 82% specificity, and 68% accuracy. Regarding interobserver agreement, only the posteroinferior and posterosuperior quadrants showed moderate results, and all the others showed strong reliability. The odds ratio for hyperintensity in the axillary recess was 82.3 for frozen shoulder. The association of these findings increased specificity (95%). The accuracy of non-contrast magnetic resonance imaging is high for diagnosing frozen shoulder, especially when evaluating the hyperintensity of the axillary recess. The exam has high reliability and reproducibility. The presence of an association of signs increases the specificity of the test. Level III, study of diagnostic test.

Adhesive Capsulitis of the Shoulder: Current Concepts on the Diagnostic Work-Up and Evidence-Based Protocol for Radiological Evaluation.

Adhesive capsulitis is an idiopathic and disabling disorder characterized by intense shoulder pain and progressive limitation of active and passive glenohumeral joint range of motion. Although adhesive capsulitis has been traditionally considered a diagnosis of exclusion that can be established based on a suggestive medical history and the detection of supporting findings at the physical exam, imaging studies are commonly requested to confirm the diagnostic suspicion and to exclude other causes of shoulder pain. Indeed, clinical findings may be rather unspecific, and may overlap with diseases like calcific tendinitis, rotator cuff pathology, acromioclavicular or glenohumeral arthropathy, autoimmune disorders, and subacromial/subdeltoid bursitis. Magnetic resonance imaging, magnetic resonance arthrography, and high-resolution ultrasound have shown high sensitivity and accuracy in diagnosing adhesive capsulitis through the demonstration of specific pathological findings, including thickening of the joint capsule and of the coracohumeral ligament, fibrosis of the subcoracoid fat triangle, and extravasation of gadolinium outside the joint recesses. This narrative review provides an updated analysis of the current concepts on the role of imaging modalities in patients with adhesive capsulitis, with the final aim of proposing an evidence-based imaging protocol for the radiological evaluation of this condition.

Percutaneous Ultrasound-Guided Coracohumeral Ligament Release for Refractory Adhesive Capsulitis: A Prospective, Randomized, Controlled, Crossover Trial Demonstrating One-Year Efficacy

BACKGROUND: Adhesive capsulitis (AC) is a painful and disabling condition with restricted range of motion (ROM) that affects 2% to 3% of the population and up to 20% of patients with diabetes. AC can be idiopathic, iatrogenic, or secondary to shoulder injuries. Some associated conditions include diabetes mellitus, thyroid disorders, dyslipidemia, stroke, prolonged immobilization, and autoimmune conditions. Management ranges from analgesics to physical therapy, local injections, hydrodilatation, and advanced surgical interventions. This study examines percutaneous coracohumeral ligament (PCHL) sectioning with the hypothesis that interruption would improve pain and ROM in patients with AC refractory to conservative management. OBJECTIVES: To use sonographically guided percutaneous interruption of the CHL for the treatment of refractory AC. STUDY DESIGN: A prospective, randomized, controlled, cross-over trial. SETTING: Academic medical center. METHODS: Patients were identified based on inclusion and exclusion criteria under the supervision of the Principal Investigator. After primary screening, research staff explained the study, risks, and benefits to the patients, and consent was obtained. Patients’ pain score and shoulder ROM were assessed before and after the procedure, at one month, and one year. The Oxford Shoulder Scoring (OSS) questionnaire was also completed before the procedure and in the one-year follow-up visit. Forty patients were enrolled with refractory AC. Forty-six shoulders were treated; 6 patients underwent a bilateral procedure. Block 2:1 randomization was performed for the 2 groups (PCHL release [PCHLR] and local anesthetic CHL [LACHL]). The LACHL group received a lidocaine injection at CHL, and the PCHLR group received the CHL using a Tenex® (Tenex Health, Lake Forest, CA) needle. ROM, Numeric Rating Scale (NRS-11), and OSS were evaluated at baseline, immediate postprocedure, and long term. RESULTS: Among 46 shoulders included in the study, 7 were excluded due to lost to follow-up, total shoulder replacement, and shoulder manipulation. Twenty-six were randomized to the PCHLR group and 13 to LACHL group. ROM (external rotation and abduction), pain, NRS-11 score, and OSS score were measured at baseline and long term, confirmed by a nonbiased health care personnel. There was no statistically significant difference in ROM, NRS-11, and OSS between the 2 cohorts at the baseline visit. Nine patients in LACHL group crossed over to the PCHLR arm at one month. Data analysis in the long term revealed durability of the PCHLR group with a statistically significant difference in ROM, NRS-11, and OSS. External rotation improved by double, and abduction improved by almost 30% (P value &lt; .001). NRS-11 decreased from 8 (IQR 8, 9) at baseline to 3 (IQR 2, 7) at long term among those who received PCHLR. The baseline mean OSS in the PCHLR group increased from 7.44 to 31.86 at one-year follow-up and was statistically significant (P value &lt; .001). LIMITATIONS: This study represents a small population of patients with a CHL-related ROM deficit. Patients were not excluded for osteoarthritis or other motion-disabling shoulder conditions. We submit that the strength of the study could have been improved if the physician performing the procedure was blinded and if the patient was blinded as well to minimize operator and patient bias. CONCLUSIONS: We demonstrate that our technique for PCHLR is a safe, effective, and durable procedure that improved ROM, pain, and shoulder function in our patient population when compared to the control. KEY WORDS: Tenex, frozen shoulder, pain, range of motion, function, shoulder, minimally invasive, durable

