J Korean Med Sci.  2020 Apr;35(15):e99. 10.3346/jkms.2020.35.e99.

Optimal Cut-Off Value of the Coracohumeral Ligament Area as a Morphological Parameter to Confirm Frozen Shoulder

Affiliations
  • 1Department of Anesthesiology and Pain Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
  • 2Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Korea
  • 3Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International St. Mary's Hospital, Incheon, Korea

Abstract

Background
Thickened coracohumeral ligament (CHL) is one of the important morphological changes of frozen shoulder (FS). Previous research reported that coracohumeral ligament thickness (CHLT) is correlated with anterior glenohumeral instability, rotator interval and eventually FS. However, thickness may change depending on the cutting angle, and measurement point. To reduce measurement mistakes, we devised a new imaging criteria, called the coracohumeral ligament area (CHLA).
Methods
CHL data were collected and analyzed from 52 patients with FS, and from 51 control subjects (no evidence of FS). Shoulder magnetic resonance imaging was performed in all subjects. We investigated the CHLT and CHLA at the maximal thickened view of the CHL using our picture archiving and communications system. The CHLA was measured as the whole area of the CHL including the most hypertrophied part of the MR images on the oblique sagittal plane. The CHLT was measured at the thickest point of the CHL.
Results
The average CHLA was 40.88 ± 12.53 mm2 in the control group and 67.47 ± 19.88 mm2 in the FS group. The mean CHLT was 2.84 ± 0.67 mm in the control group and 4.01 ± 1.11 mm in the FS group. FS patients had significantly higher CHLA (P < 0.01) and CHLT (P < 0.01) than the control group. The receiver operator characteristic analysis showed that the most suitable cut-off score of the CHLA was 50.01 mm2, with 76.9% sensitivity, 76.5% specificity, and area under the curve (AUC) of 0.87. The most suitable cut-off value of the CHLT was 3.30 mm, with 71.2% sensitivity, 70.6% specificity, and AUC of 0.81.
Conclusion
The significantly positive correlation between the CHLA, CHLT and FS was found. We also demonstrate that the CHLA has statistically equivalent power to CHLT. Thus, for diagnosis of FS, the treating physician can refer to CHLA as well as CHLT.

Keyword

Adhesive Capsulitis; Area Under Curve; Frozen Shoulder; Ligaments; ROC Curve

Figure

  • Fig. 1 T2-weighted TSE oblique sagittal shoulder magnetic resonance images: (A) CHLT in the FS, (B) CHLA in the FS.TSE = turbo-spin-echo, CHLT = coracohumeral ligament thickness, CHLA = coracohumeral ligament area, FS = frozen shoulder, C = coracoid process, H = humerus.

  • Fig. 2 ROC curve of CHLT and CHLA for confirmation of FS. The best-cut-off-point of CHLA was 50.01 mm2 vs. 3.30 mm of CHLT, with sensitivity 76.9% vs. 71.2%, specificity 76.5% vs. 70.6%.ROC = receiver operating characteristic, CHLT = coracohumeral ligament thickness, CHLA = coracohumeral ligament area, FS = frozen shoulder.


