Ultrasound, IGHL &

Capsular Contracture

Paul Michelin - Radiology

Yohann Delarue - Physical Medicine & Rehabilitation
Fabrice Duparc - Orthopaedic Surgery - Anatomy
Jean Nicolas Dacher - Radiology

ESSR, York June 20, 2015

 Introduction
•  Adhesive capsulitis, frozen shoulder,
capsular contracture...

•  Frequent
–  2.4 cases / 1000pers / year

•  Inflammatory pain
•  Limited active and passive range of motion

Hsu JE et al. J Shoulder Elbow Surg 2011

Robinson CM et al. J Bone Joint Surg Br 2012
 •  Synovium + articular capsule
•  Fibrous + inflammatory thickening

•  Rotator interval + IGHL

Emig EW et al. AJR Am J Roentgenol 1995

Ahn KS et al. Skeletal Radiol 2012
 Ultrasound

Capsulitis Capsulitis

Normal

Normal •  Coraco-Humeral
•  Rotator Interval Ligament
Lee JC et al. Skeletal Radiol 2005
Homsi C et al. Skeletal Radiol 2006
 Inferior Capsule

•  Inferior Glenohumeral Ligament

•  2 bands, 1 axillary pouch

Ticker JB et al. J Shoulder Elbow Surg 2006

Ultrasound
 Material & Methods

•  Patients inclusion
–  June 2011 - June 2013

•  Final diagnosis by an
expert clinician
•  Aware of US result

•  Normal Radiographs

•  MRI if requested
 Population
•  42 unilateral adhesive capsulitis
•  28 female, 14 male
•  Age 54,3 years [39-76]
•  22 Right, 20 Left Shoulders
 Ultrasound

•  Siemens S2000 (2009) •  Views

•  Linear HD transducer –  Short axis
–  18-7 MHz (n=35)
–  Long axis when
–  9-4 MHz (n=7)
possible
•  1 examiner
•  Statistics
–  Mann & Whitney Test
 Normal IGHL

•  Axillary pouch: extremely thin

•  Anterior and posterior bands: slightly thicker
 Case 1
•  Major thickening
•  Woman, 47

Contralateral Capsulitis

Right Left
1.1 mm 4.7 mm
 Case 2
•  Moderate thickening
•  Woman, 54

Contralateral Capsulitis

Right Left
1.0 mm 3.4 mm
 Case 3
•  Limited thickening
•  Woman, 60

Capsulitis Contralateral

Right Left
2.1 mm 1.0 mm
 Results

•  Difference in thickness:

•  Significant
- p<0.0001

group average median SD Min Max

Adhesive capsulitis 4.3 mm 3.8 mm 1.0 mm 2.1 mm 6.3 mm

Asymptomatic 1.3 mm 1.5 mm 0.26 mm 1.0 mm 1.9 mm

Difference 2.6 mm 2.5 mm 1.0 mm 0.80 mm 5.6 mm

 MRI correlation
•  8 clinically questionnable cases
–  7 shoulders: increased T2 signal of the IGHL
–  1 shoulder: thickened CHL

Capsulitis

Contralateral T2 FS
 Associated diseases
•  In addition to the thickening of the capsule:
–  6 inflammatory calcifying tendinopathies
–  3 small sized tears of the supraspinatus

•  Abnormalities of the cuff: 14% of cases

•  Expert Clinician:
–  symptoms mainly due to the capsulitis
•  Active calcifying tendinosis
•  + capsulitis

•  Male, 39
 Discussion
•  Inferior Capsule:
–  Large capsular area, free from overlying tendon
–  Frequently involved in adhesive capsulitis
–  Remote from deseases/surgery of the cuff
–  Not involved in the degenerative processes of the
biceps pulley
 Discussion
•  IGHL vs CHL Ultrasound
–  CHL: complex anatomy

•  US vs IRM of the inferior capsule

–  Mesurement of a taut ligament
–  Bilateral comparative
–  Cheap, non invasive

Edelson JG et al. J Bone Joint Surg Br 1991

 Limits
•  Only stiff shoulders
•  Examiner aware of the limited range of motion
•  Reproductibility of the measurements?
•  Is a normal IGHL thickened in incompletely
abducted shoulders?
 Limits
•  Inferior view: difficult to perform
–  in totally frozen shoulders: no clinical doubt

•  Differential diagnosis
–  synovitis or fluid effusion / capsular thickening

Tra Long
•  Conclusion:

•  The IGHL is visible with

Ultrasound
•  The thickening of the IGHL is a
sign for adhesive capsulitis

Thank you