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Okay.

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This is a patient with shoulder pain for several

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months, had surgery 20 years earlier, and remarkably,

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you know, we picked this out out of the teaching file.

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Actually, Paul picked it out of the teaching file, and

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it's a great first case to review with you, because it

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has two major findings, which usually do not go together.

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And I hate to show you a case that kind of breaks the

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rules first, but I'll just tell you it breaks the rules.

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Usually when I start out looking at

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a shoulder, I have the axial first.

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So I'll throw that up cause that's the

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order that I'd normally go in and you

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know, I work pretty fast, but so do you.

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And so will you, some of you are already fast, but as

1:00

you know, you know, it doesn't pay to be fast if you

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don't get it right, if you're fast and you can get it

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right, that's terrific, but rather you get it right.

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So we start out with the axial and the first thing I

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look at on the axial, which I prefer to have a water

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weighted axial is what does a capsule look like?

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And the capsule looks a little puffy.

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It's kind of a little, a little bright, a little displaced.

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The labrum's a little grayish.

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All right, it's a man.

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He's had surgery.

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At least the idea of adhesive

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capsulitis has crept into my brain.

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And there's a little fluid in the biceps, which

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kind of goes along with adhesive capsulitis.

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Because, you know, when it, when it

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contracts, it pushes the fluid out.

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Let's keep going.

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Now, one thing that is completely illogical is

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when somebody sees that, and they call it adhesive

1:56

capsulitis, and they start talking about dislocation.

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And does that happen?

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It happens a lot.

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Because look what's happened to the labrum.

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The labrum is a ghost.

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So someone that's inexperienced, that either

2:09

does or doesn't pick up on adhesive capsulitis,

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let's assume they don't pick up on it.

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First thing they think of is dislocation in a man.

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Right?

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Where'd the labrum go?

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Or if there is adhesive capsulitis, they

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don't realize what it does to the labrum.

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So then they start giving two diagnoses

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that are completely contradictory.

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One with decreased range of motion,

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one with increased range of motion.

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Now unfortunately, some patients that are dislocators,

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They will not pick up their arm and reach backwards

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because they know they're going to dislocate.

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So they actually report that they

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have decreased range of motion.

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It's more voluntary guarding, but it

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happens about 30 percent of the time.

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So you're going to get, you're going to get that

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history, unfortunately, in some dislocators.

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So you really have to tease it out,

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but you can't have it both ways.

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You can't have a dislocator and

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you can't have adhesive capsulitis.

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So let's keep going.

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And by the way, there's a little

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swelling in the back of the shoulder too.

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Right?

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The posterior labrum is a little ghosted.

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Let's keep going.

3:11

Here's the middle glenohumeral ligament.

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Here's the subscapularis.

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There's a little bit of clefting of the labrum.

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I don't mind that at the mid, mid coronal level.

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Let's keep going up.

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There's a little sulcus here.

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There's the labrum.

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There's the MGHL, which is attached to the labrum.

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We go all the way to the top and we see the biceps

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labral anchor and we actually see the rotator cuff.

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Now, I don't see a tear.

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Let's move down a little bit.

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I do see a focal defect now, and I'm not sure what to

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make of it without looking at the other projection.

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Now, when I look at the other projection,

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it'll become inherently clear in a moment.

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But I would describe that as focal.

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I would describe this as an ill defined diffuse finding.

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Focal, hyper intense, well marginated, diffuse, ill defined.

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Kind of glassy looking.

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Okay, let's keep going, shall we?

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And I also use this projection really quickly to

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look at the AC joint, which is a little swollen.

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But it is a PD fat suppression, and you

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already know that you can't really gauge how

4:29

symptomatic an AC joint is unless you have a T2.

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If it's swollen on the T2, then it's probably symptomatic.

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So now let's drop down the T1, T1 in the middle,

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T2 on the left, PD spur on the far right.

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Let's blow them up a little bit.

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We're gonna scroll them together.

4:57

You guys in the room are really experienced.

