RTC Int Vascularity and thickened GH capsule

[Diane]

Hi Stephen,

I was wondering if the attached pictures qualify for increased rotator cuff interval vascularity?
Normally, does the RTC int display absolutely no vascularity at all or is there minor vasc? Sometimes I don’t know if Im calling the right thing.

Also, in terms of adhesive capsulitis (AC), do any of the following features form first i.e. RTC vascularity or thickened glenohumeral capsule. Do we have to see both to call AC or does seeing one of these features suffice for indicating AC.

I recently scanned a patient where I was convinced he had AC but the radiologist wasn’t as excited as me and decided to just inject the biceps tendon sheath effusion instead (which would just leak into the glenohumeral capsule area anyway right?)
He had a biceps tendon sheath effusion, a thickened glenohumeral joint capsule (comparison with asymptomatic side provided) and I thought he may have had a thickened CHL? What do you think of the pictures?

I’ve also attached some pictures labelled patient C. She had trouble externally rotated and fully extending the shoulder up for an axillary view. I saw an effusion (yay!) and thought glenohumeral capsule looks thickened and hypoechoic compared to the asymptomatic right side but is this appearance just because she can’t extend the shoulder fully?
I find that whenever a patient can’t extend their shoulder fully to scan under the armpit, I see a ?thickened glenohumeral capsule. Im not sure if this is because they actually do have a thickened capsule or that it’s giving a false appearance because of the restricted position.

Thanks!

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[Stephen Bird]

Hi Diane,

These are lovely pictures,

You are doing them perfectly,

I think all cases are positive.

In a normal rotator cuff interval there should be no flow and you have significant flow in all cases which indicates some inflammation of the glenohumeral joint capsule which may be adhesive capsulitis or simple synovitis of the GH joint.
If it is adhesive cap range of movement will be significantly restricted and if it is simple synovitis range of movement will be preserved but there will be pain with all movements.

The RCI vascularity is best seen in the acute onset stage and then it diminishes in usefulness as the time since symptoms begin lengthens.
The thickening of the IGHL should appear at the same time as the RCI findings.

They may not both be present but one or the other of these findings raises the suspicion of adhesive cap or synovitis. The presence of both raises suspicion further.

I agree if the patient can’t raise the arm the IGHL can look a little thicker but I think in your cases it is simply thick and the inability to raise the are is caused by the fact that that ligament / joint capsule can not stretch more and hence it is thick.

The injection of the biceps sheath in that patient was funnily enough exactly the right treatment as the patient with adhesive cap or synovitis needs a catabolic injection into the GH joint and injecting the LHBT sheath achieves exactly that.

If you injected the posterior G joint in the usual way you achieve the same outcome. Once the patient stands up and moves around it is mixed evenly inside the GH joint / LHBT sheath combined space.

Remember to look at the scapulo-humeral rhythm and the external rotation range clinically as well as the posterior GH joint capsule thickness sonographically.

Lovely work,

Steve

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