Adhesive Capsulitis in Physical Medicine and Rehabilitation Workup
- Author: André Roy, MD, FRCPC; Chief Editor: Stephen Kishner, MD, MHA more...
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- Whether laboratory investigations should be mandatory in patients presenting with the classic syndrome of idiopathic FS but without symptoms of concomitant systemic rheumatologic, inflammatory, peptic, or metastatic disorders remains unclear.
- The scientific literature shows an elevated incidence of diabetes, hyperthyroidism, and hypertriglyceridemia in patients with FS.
- Lequesne and colleagues found that 28% of 60 new patients who presented with idiopathic FS had unsuspected diabetes.
- This association should prompt possible testing of thyroid-stimulating hormone (TSH), serum triglyceride, and fasting blood sugar levels in most patients, particularly those presenting with bilateral disease and patients presenting with FS who are younger than 45 years.
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- Radiologic studies
- In general, idiopathic FS is considered a clinical diagnosis that does not require confirmation with radiologic imaging.
- Current radiologic studies do not seem to confer any useful information, prognostic or otherwise, that changes the way the patient is treated.
- For the moment, the principal utility of these tests is in ruling out concomitant conditions that may influence the treatment of an individual patient.
- Plain radiography
- All patients presenting with FS should undergo plain radiography of the shoulder, with the acquisition of soft-tissue views of the rotator cuff to rule out a septic or metastatic process.
- A plain radiograph may also show evidence of a large calcification of the rotator cuff in the painful resorptive phase, an avascular necrosis of the humeral head (that is, Milwaukee shoulder), or a Charcot joint.
- Gallium nuclear scanning - Patients who are immunocompromised, as well as those who abuse intravenous (IV) drugs, should undergo gallium nuclear scanning to rule out a septic joint.
- Arthrography of the glenohumeral joint
- Binder and colleagues examined the arthrographic and scintigraphic features of 36 patients who presented with clinically diagnosed FS. They reported no association between uptake on bone scans and arthrographic features (glenohumeral contrast enhancement), and neither finding was useful in predicting the rate or extent of recovery. FS of traumatic onset behaved no differently than did spontaneously arising FS. The authors concluded that arthrography or99m Tc diphosphonate scanning performed at presentation did not contribute to the assessment of a painful, stiff shoulder.
- The present authors share the opinions of Binder and coauthors on this matter.
- Of 36 subjects who met strict clinical criteria for FS in the study by Binder and colleagues (ie, loss of ≥ 50% of glenohumeral PROM in abduction and external rotation), only 50% had a positive arthrogram. Either arthrography had low sensitivity in diagnosing FS, or the expert physicians tended to overdiagnose FS. The fact that a positive arthrogram had no affect on the clinical outcome in this 4-year prospective study suggests that arthrography of the glenohumeral joint is a poorly sensitive test for diagnosing FS, although a positive glenohumeral arthrogram showing the classic signs of FS confirms the diagnosis beyond any doubt.
- A study by Mao and coauthors showed a poor correlation between ROM of the glenohumeral joint and its arthrographic appearance in patients with shoulder pain for 2 months or longer. This result once again showed the limited prognostic usefulness of arthrography of the glenohumeral joint.
- To date, arthrography is used mostly to treat FS, rather than to diagnose the condition.
- The injection of contrast medium into the glenohumeral joint helps to determine its volume and configuration. The normal volume of the joint is 13 mL. In FS, the volume can be reduced to 5-8 mL.
- 99m Tc methylene diphosphonate (MDP) bone scanning
- Binder and colleagues also examined the utility of nuclear bone scanning in the diagnosis and treatment of patients with FS. They again found that these studies had little prognostic value, although they were considerably more sensitive, with 92% of the study subjects having a positive scan.
- In general, the problem with bone scans in the practice of musculoskeletal medicine is that they are highly sensitive but not specific. The pilot work by Clunie and colleagues showed that abnormalities on posterior99m Tc MDP shoulder studies of patients with shoulder pain did tend to be specific for FS. However, this work must be reproduced on a large scale to be considered conclusive.
- Other studies - Computed tomography (CT) scanning, CT arthrography, ultrasonography, and magnetic resonance imaging (MRI) are sensitive imaging modalities that depict specific signs for FS. However, use of these modalities is rarely indicated.
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