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<v ->Now, when I was doing procedures,

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we were sometimes called upon,

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to do this procedure known as the Brisement procedure.

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And what you would do,

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is a standard arthrogram of the Glenohumeral joint.

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You would go ahead

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and start to inject the contrast material into the joint.

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And normally, for any

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of you who have MR arthography or standard arthography

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you recognize that typically you can inject 15

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20 milliliters without any difficulty.

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But if you are dealing with adhesive capsulitis,

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you run into difficulty sometimes

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after two or three milliliters

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it's difficult to push the plunger any further.

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Now, when that occurs, there's two possibilities.

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One is you've got cartilage

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in the tip of the needle, which is blocking injection.

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The second is you have pressure in the joint.

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So the way you can differentiate it

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take your finger off the plunger and see

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if the contrast material comes back into the plunger.

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If that's the case then indeed

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you're dealing with adhesive capsulitis.

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Once you've established that diagnosis

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you can start the Brisement procedure.

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And what you do is you use saline.

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You don't have to inject contrast

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but you slowly distend The Glenohumeral joint slowly

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put in 10 milliliters, take out five, put in 10 more,

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take out another five and keep doing that

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until the capsule ruptures.

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And when the capsule ruptures

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all of a sudden there'll be no more resistance

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to the injection of the contrast agent,

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patient might hear a noise

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but there's no particular pain.

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Especially if you put a little bit of Hexylcaine

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in with this.

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As soon as you done with this, it is most important

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the patient go to physical therapy.

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And that patient should go

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to physical therapy probably every day, at least for a week.

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It's not unusual that months or years later

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the same patient will come back for a second treatment.

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This does work.

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Now the alternative is the orthopedic surgeon

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takes the patient up to the OR,

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or puts the patient to sleep and manipulates the shoulder.

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But I would tell you, although I'm not gonna show you this.

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If you go into the literature

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you're gonna see examples of MR before,

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and MR after the surgeon has done that manipulation.

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And the amount of tissue that can be injured

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during the surgical manipulation is pretty impressive

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as seen by MR.

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So this might be a better procedure.

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If you're gonna do it

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because of the amount of pressure that is involved.

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Often you can see a mark left

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in your hand because of the syringe use a plastic syringe.

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Don't use a glass syringe.

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If you're gonna do this procedure.

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Now, there are cases of adhesive capsulitis elsewhere.

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We've seen a few cases in the hip

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with edema here shown mainly about the femoral neck.

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It's not common, at least in my experience

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but something that you may see.