I recently attended a lecture on frozen shoulder (FS), where the specialist was in favor of hydrodilatation as a treatment at all stages of the condition. This prompted me to see what the available research had to say.
The symptoms of frozen shoulder generally arise insidiously, and the patient usually describes a period of discomfort before shoulder movements become restricted. The presentation during this stage is like your typical ‘impingement syndrome’. Night pain is a regular feature. This will be followed by gradual limitation of both active and passive range of motion. Eventually the pain subsides and there is loss of motion in every direction.
FS involves a thickening and contraction of the joint capsule, with a marked reduction in joint volume. The condition affects between 2-5% of the general population, and between 10-30% of diabetics, with the incidence being higher in type I. The incidence of presentation to GP’s has been reported to be 2.4/1000/year. The most common age is between 40 to 65 years, and women are affected slightly more than men. Around 30% will experience FS in the contralateral side, but not usually at the same time.
The consensus of the literature is that FS resolves in 18 to 24 months, however certain studies have reported the time course in a significant number to be up to 3 or more years. Up to 15% of people experience long-term pain and stiffness. Since 1945 the medical term for FS has been adhesive capsulitis. This is because it was felt the condition involved adhesion of the capsule to the bony joint surfaces. This probably does not occur, however there is likely to be intra-capsular adhesions at the axillary pouch.
The diagnosis of FS is a clinical one, and imaging is rarely required. A plain x-ray may be considered to rule out glenohumeral osteoarthritis, which is most likely alternative cause of global shoulder restriction. Arthrography was the favored imaging of the past, and was used to demonstrate loss of joint fluid volume, a feature of FS. MRI arthrography is sometimes used, but is expensive and usually unnecessary. Ultrasound is not helpful. It will not demonstrate capsular changes, and cannot show loss of synovial fluid volume.
Management
Many different forms of treatment have been described for FS. The most common approach has been to let the disease run its natural course. Physiotherapy on its own has not been shown to be helpful, particularly in the acute inflammatory or frozen stages of the condition. Surgical approaches such as arthroscopic debridement or manipulation under anaesthetic have generally been reserved for recalcitrant cases, where there is persistent loss of range of motion. More recently, injection of corticosteroid, either alone or in combination with hydrodilatation, has been advocated. There are claims that these approaches can hasten recovery of movement, and at the very least settle pain. This is an attractive proposition in the acute stages, where pain is a feature and often disturbs sleep.
Hydrodilatation (or ‘distension arthrography’) usually involves the injection of local anaesthetic, a steroid, and normal saline. The procedure is performed under local anaesthesia, takes around 15 minutes, and the patient goes home immediately afterwards. The saline is injected at a volume sufficient to rupture the joint capsule. This may be anywhere between 10 and 55ml (1). Not all authors have intentionally injected to the point of rupture, however most feel that this is an important aspect of the approach. The proposed mechanism is a combination of anti-inflammatory from the cortisone, and joint distension resulting in a reduction in stretch in pain receptors in the capsule & periosteal attachments. It may also help by disrupting adhesions. There is often transient pain at the time of injection, but otherwise it is considered to be a safe procedure.
Hydrodilatation has been reported to be effective in late stage recalcitrant FS. However its use during the early or middle stages of the condition is the subject of this review. It has been advocated even in the acute painful stage, however some authors felt the stage I patients would be unable to tolerate the procedure (Trehan et al 2010).
The literature is inconsistent with regard to the success of hydrodilatation. While benefits have generally been found, many studies have failed to use a control group, or even to compare hydrodilatation to other approaches. As corticosteroid is used in conjunction with the procedure, it is possible it is the steroid alone that provides the benefit. In Trehan et al (2010), all 36 study patients received corticosteroid and hydrodilatation & were followed up for a mean of 15 months. The procedure was generally performed during stage II FS. Patients reported benefit, but no control group was available for comparison. It was therefore impossible to determine the effect of the procedure compared to time and natural recovery.
