Skip to main content

Letter to the Editor Regarding “Ultrasound Features of Adhesive Capsulitis”

To the editor:


We have read with great interest the recently published article entitled, "Ultrasound Features of Adhesive Capsulitis" by Stella et al. [1] Their main ultrasound findings on 106 patients with adhesive capsulitis included axillary pouch thickening, reduced sliding of the infraspinatus tendon, and thickening of the shoulder pulleys. Regarding axillary pouch thickening, the cut-off values they presented of > 4 mm or > 60% of the contralateral unaffected side strengthen the ones that had been obtained by Michelin et al. [2] in smaller cohort of 20 patients with unilateral adhesive capsulitis with affected shoulders having an average AP thickness of 4.0 mm and unaffected ones, 1.3 mm.

The authors also mention, in the ultrasound signs of adhesive capsulitis, a “pseudo-double’’ tendon appearance of the long head of the biceps brachii tendon (LHBT) at the level of the pulley in 43 of the 106 patients, with a corresponding image (Fig. 6). Based on the pseudo-double tendon appearance of the LHBT, the tendon would be the coracohumeral ligament (CHL) if it was lateral to the biceps tendon and the superior glenohumeral ligament (SGHL) if it was medial.

Firstly, the ultrasound image presented in Fig. 6 is at the level of the bicipital groove, with the greater and lesser tuberosities well visible, and not at the more proximal biceps pulley, also known as biceps sling. An ultrasound scanning technique for the coracohumeral ligament at the rotator interval has previously been described [3]. To our knowledge, no description of the coracohumeral ligament or the superior glenohumeral ligament within the bicipital groove has been made so far, despite numerous cadaveric [4, 5] and imaging studies [6,7,8].

A detailed look at the transverse humeral ligament taken on 13 cadavers by Snow et al. in 2013 demonstrated that on top of being an innervated distinct structure, the transverse humeral ligament was continuous with the rotator cuff tendons and the coracohumeral ligament [9]. However, this did not result in an additional bundle-like structure.

The presence of a second oval or circular shaped structure at the level of the bicipital groove should suggest either a bifurcate biceps brachii tendon [10,11,12] or an aponeurotic expansion of the supraspinatus tendon [13, 14]. Bergman et al. estimated the existence of one or more additional heads of the long head of biceps to be up to 20% [15]. Moser et al. estimated at 49% the prevalence of an aponeurotic expansion of the supraspinatus in their retrospective review of 150 consecutive shoulder magnetic resonance imaging (MRI) studies. [13]

If that “pseudo-double” tendon was at the level of the rotator interval where the biceps pulley is visible on ultrasound, either an anisotropy artifact of the CHL or SGHL could account for a 2nd structure adjacent to the LHBT, and an aponeurotic expansion of the supraspinatus would be in the differential diagnosis.

If the structure is indeed more distal as shown in Fig. 6, at the level of the bicipital groove, then the most likely diagnoses are an aponeurotic expansion of the supraspinatus or a bifurcate biceps brachii tendon, and not CHL or SGHL. If some of the 43 patients in which the pseudo-double tendon was seen also had an MRI, a post hoc analysis of these exams would be helpful in sorting this question out.

References

  1. Stella SM, Gualtierotti R, Ciampi B, Trentanni C, Sconfienza LM, Del Chiaro A, et al. Ultrasound features of adhesive capsulitis. Rheumatol Therap. 2021:1–15.

  2. Michelin P, Delarue Y, Duparc F, Dacher JN. Thickening of the inferior glenohumeral capsule: an ultrasound sign for shoulder capsular contracture. Eur Radiol. 2013;23(10):2802–6.

    Article  Google Scholar 

  3. Majdalani C, Boudier-Reveret M, Pape J, Brismee JM, Michaud J, Luong DH, et al. Accuracy of two ultrasound-guided coracohumeral ligament injection approaches: a cadaveric study. Pm & R. 2019;11(9):989–95. https://doi.org/10.1002/pmrj.12079.