Reference

1. Koide M, Hamada J, Hagiwara Y, Kanazawa K, Suzuki K. A thickened coracohumeral ligament and superomedial capsule limit internal rotation of the shoulder joint: report of three cases. Case Rep Orthop. 2016; 2016:9384974. PMID: 27123353.
Article
2. Li JQ, Tang KL, Wang J, Li QY, Xu HT, Yang HF, et al. MRI findings for frozen shoulder evaluation: is the thickness of the coracohumeral ligament a valuable diagnostic tool? PLoS One. 2011; 6(12):e28704. PMID: 22163326.
Article
3. Homsi C, Bordalo-Rodrigues M, da Silva JJ, Stump XM. Ultrasound in adhesive capsulitis of the shoulder: Is assessment of the coracohumeral ligament a valuable diagnostic tool? Skeletal Radiol. 2006; 35(9):673–678. PMID: 16724200.
Article
4. Neer CS 2nd, Satterlee CC, Dalsey RM, Flatow EL. The anatomy and potential effects of contracture of the coracohumeral ligament. Clin Orthop Relat Res. 1992; (280):182–185.
Article
5. Ferrari DA. Capsular ligaments of the shoulder. Anatomical and functional study of the anterior superior capsule. Am J Sports Med. 1990; 18(1):20–24. PMID: 2301686.
6. Gondim Teixeira PA, Balaj C, Chanson A, Lecocq S, Louis M, Blum A. Adhesive capsulitis of the shoulder: value of inferior glenohumeral ligament signal changes on T2-weighted fat-saturated images. AJR Am J Roentgenol. 2012; 198(6):W589–W596. PMID: 22623575.
7. Lee KH, Park HJ, Lee SY, Youn IY, Kim E, Park JH, et al. Adhesive capsulitis of the shoulder joint: value of glenohumeral distance on magnetic resonance arthrography. J Comput Assist Tomogr. 2017; 41(1):116–120. PMID: 27560018.
8. Loveday DT, Johnston P, Arthur A, Tytherleigh-Strong GM. Frozen shoulder: a clinical review. Br J Hosp Med (Lond). 2009; 70(5):276–278. PMID: 19451871.
Article
9. Uppal HS, Evans JP, Smith C. Frozen shoulder: a systematic review of therapeutic options. World J Orthop. 2015; 6(2):263–268. PMID: 25793166.
Article
10. Wong PL, Tan HC. A review on frozen shoulder. Singapore Med J. 2010; 51(9):694–697. PMID: 20938608.
11. Neviaser AS, Hannafin JA. Adhesive capsulitis: a review of current treatment. Am J Sports Med. 2010; 38(11):2346–2356. PMID: 20110457.
12. Arai R, Nimura A, Yamaguchi K, Yoshimura H, Sugaya H, Saji T, et al. The anatomy of the coracohumeral ligament and its relation to the subscapularis muscle. J Shoulder Elbow Surg. 2014; 23(10):1575–1581. PMID: 24766789.
Article
13. Clark JM, Harryman DT 2nd. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am. 1992; 74(5):713–725. PMID: 1624486.
Article
14. Harryman DT 2nd, Sidles JA, Harris SL, Matsen FA 3rd. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am. 1992; 74(1):53–66. PMID: 1734014.
Article
15. Emig EW, Schweitzer ME, Karasick D, Lubowitz J. Adhesive capsulitis of the shoulder: MR diagnosis. AJR Am J Roentgenol. 1995; 164(6):1457–1459. PMID: 7754892.
Article
16. Itoi E, Arce G, Bain GI, Diercks RL, Guttmann D, Imhoff AB, et al. Shoulder stiffness: current concepts and concerns. Arthroscopy. 2016; 32(7):1402–1414. PMID: 27180923.
Article
17. Chellathurai A, Subbiah K, Elangovan A, Kannappan S. Adhesive capsulitis: MRI correlation with clinical stages and proposal of MRI staging. Indian J Radiol Imaging. 2019; 29(1):19–24. PMID: 31000937.
Article
18. Park SH, Goo JM, Jo CH. Receiver operating characteristic (ROC) curve: practical review for radiologists. Korean J Radiol. 2004; 5(1):11–18. PMID: 15064554.
Article
19. Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005; 331(7530):1453–1456. PMID: 16356983.
Article
20. Lefevre-Colau MM, Drapé JL, Fayad F, Rannou F, Diche T, Minvielle F, et al. Magnetic resonance imaging of shoulders with idiopathic adhesive capsulitis: reliability of measures. Eur Radiol. 2005; 15(12):2415–2422. PMID: 16003508.
Article
21. Jung JY, Jee WH, Chun HJ, Kim YS, Chung YG, Kim JM. Adhesive capsulitis of the shoulder: evaluation with MR arthrography. Eur Radiol. 2006; 16(4):791–796. PMID: 16228212.
Article
22. Sofka CM, Ciavarra GA, Hannafin JA, Cordasco FA, Potter HG. Magnetic resonance imaging of adhesive capsulitis: correlation with clinical staging. HSS J. 2008; 4(2):164–169. PMID: 18815860.
Article
23. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. 2007; 89(7):928–932. PMID: 17673588.
Article
24. Omari A, Bunker TD. Open surgical release for frozen shoulder: surgical findings and results of the release. J Shoulder Elbow Surg. 2001; 10(4):353–357. PMID: 11517365.
Article
25. Kanazawa K, Hagiwara Y, Kawai N, Sekiguchi T, Koide M, Ando A, et al. Correlations of coracohumeral ligament and range of motion restriction in patients with recurrent anterior glenohumeral instability evaluated by magnetic resonance arthrography. J Shoulder Elbow Surg. 2017; 26(2):233–240. PMID: 27814944.
Article