Tveita et al (2008) compared hydrodilatation plus steroid with steroid alone. No physiotherapy was administered post-injection. Dilatation was performed to the point of capsular rupture (shown by image-intensified fluoroscopy). Both groups experienced significant subjective improvements in pain and disability, but non-significant improvements in range. The authors felt future research could look at the combination of injection with physiotherapy to see if there would be a further influence on ROM. They also suggest trials of injection and / or dilatation in the early stages of the condition, before the capsule has time to become significantly stiff.
Watson et al (2007) used combination of hydrodilatation and physiotherapy, and followed up their patients for 2 years. They reported improvements in pain and range in patients with both primary and secondary (due to rotator cuff disease) FS. While they reported improvements within days or weeks after the procedure (in fact at the time patients started physiotherapy), no control group was included, so placebo, physiotherapy alone, hydrodilatation alone, or time could have been factors in recovery. Improvements continued over the 3 month physiotherapy intervention period. The authors felt the early improvements were better than would be expected from clinical and research evidence. The results at two years were not felt to be better than with natural recovery. However the earlier improvements in pain, range and function may make the procedure worthwhile for the improved quality of life.
Bell et al (2003) reported significant improvements in pain and range of motion within the first two months after treatment. They reported a 34% improvement in external rotation, 21% in active elevation & 15% in passive abduction. By 12 months patients had recovered up to 75% of their normal range. They claimed that many patients reported an immediate improvement in pain after the procedure. Again no control group was included. As the average duration of symptoms in the group was over 8 months, it is possible that some of the improvement was due to natural resolution over time.
My conclusion from reading the available research is that the results are encouraging, but inconclusive. There is a lack of strong evidence that hydrodilatation is better than other available treatments in the short-term. Longer-term results are even less convincing, as the condition usually recovers naturally over-time. It may have additional value compared to steroid injection alone, after the acute inflammatory phase has passed, and stiffness is the main complaint. It may also be a useful minimally invasive approach in late stage recalcitrant FS. I will still advise my patients that intra-articular steroid injection followed by physiotherapy is a useful approach, particularly in the painful stages of the condition, and physiotherapy becomes more important in the later recovery stage. A lot more evidence is required to show that hydrodilatation is more effective than this approach in the early stage of FS.
References:
1. Bell, S et al (2003). Hydrodilatation in the management of shoulder capsulitis. Australasian Radiology, 47, 247-251.
2. Blanchard, V., et al (2009). The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review. Physiotherapy, 96(2):95-107
3. Buchbinder, R et al. (2008). Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2008 Jan 23;(1)
4. Buchbinder, R et al (2006). Oral steroids for adhesive capsulitis. Cochrane Database Syst Rev. 2006 Oct 18;(4)
5. Carette, S. et al (2003). Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder. Arthritis & Rheumatism, 48, 3, 829-838.
6. Favejee, M., et al (2011). Frozen shoulder: the effectiveness of conservative and surgical interventions--systematic review. BJSM, 45, 1, 49-56.
7. Griesser, M et al (2011). Adhesive capsulitis of the shoulder: a systematic review of the effectiveness of intra-articular corticosteroid injections. JBJS, 93-A, 18, 1727-1733.
8. Neviaser, A & Hannafin, J. (2010). Adhesive capsulitis: a review of current treatment. AJSM, 38, 11, 2346-2356.
9. Shah, N. & Lewis M. (2007). Shoulder adhesive capsulitis: systematic review of randomised trials using multiple corticosteroid injections.Br J Gen Pract, 57(541):662-7.
10. Simpson, J & Budge, R (2004). Treatment of frozen shoulder using distension arthrography (hydrodilatation): a case series. Australasian Chiropractic & Osteopathy, 12, 1, 25-35.
11. Trehan, R. et al (2009). Is it worthwhile to offer repeat hydrodilatation for frozen shoulder after 6 weeks? The Int J of Clinical Prac., 64, 356-359.
12. Tveita, E. et al (2008). Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskeletal Disorders, 9, 53.
13. Watson, L. et al (2007). Hydrodilatation (distension arthrograpy): a long-term clinical outcome series. BJSM, 41, 167-173.
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