    Article  Google Scholar 

  4. Werner A, Mueller T, Boehm D, Gohlke F. The stabilizing sling for the long head of the biceps tendon in the rotator cuff interval: a histoanatomic study. Am J Sports Med. 2000;28(1):28–31.

    CAS  Article  Google Scholar 

  5. Visonà E, Cerciello S, Godenèche A, Neyton L, Fessy M-H, Nové-Josserand L. The “comma sign”: an anatomical investigation (dissection of the rotator interval in 14 cadaveric shoulders). Surg Radiol Anat. 2015;37(7):793–8.

    Article  Google Scholar 

  6. Morag Y, Jacobson JA, Shields G, Rajani R, Jamadar DA, Miller B, et al. MR arthrography of rotator interval, long head of the Biceps Brachii, and Biceps Pulley of the Shoulder. Radiology. 2005;235(1):21–30. https://doi.org/10.1148/radiol.2351031455.

    Article  PubMed  Google Scholar 

  7. Nakata W, Katou S, Fujita A, Nakata M, Lefor AT, Sugimoto H. Biceps Pulley: Normal Anatomy and Associated Lesions at MR Arthrography. Radiographics: a review publication of the Radiological Society of North America, Inc. 2011;31(3):791–810. https://doi.org/10.1148/rg.313105507.

  8. Tamborrini G, Möller I, Bong D, Miguel M, Marx C, Müller AM, et al. The rotator interval - a link between anatomy and ultrasound. Ultrasound Int Open. 2017;3(3):E107–16. https://doi.org/10.1055/s-0043-110473.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Snow BJ, Narvy SJ, Omid R, Atkinson RD, Vangsness CT Jr. Anatomy and histology of the transverse humeral ligament. Orthopedics. 2013;36(10):e1295–8.

    Article  Google Scholar 

  10. Borghei P, Tehranzadeh J. Bifurcation of the long head of the biceps brachii. Appl Radiol. 2010;39(10):33.

    Article  Google Scholar 

  11. Kim KC, Rhee KJ, Shin HD, Kim YM. Biceps long head tendon revisited: a case report of split tendon arising from single origin. Arch Orthop Trauma Surg. 2008;128(5):495–8.

    Article  Google Scholar 

  12. Audenaert EA, Barbaix EJ, Van Hoonacker P, Berghs BM. Extraarticular variants of the long head of the biceps brachii: A reminder of embryology. J Shoulder Elbow Surg. 2008;17(1, Supplement):S114-S7. https://doi.org/10.1016/j.jse.2007.06.014.

  13. Moser TP, Cardinal É, Bureau NJ, Guillin R, Lanneville P, Grabs D. The aponeurotic expansion of the supraspinatus tendon: anatomy and prevalence in a series of 150 shoulder MRIs. Skeletal Radiol. 2015;44(2):223–31.

    Article  Google Scholar 

  14. Boissonnault E, Chang MC, Boudier-Reveret M. An often missed finding in ultrasonographic shoulder examination. J Med Ultrasound. 2020;28(4):278–9. https://doi.org/10.4103/JMU.JMU_39_20.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Bergman RA. Compendium of human anatomic variation: text, atlas, and world literature. Urban & Schwarzenberg; 1988.

Download references

Acknowledgements

Funding

No funding or sponsorship was received for this study or publication of this article. The Rapid Service Fee was funded by the authors.

Authorship

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Authors’ Contributions

Formal Analysis, Investigation, Methodology, Writing-original draft, Writing-review & editing: all authors.

Disclosures

Mathieu Boudier-Revéret, Ming-Yen Hsiao, and Min Cheol Chang have nothing to disclose.

Ethical Approval

This article is based on previous study and does not contain any new studies with human participants or animals performed by any of the authors.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Min Cheol Chang.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Boudier-Revéret, M., Hsiao, MY. & Chang, M.C. Letter to the Editor Regarding “Ultrasound Features of Adhesive Capsulitis”. Rheumatol Ther 9, 1221–1223 (2022). https://doi.org/10.1007/s40744-022-00447-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40744-022-00447-8

Keywords

  • Ultrasound
  • Adhesive capsulitis
  • Diagnosis
  • Tendon