Evaluation of Adhesive Capsulitis of the Shoulder with Fat-Suppressed T2 Weighted MRI: Association between Clinical Features and MRI Findings

Introduction •Adhesive capsulitis of the shoulder or frozen shoulder is a debilitating condition characterized by progressive pain, stiffness and limited range of motion about the glenohumeral joint, the term (adhesive capsulitis) to describe the findings of chronic inflammation and fibrosis of the joint capsule, characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder. (Zhao W, ZhengX, liu Y, et al.,2012). •MRI has, in recent years, allowed for the visualization of several characteristic signs seen with this condition, including thickening and shortening of the coracohumeral (CHL) ligament, thus limiting external rotation is due to fibroblastic proliferation within the CHL, thickening of axillary pouch and rotator interval joint capsule, in addition to the obliteration of the subcoracoid fat triangle.(Cheng X, et al.,2017). Aim of the work to examine the association between clinical features (stages) and MRI findings in adhesive capsulitis of the shoulder. Methods and material seventy patients confirmed or suspected adhesive capsulitis of the shoulder. The diagnosis is based on MRI findings and clinical criteria. Patients who complain from shoulder pain and restricted ROM with detailed clinical information and history which permit the clinical staging of AC and patients with normal ROM in the opposite shoulder are also included (the initial diagnosis was based on the history and clinical symptoms) clinical criteria for the diagnosis of AC includes: restricted passive motion for greater than 30 degrees in the two or more planes of movement, gradually increasing shoulder pain that was more severe at rest at least 1 month duration, and normal radiographic findings .Patients who fullified these criteria underwent shoulder MRI to correlate MRI findings with pain intensity, range of motion and clinical stage. Study is approved by the ethics review board of Ain Shams University Hospital. For the MRI examination, (a 1.5 tesla Philips Healthcare) MRI machine at El-Demerdash University Hospitals with a dedicated shoulder surface phased –array coil. During imaging, patients were in supine position .MRI protocol consisted of the following sequences:Fat-suppressed T2: coronal oblique, sagittal and axial weighted images, proton density(PD), fast spin echo T1-Weighted sagittal images.All patients will be subjected to complete history taking, full clinical examination. All MRI imaging examinations were conducted at radiology department of Ain Shams University. All patients were subjected to full history taking prior to scanning and full clinical examination. Results Regarding the diagnostic performance of shoulder MRI there is a statistically significant difference between degree of pain intensity according to Capsular thickening regarding humeral “mm” with p-value (p &amp;lt; 0.05). The highest value was found moderate and severe pain group (5.67±1.39) compared to absent, minimal &amp; mild pain group (4.42±1.29)., there was a statistically significant difference between two groups according to axillary recess regarding height “mm” with p-value (p &amp;lt; 0.05). The highest value was found absent, minimal &amp; mild pain group (7.02±2.68) compared to moderate and severe pain group (5.73±2.25). There is no statistically significant association between pain intensity and MRI finding regarding Capsular Edema, Extra Capsular Edema, Obliteration of Subcoracoid Fat Triangle, Effusion of Biceps Tendon Sheath, Capsular Thickening Glenoid (mm) and Axillary Recess Width (mm), with p-value (p &amp;gt; 0.05 NS). •Qualitative and quantitative analysis a highly statistically significant difference between absent and present of limitation of ROM “abduction” according to Capsular Thickening Glenoid (mm) with p-value (p &amp;lt; 0.001). The highest value was found absent group (6.29±0.99) compared to present group (5.21±1.39). •Additionally, the results showed 25 patients out of 70 having extra capsular edema anterior, 20 patients (48.8%) belong to absent abduction group and 5 patients (17.2%) belong to present abduction group, as there was a statistically significant negative relation with p-value (p = 0.014). •There is no statistically significant association between absent and present of limitation of ROM “abduction” and MRI finding regarding Capsular Edema Glenoid, Capsular Edema Humeral, Extra Capsular Edema Posterior, Obliteration of Subcoracoid Fat Triangle, Effusion of Biceps Tendon Sheath, Capsular Thickening Humeral (mm), Axillary Recess Height (mm) and Axillary Recess Width (mm), with p-value (p &amp;gt; 0.05 NS) Conclusion MRI can be useful for assessment several measures of clinical impairment in patients with adhesive capsulitis . thickening and hyperintensity of the joint capsule in the axillary recess on MRI is associated with limited ROM and duration of symptoms.