26. Hagiwara Y, Sekiguchi T, Ando A, Kanazawa K, Koide M, Hamada J, et al. Effects of arthroscopic coracohumeral ligament release on range of motion for patients with frozen shoulder. Open Orthop J. 2018; 12(1):373–379. PMID: 30288192.
Article
27. Yukata K, Goto T, Sakai T, Fujii H, Hamawaki J, Yasui N. Ultrasound-guided coracohumeral ligament release. Orthop Traumatol Surg Res. 2018; 104(6):823–827. PMID: 29567320.
Article
28. Hagiwara Y, Ando A, Kanazawa K, Koide M, Sekiguchi T, Hamada J, et al. Arthroscopic coracohumeral ligament release for patients with frozen shoulder. Arthrosc Tech. 2017; 7(1):e1–5. PMID: 29379707.
Article
29. DePalma AF. The classic. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193-204. Clin Orthop Relat Res. 2008; 466(3):552–560. PMID: 18264843.
30. Leffert RD. The frozen shoulder. Instr Course Lect. 1985; 34:199–203. PMID: 3833940.
31. Ozaki J, Nakagawa Y, Sakurai G, Tamai S. Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J Bone Joint Surg Am. 1989; 71(10):1511–1515. PMID: 2592391.
Article
32. Tetro AM, Bauer G, Hollstien SB, Yamaguchi K. Arthroscopic release of the rotator interval and coracohumeral ligament: an anatomic study in cadavers. Arthroscopy. 2002; 18(2):145–150. PMID: 11830807.
33. Mengiardi B, Pfirrmann CW, Gerber C, Hodler J, Zanetti M. Frozen shoulder: MR arthrographic findings. Radiology. 2004; 233(2):486–492. PMID: 15358849.
Article
34. Zhao W, Zheng X, Liu Y, Yang W, Amirbekian V, Diaz LE, et al. An MRI study of symptomatic adhesive capsulitis. PLoS One. 2012; 7(10):e47277. PMID: 23082152.
Article
35. Lee SY, Park J, Song SW. Correlation of MR arthrographic findings and range of shoulder motions in patients with frozen shoulder. AJR Am J Roentgenol. 2012; 198(1):173–179. PMID: 22194494.
Article
36. Yang HF, Tang KL, Chen W, Dong SW, Jin T, Gong JC, et al. An anatomic and histologic study of the coracohumeral ligament. J Shoulder Elbow Surg. 2009; 18(2):305–310. PMID: 19095467.
Article
37. Toprak U, Ustüner E, Uyanık S, Aktaş G, Kınıklı GI, Baltacı G, et al. Comparison of ultrasonographic patellar tendon evaluation methods in elite junior female volleyball players: thickness versus cross-sectional area. Diagn Interv Radiol. 2012; 18(2):200–207. PMID: 22105710.
38. Bang YS, Park J, Lee SY, Park J, Park S, Joo Y, et al. Value of anterior band of the inferior glenohumeral ligament area as a morphological parameter of adhesive capsulitis. Pain Res Manag. 2019; 2019:9301970. PMID: 31205575.
Article
39. Couppé C, Svensson RB, Sødring-Elbrønd V, Hansen P, Kjaer M, Magnusson SP. Accuracy of MRI technique in measuring tendon cross-sectional area. Clin Physiol Funct Imaging. 2014; 34(3):237–241. PMID: 24119143.
Article
40. Galanis N, Savvidis M, Tsifountoudis I, Gkouvas G, Alafropatis I, Kirkos J, et al. Correlation between semitendinosus and gracilis tendon cross-sectional area determined using ultrasound, magnetic resonance imaging and intraoperative tendon measurements. J Electromyogr Kinesiol. 2016; 26:44–51. PMID: 26708406.
Article
41. Cho H, Kang S, Won HS, Yang M, Kim YD. New insights into pathways of the dorsal scapular nerve and artery for selective dorsal scapular nerve blockade. Korean J Pain. 2019; 32(4):307–312. PMID: 31569924.
Article
42. Ghavidel-Parsa B, Bidari A, Hajiabbasi A, Shenavar I, Ghalehbaghi B, Sanaei O. Fibromyalgia diagnostic model derived from combination of American College of Rheumatology 1990 and 2011 criteria. Korean J Pain. 2019; 32(2):120–128. PMID: 31091511.
Article
43. Kim YD, Yu JY, Shim J, Heo HJ, Kim H. Risk of encountering dorsal scapular and long thoracic nerves during ultrasound-guided interscalene brachial plexus block with nerve stimulator. Korean J Pain. 2016; 29(3):179–184. PMID: 27413483.
Article
44. Schwenk ES, Mariano ER. Designing the ideal perioperative pain management plan starts with multimodal analgesia. Korean J Anesthesiol. 2018; 71(5):345–352. PMID: 30139215.
Article
45. Shanmugam S, Mathias L, Thakur A, Kumar D. Effects of intramuscular electrical stimulation using inversely placed electrodes on myofascial pain syndrome in the shoulder: a case series. Korean J Pain. 2016; 29(2):136–140. PMID: 27103970.
Article
46. Tantawy SA, Abdul Rahman A, Abdul Ameer M. The relationship between the development of musculoskeletal disorders, body mass index, and academic stress in Bahraini University students. Korean J Pain. 2017; 30(2):126–133. PMID: 28416996.
Article
47. Lee S, Cho HR, Yoo JS, Kim YU. The prognostic value of median nerve thickness in diagnosing carpal tunnel syndrome using magnetic resonance imaging: a pilot study. Korean J Pain. 2020; 33(1):54–59. PMID: 31888318.
Article
Full Text Links
  • JKMS
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr