 This is a patient with shoulder pain for several months, had surgery 20 years earlier. Wow. And remarkably, you know, we picked this out of the teaching file. Actually, Paul picked it out of the teaching file. And it's a great first case to review with you. Because it has two major findings, which usually do not go together. And I hate to show you a case that kind of breaks the rules first, but I'll just tell you it breaks the rules. So, usually when I start out looking at a shoulder, I have the axial first. So, I'll throw that up because that's the order that I'd normally go in. And, you know, I work pretty fast, but so do you and so will you. Some of you are already fast. But as you know, you know, it doesn't pay to be fast if you don't get it right. If you're fast and you can get it right, that's terrific. But rather, you get it right. So, we start out with the axial. And the first thing I look at on the axial, which I prefer to have a water-weighted axial, is what does the capsule look like? And the capsule looks a little puffy. It's kind of a little bright, a little displaced. The labrum's a little grayish. All right. It's a man. He's had surgery. At least the idea of adhesive capsulitis has crept into my brain. And there's a little fluid in the biceps, which kind of goes along with adhesive capsulitis. Because, you know, when it contracts, it pushes the fluid out. So, let's keep going. Now, one thing that is completely illogical is when somebody sees that and they call it adhesive capsulitis and they start talking about dislocation. And does that happen? It happens a lot. Because look what's happened to the labrum. The labrum is a ghost. So, someone that's inexperienced, it either does or doesn't pick up on adhesive capsulitis. Let's assume they don't pick up on it. First thing they think of is dislocation in a man, right? Where'd the labrum go? Or if there is adhesive capsulitis, they don't realize what it does to the labrum. So then they start giving two diagnoses that are completely contradictory. One with decreased range of motion, one with increased range of motion. Now, unfortunately, some patients that are dislocators, they will not pick up their arm and reach backwards because they know they're going to dislocate. So they actually report that they have decreased range of motion. It's more voluntary guarding, but it happens about 30% of the time. So you're going to get that history, unfortunately, in some dislocators. So you really have to tease it out. But you can't have it both ways. You can't have a dislocator, and you can't have adhesive capsulitis. So let's keep going. And by the way, there's a little swelling in the back of the shoulder, too. The posterior labrum is a little ghosted. Let's keep going. Here's the middle glenohumeral ligament. Here's the subscapularis. There's a little bit of clefting of the labrum. Let's find that at the mid-coronal level. Let's keep going up. There's a little sulcus here. There's the labrum. There's the MGHL, which is attached to the labrum. We go all the way to the top, and we see the biceps, labral anchor, and we actually see the rotator cuff. Now, I don't see a tear. Let's move down a little bit. I do see a focal defect now, and I'm not sure what to make of it without looking at the other projection. Now, when I look at the other projection, it will become inherently clear in a moment. But I would describe that as focal. I would describe this as an ill-defined diffuse finding. Focal, hyper intense, well-marginated, diffuse, ill-defined, kind of glassy looking. Okay, let's keep going, shall we? And I also use this projection really quickly to look at the AC joint, which is a little swollen, but it is a PDFAT suppression, and you already know that you can't really gauge how symptomatic an AC joint is unless you have a T2. If it's swollen on the T2, then it's probably symptomatic. So now let's drop down the T1, T1 in the middle, T2 on the left, PD spur on the far right. Let's blow them up a little bit. We're going to scroll them together. You guys in the room are really experienced, and I know you're already salivating at this little oval football. Looks like somebody tucked a football under the axilla, right? And it's not fluid, and it's kind of gray, and it goes from a little bright, a little glowy to pretty dark. There's just nothing else that can be. And with that degree of fibro-inflammatory change, that's going to be symptomatic. So there are people that have subplenical adhesive capsulitis. This is one that has the MR findings of a dry fibro-inflammatory non-iffusion type capsulitis consistent with adhesive capsulitis. That's how to say it. And adhesive capsulitis is a nasty little bug. It infiltrates into everything. It makes the sulcus more conspicuous because it infiltrates in the sulcus. So you could easily read a slap lesion that isn't there. It just brightens it up, makes it more conspicuous. It's not as sliver-like and as full-thickness as a slap lesion would be. It's not as complex as a slap lesion would be, but you see that sulcus does tamp down as you go posteriorly. But that is part of the disease. Namely, it infiltrates crevices. So it makes those crevices look like they're something when they're nothing. It infiltrates the rotator cuff, like it's doing right here. That is all adhesive capsulitis in that cuff. Now the reason this case is counter-intuitive is because this is one of the, I won't say rare, I'll say uncommon examples of somebody that has both. A full-thickness tear and adhesive capsulitis. Now why don't those two go together? Because adhesive capsulitis, for it to form, requires a closed environment, requires a closed space with an inflammatory reaction that produces a tense, fibro-inflammatory reaction within an enclosed sphere. So if the cuff is blown, then if there's an inflammatory process that generates adhesive capsulitis, it can blow out the hole, like a whale blowing through the blow hole. Now in the cases of rotator cuff tears that I've seen associated with adhesive capsulitis, the tears are almost always chronic. The tears are almost always not accompanied by fluid and the peritendinous space, because they're chronic. The tears are not associated with big gaps, big retractions, because otherwise the fibro-inflammatory process would have gone out that hole. So it's usually a centimeter or less. This is a pretty big one. It's about a centimeter. That's about the upper limit of normal you're going to see in rotator cuff tears associated with adhesive capsulitis. No fluid around it. So that thing is filled in with fibro-inflammatory and inflammatory tissue. It's a little bright on T2, so there is active inflammation there. But you see how it doesn't really bunch up because it's glued to the humeral head. It's glued here, it's glued here, it's glued here. So usually non-retracted, focal inflammation in the hole, but not around. If there is inflammation around, it's usually not fluid because it's extension of the adhesive capsulitis. The rotator cuff is often gray and ghosted like this one, especially on the T1 weighted image. And this patient has both adhesive capsulitis and a rotator cuff tear. Just for completion's sake, let's look at our rotator cuff tear on the sagittal. We can see the AP dimension of it. Let's just mag it up a little bit. Not very easy to see on the T2. Sorry, not very easy to see on the T1. I apologize. There's the T1 because you've got all that fibro-inflammatory in the hole, both acute and chronic. You can only see the acute or active part. I should say active rather than acute on the PD spur. There's the hole where the tear is. Where is the adhesive capsulitis? You've got to go to the glenoid. Let's go to the glenoid. And there it is, right in the axillary space. And the whole glenoid is kind of glowy looking. Diagnosis, adhesive capsulitis, rotator cuff tear. Don't forget to define the muscular atrophy, volume and fat.