Clinical outcomes and cost-effectiveness of manipulation under brachial plexus block versus physiotherapy for refractory frozen shoulder: a prospective observational study

Frozen shoulder (FS) is a pathological condition that involves a painful and stiff shoulder joint, most commonly in people aged 40-60 years. Most literature supports treatment with physical therapy (PT), although some studies have demonstrated years of continuing pain and functional deficits. Manipulation under anesthesia is effective at eliminating the contracture of intra-articular lesions for refractory FS. This study aimed to compare whether manipulation under anesthesia or PT is a more effective treatment in refractory FS. This study was a prospective observational study. A total of 102 patients with refractory FS were enrolled in this study in the medical records, all of whom had severe and multidirectional loss of motion and thickening of the joint capsule and coracohumeral ligament on magnetic resonance imaging. Fifty-one patients were in the manipulation under brachial plexus block (MUB) group (34 females, median age: 57 years), and 51 patients were in the PT group (34 females, median age: 59 years). The MUB procedure consisted of the conventional method with additional adduction manipulation, in which one examiner initially abducted the shoulder joint as much as possible. We recorded the visual analog scale, shoulder range of motion, and American Shoulder and Elbow Surgeons and Constant Scores at the initial baseline visit and at the 1-, 3-, 6-, and 12-month follow-ups. The total cost was calculated from the medical records, and cost-effectiveness was evaluated using quality-adjusted life year and incremental cost-effectiveness ratio. Visual analog scale (P<.001), range of motion (P<.001), and American Shoulder and Elbow Surgeons and Constant Scores (P<.001) in the MUB group were significantly superior to those in the PT group at 1, 3, 6, and 12 months after treatment. The median cost and total quality-adjusted life year in the MUB and PT groups were $1375 versus $2751 and 2.95 versus 2.68, respectively, and the cost-effectiveness ratio between the MUB and PT groups was calculated as -$560. The new MUB procedure provides a shorter treatment period, better clinical outcomes, and higher cost-effectiveness in patients with refractory FS compared to PT.

