Preliminary Diagnosis: Adhesive Capsulitis

I. What imaging technique is first-line for this diagnosis?

  • MR arthrography is the first-line imaging modality for detection of adhesive capsulitis.

  • Imaging protocol should include both fat-suppressed and non-fat-suppressed images, plus T1WI postcontrast images.

II. Describe the advantages and disadvantages of this technique for diagnosis of adhesive capsulitis.

Advantages

  • MR arthrography is diagnostic with findings of fibrosis in the rotator cuff interval, <8-10 mL joint capacity before contrast extravasation, and enhancing thickened capsule in the rotator cuff interval.

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  • MRI is able to detect other causes of pain or weakness in the joint such as tendinopathy, tenosynovitis, bursitis, or tears.

  • MRI does not make use of any ionizing radiation.

Disadvantages

  • Normally with adhesive capsulitis a joint capacity of <8-10 mL with arthrography is diagnostic. However, false-negative results occur with an associated full-thickness rotator cuff tear. This can be detected on subsequent MRI of the joint.

  • As with any invasive procedure, complications do exist with arthrography although they are very rare and usually minor.

  • MRI is an expensive and time-consuming modality that requires marked patient cooperation to limit motion artifact.

  • MRI with intravenous contrast requires that the patient have good renal function with a GFR >60. Administration of intravenous contrast is decided individually on a case-by-case basis with a GFR >30 and <60.

III. What are the contraindications for the first-line imaging technique?

  • Patients with non-MR-compatible metallic hardware or foreign bodies.

IV. What alternative imaging techniques are available?

  • CT arthrography

  • Ultrasound

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of adhesive capsulitis.

CT arthrography
Advantages

  • Can also detect a joint capactiy of <8-10 mL

  • CT scanning may be perfomed much quicker, requires less patient cooperation, and is associated with less motion artifact compared with MRI.

Disadvantages

  • CT does not demonstrate soft tissues of the rotator cuff interval, rotator cuff musculature, and tendons with as precise anatomic detail as can MRI. MR arthrography is far superior.

  • Subsequent MRI will likely need to be performed in light of negative CT results, increasing costs and delaying time to diagnosis.

Ultrasound
Advantages

  • Ultrasound may be diagnostic is diagnosing adhesive capsulitis.

  • Allows real-time imaging with assessment of capsular compliance during patient movement.

  • Can also detect tendinopathy, tendonitis, bursitis, and tear

Disadvantages

  • Requires a skilled technician trained in musculoskeletal imaging with a high index of suspicion for detection of pathology

  • Limited evaluation in obese patients

VI. What are the contraindications for the alternative imaging techniques?

CT arthrography

  • Contraindicated in pregnancy, especially within the first two trimesters

  • Documented history or multiple prior significant reactions to contrast

Ultrasound

  • No significant contraindications exist.

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