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Discussion:The CT images demonstrate a demonstrates mild intrahepatic ductal dilatation and a small perihepatic fluid collection.
Magnetic resonance imaging (MRI) of the shoulder demonstrated soft tissue thickening and increased signal intensity in the rotator interval, obscuring the normal fat surrounding the coracohumeral ligament, seen on both coronal and sagittal oblique images (Figure 1).
Figure 1: Sagittal oblique T1 (A) and fat-saturated T2 (B), and coronal oblique fat-saturated T2 (C), images of the anterior rotator cuff interval in the right shoulder demonstrate replacement of the normal fat surrounding the coracohumeral ligament (arrow) with high-signal soft tissue thickening. Figure 3: Sagital oblique T1 (A) and coronal oblique T2 (B) images of the right shoulder demonstrate a normal coracohumeral ligament (arrow) surrounded by fat as it traverses the anterior rotator cuff interval.
The rotator interval is a triangular space bordered superiorly by the supraspinatus tendon, inferiorly by the superior aspect of the subscapularis tendon, laterally by the long head of the biceps tendon, and medially by the base of the coracoid process. In addition to the rotator interval, the axillary recess commonly demonstrates abnormalities in adhesive capsulitis.
Treatment Adhesive capsulitis is typically a self-limiting disease that improves over an 18- to 24- month period. AuthorsDrs Shaikh and Sundaram are from the Department of Radiology, Cleveland Clinic Foundation, Cleveland, Ohio.
Clinical History: 54-year-old female with decreased range of motion and right shoulder pain increasing over the last 2 months. The sagittal T2-weighted image demonstrates a thickened coracohumeral ligament (arrow) and soft tissue thickening in the rotator interval (arrowheads). The coronal T2-weighted fat-suppressed image (B) demonstrates an abnormally thickened inferior glenohumeral ligament (arrow). Adhesive capsulitis or "frozen shoulder" is an inflammatory condition of the glenohumeral joint synovium and capsule leading to a restricted range of motion.
The clinical diagnosis of idiopathic adhesive capsulitis relies on the detection of a global decreased range of motion at the glenohumeral joint, absence of previous major trauma, and a normal joint space on plain radiographs.2 However, these diagnostic criteria are nonspecific, as the clinical features of rotator cuff pathology and impingement often mimic those of adhesive capsulitis. MRI effectively demonstrates the rotator interval and the axillary recess, which are sites commonly affected by adhesive capsulitis. A coronal T1-weighted image through the anterior shoulder demonstrates the normal coracohumeral ligament (arrow) arising from the coracoid process (Cor) and extending laterally toward its insertion on the greater and lesser tuberosities of the humerus.
A coronal T2-weighted image following an MR arthrogram demonstrates the normal thickness of the inferior glenohumeral ligament (arrow). The MRI findings that suggest adhesive capsulitis include soft tissue thickening in the rotator interval, which may encase the coracohumeral and superior glenohumeral ligaments, and soft tissue thickening adjacent to the biceps anchor (A, F). A coronal T2-weighted fat suppressed image through the anterior aspect of the shoulder demonstrates increased signal intensity (asterisk) in the rotator interval region, obscuring the normal fat, suspicious for adhesive capsulitis. Post IV gadolinium enhanced sagittal T1-weighted image with fat-suppression demonstrates enhancement in the rotator interval region (arrows), confirming the diagnosis of adhesive capsulitis. The natural history of idiopathic or secondary forms of adhesive capsulitis is quite variable with residual pain and stiffness persisting in some studies up to 7 years.6 Treatment regimens vary greatly, reflecting the complexity of this condition. The MRI changes of adhesive capsulitis are most often observed at the rotator interval and the inferior glenohumeral ligament.
3 Carillon Y, Noel E, Fantino O, Perrin-Faylle O, Tran-Minh VA: Magnetic resonance imaging findings in idiopathic adhesive capsulitis of the shoulder.
Vascular territories of the cerebral arteries (adapted and modified with permission from M.
The PICA territory is on the inferior occipital surface of the cerebellum and is in equilibrium with the territory of the AICA in purple, which is on the lateral side (1). The territory of the AChA is part of the hippocampus, the posterior limb of the internal capsule and extends upwards to an area lateral to the posterior part of the cella media.

