US intervention for adhesive capsulitis, targeting coracohumeral ligament and inferior capsule

Today, I will share a practical ultrasound intervention for adhesive capsulitis, direct targeting the coracohumeral ligament and inferior glenohumeral joint capsule. I will put her MRI scan in the back of this video clip.
If you want more information about the coracohumeral ligament, find and study these videos.
I will give you a small tip for smooth interventional processing. I am putting shift the little pillow or towel to the opposite side to allow enough procedure space.
Sometimes, I forget one step during preparation. So, make it systemically.
Next, I will prepare the drugs. First, I will draw 25 units of botulinum toxin.
I will draw another 25 units of botulinum toxin in another syringe.
In one syringe, I add 20mg of triamcinolone. It is for the inferior capsular injection.
I will connect this syringe to the 2-inch 24- gauge needle.
I add 1 ml of dexamethasone palmitate to another syringe.
I will connect this syringe to the 1.5 inches 24- gauge needle. It is for the coracohumeral ligament injection. I prefer dexamethasone for the coracohumeral injection. It will be absorbed soon because of water-soluble steroids.
I will put gel on the surface before the procedure. It is a mixture of chlorohexidine cream and 80% alcohol.
my first target is the coracohumeral ligament. I will trace the coracohumeral ligament transversely and trace the intra-articular portion of the biceps tendon.
I will go to the triangular low echo coracohumeral ligament.
I have two different feelings on my fingertip. Mostly the ligament is soft. It may suggest inflammation and soft fibrosis. When the patient comes after the initial symptom six months to years, I feel resistance.
The next target is the inferior glenohumeral capsule. Most of the patients had difficulties rotating the arm externally in the frozen shoulder. So, I ask the patient to rotate the arm as much as they can bear. For the left shoulder intervention, I put my left hand holding an ultrasound probe like this.
here is the tip on how to find the target and put the needle. Trace the bony cortical echo of the humerus shaft and the lesser tubercle first.
Slide the probe medially while everting the probe to the outer side until you find this hypoechoic inferior capsule.
I will put the needle into the inferior capsule. The pulsating vessels are anterior or posterior circumflex humeral arteries. It passes and forms the inferior border of the subscapularis muscle.
Would you please observe the fluid expansion in the inferior capsule and to the joint space? After the procedure, make sure to compress the area for several minutes to prevent bleeding deeply.
Here are the MRI images of this patient.
It is a coronal T2 weighted in-phase image of the glenohumeral joint.
The subcutaneous fat, bone marrow, cortex, and tendons look black. The joint fluid and inflammatory process appear as white.
the superior labrum, coracohumeral ligament, inferior joint capsule consist of fibers and fatty tissue and should look black. But this patient shows the high signal intensity of the superior labrum, coracohumeral ligament, and inferior joint capsule.
the inferior capsule shows diffuse thickening and high signal intensity in the humeral attachment site.
it shows bright signal intensity in the humeral attachment site.
it is a sagittal T2 weighted image. I will move the sectional image from the lateral to the medial aspect.
It shows the subscapular tendon, biceps tendon, and supraspinatus tendon.
it shows the high signal intensity of the coracohumeral ligament and thickening of the inferior joint capsule.
it is the axial T2 weighted in-phase of the upper aspect of the coracohumeral ligament. It shows the high signal intensity of the coracohumeral ligament
it is the axial image of the inferior glenohumeral joint capsule showing thick and high signal intensity.
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