Posterior capsule edema in adhesive capsulitis: comparison with established non-contrast MRI findings and multivariable analysis.

To evaluate posterior glenohumeral capsule edema compared to other MRI findings in adhesive capsulitis (AC). This study was approved by the local Institutional Review Board and it is HIPAA compliant. A retrospective search identified subjects who received fluoroscopically guided intra-articular corticosteroid injections for AC and had an MRI within 6months prior to injection. The study group was compared with an age-, sex-, and side-matched control group who underwent the same procedures but did not have AC. MRIs were evaluated for edema of posterior capsule, anterior capsule, axillary pouch, coracohumeral ligament (CHL) and rotator interval (RI), thickness of axillary pouch and CHL, thickness of anterior capsule, RI and subcoracoid fat replacement, and teres minor atrophy and edema. Multivariable analysis was performed. A total of 57 subjects with AC and 57 matched controls were studied: mean age 52 ± 7 (range 31-71) years, 37 female and 20 male, 22 right and 35 left. Posterior capsule edema was more common in the AC group vs. control group (66.7 vs 17.5%, p < 0.001). Multivariable analysis showed posterior capsule edema, CHL edema, and axillary pouch (glenoid) thickness (optimum cutoff = 4mm) were significant independent predictors of AC. Simplified analysis using these three variables had an area under the curve of 0.860 (95%CI: 0.792-0.928). With all three variables present, the sensitivity and specificity for AC were 32% and 98%, respectively. Posterior joint capsule edema may be helpful to confirm AC. Posterior capsule edema, CHL edema, and axillary pouch (glenoid) thickness produce a strong model for distinguishing AC from controls. Edema involving the posterior shoulder joint capsule is an imaging marker of capsulitis and is useful in differentiating patients with adhesive capsulitis from those without in conjunction with other proven MRI findings. • Posterior capsule edema has a sensitivity of 66.7% and a specificity of 82.5% for the detection of adhesive capsulitis. • Posterior capsule edema, coracohumeral ligament (CHL) edema, and axillary pouch (glenoid) thickness were significant independent predictors of adhesive capsulitis, and combining these variables together produces a very strong model for distinguishing cases from controls (AUC = 0.860). • Optimal cutoff values for CHL, axillary pouch (humeral), axillary pouch (glenoid), and axillary pouch (total) thickness were 2.5, 2.6, 4, and 6.3mm, respectively.

Changes in blood flow in the dorsal scapular artery and relationship to shoulder joint function in rotator cuff tears

One of the pain-related factors in rotator cuff tears (RCTs) is abnormal scapular motion, which is thought to be related to the levator scapulae muscle activation. Additionally, attention has recently focused on the peak systolic velocity (PSV) as one of the causes of pain, but blood flow outside of the vessels supplying the rotator cuff has not been clarified. This study aimed to determine the difference in PSV in the dorsal scapular artery (DSA), which is the vessel that supplies the levator scapulae muscles, and the association between PSV and pain and shoulder function in patients with RCTs between the tear and nontear sides. This study included 31 patients with RCTs with tear and nontear sides. Magnetic resonance imaging and radiographic examinations included Cofield classification, Goutallier classification, thickening of the coracohumeral ligament, and measurement of the acromiohumeral interval. Clinical evaluation included an automatic range of motion (ROM) for flexion, abduction, and external rotation (ER), a visual analog scale, and the Shoulder36. PSV was evaluated using ultrasound pulsed Doppler mode to assess PSV of DSA. The PSV of DSA on the first rib was drawn in the medial aspect of the suprascapular angle in the long axis, and the maximum PSV waveform was measured three times. The average value was used for further analysis. The PSV in the DSA was significantly higher (P=.04, 95% confidence interval: 0.2-7.6) on the tear (22.6±7.4 cm/s) than the nontear sides (18.9±6.9 cm/s). In addition, a significant negative correlation (r=-0.46, P=.0087) was found between PSV in DSA and ER on the tear side. This study revealed a significantly increased PSV in the DSA on the tear side in RCTs and negatively correlated with ER ROM. The results suggest that increased PSV in the DSA may contribute to ER ROM limitation in the glenohumeral joint.

