教你一招 | 如何诊断粘连性肩关节囊炎（冰冻肩）？

来源：jxradiology

译者：HW ZHAO译

腋隐窝解剖示意图：

腋囊的增厚和水肿：

肩袖间隙异常软组织信号（细箭）：

腋囊增厚和水肿(细箭)：

腋囊增厚纤维化（T1/T2均为低信号）：

MRI关节囊造影提示腋囊体积缩小：

Adhesive capsulitis of the shoulder, also known as frozen shoulder, is a condition characterised by thickening and contraction of the shoulder joint capsule and surrounding synovium. Adhesive capsulitis can rarely affect other sites such as the ankle .

粘连性肩关节囊炎 ，也称冻结肩，其特征是肩关节囊和周围滑膜的增厚和挛缩。粘连性关节囊炎很少影响其他部位，如踝关节。

Epidemiology

The incidence in the general population is thought to be 3-5%. Adhesive capsulitis typically affects women in the 5th to 6th decades of life, although patients with co-morbidities such as diabetes may develop the condition at earlier ages. The incidence in patients with diabetes is reported to be 2 to 4 times higher than in the general population.

流行病学

一般人群的发病率为3-5％。粘连性关节囊炎通常见于50-60岁的女性，患有糖尿病等并发症的患者发病年龄可能会提前。糖尿病患者的发病率高于普通人群的2〜4倍。

Clinical presentation

Adhesive capsulitis presentation can be broken into three distinct stages:

freezing: painful stage 

patients may not present during this stage because they think that eventually, the pain will resolve if self-treated.

as the symptoms progress, pain worsens and both active and passive range of motion (ROM) becomes more restricted

this can eventually result in the patient seeking medical consultation

typically lasts between 3 and 9 months and is characterised by an acute synovitis of the glenohumeral joint

frozen: transitional stage

most patients will progress to the second stage

during this stage, shoulder pain does not necessarily worsen

because of pain at end ROM, use of the arm may be limited causing muscular disuse

can last between 4 to 12 months

the common capsular pattern of limitation has historically been described as diminishing motions with external shoulder rotation being the most limited, followed closely by shoulder flexion, and internal rotation

there eventually becomes a point in the frozen stage that pain does not occur at the end of ROM

thawing stage

begins when ROM begins to improve

lasts anywhere from 12 to 42 months and is defined by a gradual return of shoulder mobility

临床症状：

粘连性关节囊炎分为三个阶段：

凝结期：疼痛期

患者在这个阶段可能不会出现，因为他们认为最终，如果自我治疗，疼痛就会解决。

随着症状的进展，疼痛恶化，主动和被动的运动范围（ROM）变得更加受限制

这可能最终导致病人寻求医疗咨询

通常持续3至9个月，其特征是盂肱关节的急性滑膜炎

冻结期：过渡期

大多数患者将进入此阶段

在这个阶段，疼痛并不一定会恶化

由于运动时的疼痛，手臂功能可能会受到限制，导致肌肉废用

可持续4至12个月

常见的限制模式历史上被描述为减少运动，外肩旋转是最受限的，其次是肩部屈曲和内旋

最终在慢性期运动受限成为一个点，在运动范围结束时不会发生疼痛

解冻期

开始时运动范围开始改善

持续12至42个月，肩关节运动逐步恢复

Pathology

Adhesive capsulitis is divided into two main types: 

primary or idiopathic

absence of preceding trauma

secondary 

major or minor repetitive trauma

shoulder or thoracic surgery

endocrine, e.g. diabetes, hyperthyroidism 

rheumatological conditions

病理

粘连性关节囊炎分为两大类：

原发性或特发性

无外伤病史

继发性

重大或轻微的重复创伤

肩部或胸部手术

内分泌，例如糖尿病，甲状腺功能亢进

风湿病

Radiographic features

MRI/MR arthrography

normal inferior glenohumeral ligament measures <4 mm and is best seen on coronal oblique images at the mid glenoid level; in adhesive capsulitis, the axillary recess may show thickening ≥1.3 cm

joint capsule thickening 

abnormal soft tissue thickening within the rotator interval with signal alteration

abnormal soft tissue encasing the biceps anchor

variable enhancement of the capsule and synovium within the axillary recess and rotator interval

Other MR arthrography features include

thickening of the coracohumeral ligament (CHL) 

subcoracoid triangle sign 

影像学表现

MRI / MRI关节造影

正常下盂肱韧带测量值<4毫米，在斜冠位上关节囊中间层面显示最好；在粘连性关节囊炎患者中，腋隐窝软组织增厚≥1.3厘米

关节囊增厚

肩袖间隙异常软组织增厚伴信号异常

异常软组织包绕肱二头肌腱

增强后腋隐窝和肩袖间隙的关节囊或滑囊强化

其他MR关节造影包括

喙肱韧带（CHL）增厚

喙突下三角征

腋囊正常容量15-18ml，本病小于10ml，多数小于5ml（文献上）

Treatment and prognosis

Adhesive capsulitis is typically a self-limiting disease that improves over 1-2 years. Treatment options include:

physiotherapy

corticosteroid injections

glenohumeral hydrodilatation

closed manipulation under anaesthesia

arthroscopic capsular release with lysis of adhesions