The lateral LSA' s (in orange) are deep penetrating arteries of the middle cerebral artery (MCA). The medial LSA' s (indicated in dark red) arise from the anterior cerebral artery (usually the A1-segment).
Heubner's artery is the largest of the medial lenticulostriate arteries and supplies the anteromedial part of the head of the caudate and anteroinferior internal capsule. The ACA supplies the medial part of the frontal and the parietal lobe and the anterior portion of the corpus callosum, basal ganglia and internal capsule.
The cortical branches of the MCA supply the lateral surface of the hemisphere, except for the medial part of the frontal and the parietal lobe (anterior cerebral artery), and the inferior part of the temporal lobe (posterior cerebral artery).
P1 extends from origin of the PCA to the posterior communicating artery, contributing to the circle of Willis. Posterior thalamoperforating arteries branch off the P1 segment and supply blood to the midbrain and thalamus. Cortical branches of the PCA supply the inferomedial part of the temporal lobe, occipital pole, visual cortex, and splenium of the corpus callosum. This likely is secondary to distended gallbladder with pericholecystic fluid and a small amount of free fluid tracking along the medial aspect of the liver with a common bile duct that is prominent measuring 7 mm in greatest dimension. There is periosteal reaction (white circle) at the site of a stress fracture of the shaft of the 3rd metatarsal. Coracoid process (C), acromion (A), and subscapularis tendon (S) are labeled for orientation. Coracoid process (C), acromion (A), and subscapularis tendon (S) are labeled for orientation.Role of MRI in Diagnosis Patients typically demonstrate an insidious onset of pain, followed by gradual loss of motion in the shoulder with preservation of the glenohumeral joint space on radiographs.
Coronal oblique T2-weighted image demonstrates a normal inferior glenohumeral ligament (arrow) measuring 4 mm in thickness. The coracohumeral ligament arises from the coracoid process and passes through the rotator interval before inserting on the greater tuberosity and bicipital sheath.3 Figure 3 demonstrates the normal appearance of the coracohumeral ligament as a curvilinear low-signal structure in the anterior rotator interval surrounded by fat. The normal inferior glenohumeral ligament measures <4 mm and is best seen on coronal oblique images at the mid glenoid level (Figure 4).
Intra-articular corticosteroid injection for the treatment of idiopathic adhesive capsulitis of the shoulder.
The rotator interval lies between the supraspinatus muscle and tendon posterosuperiorly and the subscapularis muscle and tendon anteroinferiorly. The coracohumeral ligament (arrow), which along with the superior glenohumeral ligament forms the rotator interval capsule, is normally surrounded by fat. A thickened inferior glenohumeral ligament greater than 4 mm is often seen in the axillary pouch (B). The supraspinatus muscle (Sup), subscapularis muscle (Sub), clavicle (Cl), Acromion (Ac) are also indicated. The long biceps tendon (short arrow), supraspinatus muscle (Sup), subscapularis (Sub), and Coracoid (Cor) are indicated.
Supportive treatment, oral and injected medications, physical therapy, the brisement procedure, manipulative therapy, and surgical release are all used in addressing this disorder, depending on the severity and duration of symptoms. Recent evidence indicates that IV gadolinium enhanced MR provides even greater specificity in diagnosing adhesive capsulitis.
Note superior subscapularis recess and subcoracoid bursa located anterior to subscapularis muscle. These findings are compatible with adhesive capsulitis, an inflammatory condition of the glenohumeral joint capsule and synovium leading to restricted range of motion.

Compare this to the previous images of our patient showing soft tissue thickening of the rotator interval capsule replacing the fat surrounding the coracohumeral ligament. In adhesive capsulitis, the axillary recess may show thickening up to 1.3 cm or more,4 as demonstrated in our patient. Primary or idiopathic adhesive capsulitis is encountered in the absence of preceding trauma. The rotator interval capsule is composed of the coracohumeral ligament and the superior glenohumeral ligament. The supraspinatus muscle (Sup), subscapularis muscle (Sub), coracoid process (Cor), acromion (Ac) and long head of the biceps (short arrow) are indicated.
Loss of definition of the inferior capsule secondary to edema and synovitis may also be demonstrated.
MRI is therefore an invaluable tool in differentiating adhesive capsulitis from other conditions that may have a similar clinical presentation. The findings highly likely represent acute cholecystitis with cholelithiasis as there is a large stone within the gallbladder as well.
The patient’s symptoms improved slightly with physical therapy and corticosteroid injections. Secondary adhesive capsulitis results from injury, repetitive low-level trauma, surgery, or endocrine or rheumatological conditions.
However, these diagnostic criteria are nonspecific and overlap with clinical features of rotator cuff disease and impingement.
Secondary adhesive capsulitis or post-traumatic arthritis results from antecedent injury, low-level repetitive trauma, surgery, or rheumatologic conditions. The coracohumeral ligament is readily identified on sagittal and coronal T1-weighted or T2-weighted FSE images as a curvilinear low-signal structure surrounded by fat, lateral to the coracoid process (C and D).
IV gadolinium enhancement increases the specificity of the diagnosis by demonstrating enhancement of the rotator interval capsule (G) and enhancement of the capsuloligamentous structures in the axillary recess.3,4 MR Arthrography has also been utilized as a means of making the diagnosis of adhesive capsulitis. However, after a year of intermittent relief from corticosteroid injections, his range of motion was still limited, and he was scheduled for closed manipulation under anesthesia in an attempt to increase his range of motion. Magnetic resonance imaging can help in differentiating adhesive capsulitis from more common shoulder pathology by effectively demonstrating the rotator interval and axillary recess, two sites commonly affected by adhesive capsulitis. Although poorly understood, adhesive capsulitis is felt to begin as an inflammatory hypervascular synovitis, which prompts a progressive fibroblastic response in the adjacent capsule. The thickness of the capsule of the axillary recess is best demonstrated on coronal images at the mid glenoid level (E).
On the ultrasound images, there is a large calcification in the gallbladder with significant posterior shadowing. Capsular thickening and contraction ensue.1 At arthroscopy, synovial inflammation or capsular thickening may be seen.
The abnormalities most commonly involve the rotator interval capsule, the biceps tendon root, and the inferior and posterior capsule.

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