4:59

And I, I know you're already salivating

5:02

at this little oval football.

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It's like somebody tucked a

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football under the axilla, right?

5:09

And it's not fluid, and it's kinda gray.

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And it goes from a little bright,

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a little glowy, to pretty dark.

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There's just nothing else that can be.

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And with that degree of fibroinflammatory

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change, that's gonna be symptomatic.

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So there are people that have

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subclinical adhesive capsulitis.

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This is one that has.

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The MR findings of a dry, fibro inflammatory, non affusion

5:36

type capsulitis consistent with adhesive capsulitis.

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That's how to say it.

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Adhesive capsulitis is a nasty little bug.

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It infiltrates into everything.

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It makes the sulcus more conspicuous

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because it infiltrates in the sulcus.

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So you could easily read a SLAP lesion that isn't there.

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It just brightens it up, makes it more conspicuous.

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It's not as, uh, sliver like and as full

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thickness as a SLAP lesion would be.

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It's not as complex as a SLAP lesion would be, but you

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see that sulcus does tamp down as you go posteriorly.

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But that is part of the disease.

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Namely, it infiltrates crevices.

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So it makes those crevices look like

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they're something when they're nothing.

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It infiltrates the rotator cuff, like it's doing right here.

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That is all adhesive capsulitis in that cuff.

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Now the reason this case is counterintuitive is

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because this is one of the, I won't say rare, I'll

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say uncommon examples of somebody that has both.

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A full thickness tear and adhesive capsulitis.

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Now why don't those two go together?

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Because adhesive capsulitis, for it to

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form, requires a closed environment.

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Requires a closed space with an inflammatory

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reaction that produces a tense, fibro

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inflammatory reaction within an enclosed sphere.

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So if the cuff is blown Then if there's an inflammatory

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process that generates adhesive capsulitis, it can blow

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out the hole like a whale blowing through the blow hole.

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Now in the cases of rotator cuff tears that

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I've seen associated with adhesive capsulitis,

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the tears are almost always chronic.

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The tears are almost always not accompanied by fluid

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in the peritendinous space because they're chronic.

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The tears are not associated with big gaps, big

7:39

retractions, because otherwise the fibroinflammatory

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process would have gone out that hole.

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So it's usually a centimeter or less.

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This is a pretty big one.

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It's about a centimeter.

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That's about the upper limit of normal.

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You're going to see in rotator cuff tears associated

7:54

with adhesive capsulitis, no fluid around it.

7:58

So that thing is filled in with fibro

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inflammatory and inflammatory tissue.

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It's a little bright on T2.

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So there is active inflammation there,

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but you see how it doesn't really bunch

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up because it's glued to the humeral head.

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It's glued here.

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It's glued here.

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It's glued here.

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So usually non retracted.

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Focal inflammation in the hole, but not around.

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If there is inflammation around, it's usually not fluid

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because it's extension of the adhesive capsulitis.

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The rotator cuff is often gray and ghosted, like

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this one, especially on the T1 weighted image.

8:40

And this patient has both adhesive

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capsulitis and a rotator cuff tear.

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Just for completion's sake, let's look

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at our rotator cuff tear on the sagittal.

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We can see the AP dimension of it.

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Let's just mag it up a little bit.

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Not very easy to see on the T2, sorry, not

8:59

very easy to see on the T1, I apologize.

9:03

There's the T1, because you got all that fibroinflammatory

9:05

reaction in the hole, both acute and chronic.

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You can only see the acute or active part, I should

9:11

say active rather than acute, on the PD spur.

9:14

There's the hole, where the tear is.

9:17

Where is the adhesive capsulitis?

9:19

Gotta go to the glenoid.

9:20

Let's go to the glenoid.

9:22

And there it is, right in the axillary space.

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And the whole glenoid is kind of glowy looking.

9:30

Diagnosis, he's a capsulitis, rotator cuff tear, and don't

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forget to define the muscular atrophy, volume, and volume.