Hi. I'm Rick Lawley, an assistant professor at Loyola in Chicago. We're going to discuss an ultrasound consult on a patient who presented with shoulder pain and loss of range of motion. In the ultrasound case, the patient was noted to have subacromial bursitis and supraspinatus tendinopathy. In the companion case we'll discuss today, we'll go over some diagnostic findings associated with adhesive capsulitis and the capsular distension procedure. Similar to the consult case, this companion case does have some tendinopathy of the supraspinatus tendon. In this image, we can see slight thickening of the supraspinatus tendon, but no large tears. Left is lateral. In the center loop of the supraspinatus tendon, we are scanning anterior to posterior with lateral on the left. We can see some mild heterogeneous hypoecogenicity and slight cortical regularity, but no significant tears present. After ruling out large rotator cuff tears as a cause of pain and range of motion loss, we start to look for indirect signs of adhesive capsulitis. Here we can see a moderate amount of essentially circumferential fluid around the long head of the biceps tendon within the sheath. This is then transverse plane and left is lateral. A small amount of fluid within the sheath can be normal, but we can see here that it is a fair amount of fluid within the sheath. Here's a long axis view of the biceps tendon. Left is proximal. We can see that anechoic fluid within the sheath. Another area to evaluate is the rotator cuff interval. Here are some illustrations of the rotator cuff interval components. In the lower left image, we are in the transverse oblique plane and the left is lateral. The position of the ultrasound transducer is indicated by the red rectangle on the image in the top left. LBT is long head of the biceps tendon, SSP is supraspinatus tendon, SSC is subscapularis tendon, CHL is cortical humeral ligament, and SGHL is superior glenohumeral ligament. We can see some evidence of hyperemia here around the biceps tendon in the rotator cuff interval, mostly within the cortical humeral ligament. Here is a sine loop demonstrating the hyperemia in the rotator cuff interval. Again, left is lateral. Most of that hyperemia does involve that cortical humeral ligament. And now that we have sonographic evidence confirming our clinical diagnosis of adhesive capsulitis, we'll move to the capsular extension procedure. The left of the image is medial, so I take a lateral to medial approach, making sure to go under the labrum with the needle rather than through it. You can see the Doppler signal indicating flow of medication into the glenohumeral joint. As I advance through the images, you can see the capsule distend with anechoic fluid, which is sterile saline in this case. The Doppler flow confirms no leakage of fluid out of the capsule. And here we can see the capsule quite a bit distended with the anechoic fluid. Here's a sine loop of the injection somewhat earlier in the procedure. You can see the capsule distending a bit. Here's a sine loop of the procedure a few minutes later. You can see the capsule distending a fair amount with a few bubbles and still no leakage of fluid. Here's the last sine loop for this patient. At the end of the loop, you can see the capsule collapse very slightly. The patient expressed a relief of pressure, and there was significantly less pressure with pushing the plunger, indicating capsular rupture. Here's another capsular rupture on a different patient. This one is not as subtle. Again, the patient will typically endorse relief of pressure, and the saline or whatever fluid you're using to distend the capsule will go in very easily with minimal resistance once that capsule ruptures.

3rd Edition, CASE 50

3rd Edition

Shoulder

ultrasound

shoulder pain

adhesive capsulitis

capsular distension

subacromial bursitis