Diagnostic performance and interreader agreement of individual and combined non-enhanced and contrast-enhanced MR imaging parameters in adhesive capsulitis of the shoulder

ObjectiveThe aims of our study were to analyze agreement among readers with different levels of expertise and diagnostic performance of individual and combined imaging signs for the diagnosis of adhesive capsulitis of the shoulder.MethodsIn a retrospective study, contrast-enhanced shoulder MRIs of 60 patients with and 120 without clinically diagnosed adhesive capsulitis were evaluated by three readers independently. As non-enhanced imaging signs, readers evaluated signal intensity and thickness of the axillary recess capsule, thickness of the rotator interval capsule and the coracohumeral ligament as well as obliteration of subcoracoid fat. Furthermore, contrast enhancement of axillary recess and rotator interval capsule were evaluated. Data analysis included interreader reliability, ROC analysis, and logistic regression (p < 0.05).ResultsContrast-enhanced parameters showed substantially higher agreement among readers (ICC 0.79–0.80) than non-enhanced parameters (0.37–0.45). AUCs of contrast-enhanced signs (95.1–96.6%) were significantly higher (p < 0.01) than of non-enhanced imaging signs (61.5–85.9%) when considered individually. Combined evaluation of axillary recess signal intensity and thicknesses of axillary recess or rotator interval—when at least one of two signs was rated positive—increased accuracy compared to individual imaging signs, however not statistically significant.ConclusionContrast-enhanced imaging signs show both distinctly higher agreement among readers and distinctly higher diagnostic performance compared to non-enhanced imaging signs based on the imaging protocol used in this study. Combined evaluation of parameters showed a tendency to increase discrimination; however, the effect on diagnosis of ACS was not statistically significant.

What is the most predictive magnetic resonance imaging finding of rotator cuff tear concomitant with shoulder stiffness?

Common magnetic resonance imaging (MRI) findings in adhesive capsulitis are not often evident in rotator cuff tear concomitant with shoulder stiffness. This study aimed to determine the most predictive MRI finding of rotator cuff tear with shoulder stiffness to differentiate from that without stiffness. The data of patients who underwent arthroscopic rotator cuff repair between January 2014 and October 2019 were retrospectively reviewed. Stiffness was defined as forward flexion <120°, external rotation at side <30°, and internal rotation at back<L3 in the active range of motion. Propensity score matching (1-to-1) was performed between the stiff and control groups by sex, age, and tear size, and 76 patients per group were matched. Anterior capsular thickness, maximal humeral/glenoid capsular thickness in the axillary recess, coracohumeral ligament thickness, the presence of hyperintensity in the anterior capsule and humeral/glenoid capsule in the axillary recess, and hyperintensity and obliteration of the subcoracoid fat triangle were evaluated. Anterior capsular thickness, glenoid capsular thickness in the axillary recess, and anterior and axillary capsular hyperintensities were significantly more dominant in the stiff group (all P<.05) than in the control group. Anterior capsular thickness and anterior capsular abnormal hyperintensity could be used to differentiate between the stiff and control groups (P<.05). Anterior capsular thickness showed high diagnostic performance with an area under the receiver operating characteristic curve of 0.993. The cut-off value for stiffness was 3.07 mm (sensitivity, 96.1%; specificity, 100%). Anterior capsular thickening and abnormal hyperintensity were the most predictive MRI findings for stiffness in patients with rotator cuff tear and stiffness to differentiate from patients with rotator cuff tear without stiffness.