Letters to the Editor

Radiology

Frozen Shoulder

From:
Ferris M. Hall, MD
Department of Radiology, Beth Israel Deaconess Medical
Center
330 Brookline Avenue, Boston, MA 02215
e-mail: fhall@bidmc.harvard.edu

Editor:
In the Novermber 2004 issue of Radiology, Dr Mengiardi and
colleagues (1) describe several relatively subtle findings of
frozen shoulder (adhesive capsulitis) at magnetic resonance
(MR) arthrography. The authors injected 12 mL of diluted
gadopentetate dimeglumine into the shoulder, although “in-
jection volume was lower when patients indicated increased
pressure or pain” (1).
The diagnosis of adhesive capsulitis is more accurately
assigned on the basis of glenohumeral joint capacity (normal
injected volume, 12–13 mL) at the time of arthrography
rather than at subsequent evaluation of MR arthrographic
images and, in my experience, this diagnosis is occasionally
assigned at arthrography when it is clinically unsuspected
initially. One might make the case that the standard of ref-
erence for this somewhat nebulous diagnosis should be ar-
thrographic volume rather than arthroscopy. The pain dur-
ing injection mentioned by Dr Mengiardi and colleagues (1)
is, in my experience, a poor indicator of adhesive capsulitis.
Rather, decreased joint volume—as indicated by rapid back-
flow of injected liquid after injection of approximately 8
mL—is highly suggestive of the diagnosis and correlates well
with clinical symptoms. False-negative results can occur with
concomitant full-thickness rotator cuff tear because of in-
creased joint capacity. Joint capacity and pressure are difficult
to assess when injection is performed with a commonly used
22-gauge needle and, for this reason and the greater ease of
needle placement in large patients, a 20-gauge needle may be
preferred.

Volume 235 䡠 Number 2 Radiology 䡠 713

 In many departments, the fluoroscopic arthrographic pro-
Radiology
cedure and subsequent interpretation of MR images are per-
formed by different individuals without correlation of the
findings at each examination. Radiologists, particularly
younger ones trained after the era of MR arthrography, may
regard the arthrographic portion of MR arthrography to be
ancillary to the MR examination, intended only to instill
contrast material into the joint, rather than to potentially
contribute important additional information (2). Unless one
measures the injected volume and fluoroscopically assesses
joint laxity, preferably with the glenoid in profile, this readily
available information will be lost.
Although only indirectly applicable to the informative ar-
ticle by Dr Mengiardi and colleagues (1), I would make a plea
that when possible, the preliminary arthrogram and subse-
quent MR arthrogram be reviewed together because of the
complementary information that each provides. Joint capac-
ity and pressure, ligament laxity (2), and the assessment of
the humeral articular cartilage are all better assessed during
the arthrographic portion of MR arthrography and may add
important information for the referring physician.
References
1. Mengiardi B, Pfirrmann CW, Gerber C, Hodler J, Zanetti M.
Frozen shoulder: MR arthrographic findings. Radiology 2004;
233:486 – 492.
2. Hall FM. MR arthrography of the posterior labrocapsular com-
plex (letter). AJR Am J Roentgenol 2003; 181:595–596.
Drs Mengiardi and Zanetti respond:
We thank Dr Hall for his interest in our work (1). Dr Hall
emphasized that the arthrographic findings should be inter-
preted together with the MR arthrograms for assessment of
frozen shoulders. We agree that initial arthrography may
provide additional information. Thus, in our institution, the
arthrography procedure and the evaluation of the MR arthro-
graphic images are always performed by the same radiologist.
In our retrospective study, we did not measure prospec-
tively the injected contrast material volume. The signifi-
714 䡠 Radiology 䡠 May 2005
cantly smaller axillary recess in patients with frozen shoulder
compared with that in control subjects (mean, 0.53 vs 0.88
mL; P ⫽ .03), however, indicates that the injected contrast
material volume was indeed less in patients with frozen
shoulder. Rapid backflow of injected liquid was hardly seen
in our patients with frozen shoulder.
We do not agree that the diagnosis of frozen shoulder
should be made on the basis of the reduced glenohumeral
joint capacity. As already mentioned by Dr Hall, the injection
volume in patients with frozen shoulder may be normal
(12–13 mL) or even increased in the presence of full-thickness
tears of the rotator cuff. The injected contrast material vol-
ume may also be increased when contrast material escapes
from the glenohumeral joint along the subscapularis muscle.
This is a common artifact seen on shoulder arthrograms. On
the other hand, the injected volume may be decreased when
the needle tip gets stuck in small degenerative contour irreg-
ularities of the humeral head. The use of reduced joint ca-
pacity as a standard of reference for the diagnosis of a frozen
shoulder is therefore, in our opinion, not ideal. We believe
that imaging findings should be better correlated with the
findings that orthopedic surgeons see at arthroscopy, at
which point they decide whether intervention (capsulotomy)
is required.
Therefore, we would like to focus the attention of the
readers to the characteristic MR arthrographic findings at the
rotator cuff interval, where the most extensive abnormalities
are seen by orthopedic shoulder surgeons in patients with
frozen shoulder.
Reference
1. Mengiardi B, Pfirrmann CW, Gerber C, Hodler J, Zanetti M.
Frozen shoulder: MR arthrographic findings. Radiology 2004;
233:486 – 492.
Bernard Mengiardi, MD, and Marco Zanetti, MD
Department of Radiology, Orthopedic University Clinic
Balgrist
Forchstrasse 340, CH-8008 Zurich, Switzerland
e-mail: mengiardi@yahoo.de