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Ultrasound Guided
Hydro-dilatation for Frozen Shoulder
AAMIR SAFDAR-KHAN
Advance Musculoskeletal Practitioner
Diagnostic & Interventional MSK Sonographer
AIMs and Procedure
Adhesive capsulitis is considered a self-limiting disease
with the aim of hydrodilatation to reduce the duration of
pain and limited range of motion in the short- and medium-
term.
Glenohumeral joint hydrodilatation is an established
treatment for adhesive capsulitis and can be performed
using ultrasound.
 Local anesthesia to offer pain relief
 Steroid provides anti-inflammatory effect
 Saline stretches the contracted joint capsule
Procedure is performed in the outpatient
Total volume: 40-50 ml
9 ml local anethesias, 1 ml of steroid and 30-40 ml of saline
• The articles assessed types of procedure, technique of procedure,
complications and the success rate for each procedure according to
pain response and improvement in both movement and function.
• Hydrodilatation with/without steroid versus intra-articular steroid.
• Hydrodilatation capsule preservation versus Capsule rupture
• Meta-analyses.
Published evidence so far supports the effectiveness of the procedure
despite
 Techniques used
 Sample size
 Outcome measures
 Length of follow-up
 Physiotherapy input
Gina Allen 2018 and Wei-Ting Wu et al 2017
Evidence
Ladermann 2021
 Summarised Meta-analysis of RCTs
 Compared conservative treatment options for frozen
shoulder.
 Out of 319 studies only 8 meta-analysis were included.
 Physiotherapy, intra-articular and subacromial
corticosteroid injection (CSI), and guided
hydrodilatation with corticosteroid.
 Concluded: Hydro-dilatation with corticosteroid
provides superior pain relief in the short term and
improvement in range of motion across all time frames
for frozen shoulder when compared to CSI or
physiotherapy.
Makki 2021
 Study assessed clinical outcome of glenohumeral
hydrodilatation in three cohorts of patients with
adhesive capsulitis.
 Stiffness, idiopathic and post-surgical and post-trauma
 Outcome measures: Pain and ROM
 Retrospective study.
 Procedures were performed under guidance
 Solution: CS, anesthesia and Saline – Overall 35 ml
 Results show hydrodilatation resulted in an
improvement in pain and ROM; however, especially
those with diabetes, needing further procedures or
showing no improvement in range of motion and pain.
Rex 2021
 Systematic review
 Multicentred RCTs
 Compared the effectiveness of physiotherapy
techniques with a steroid injection (PTSI), manipulation
under anaesthesia (MUA) with a steroid injection, and
guided capsular release/hydrodilitation (ACR).
 Nine RCTs were included.
 Patient-reported shoulder function at long-term follow-
up (> 6 months and ≤ 12 months)
 Findings provided the strongest evidence that, when
compared with each other, neither PTSI, MUA, nor ACR
are clinically superior.
Evidence Outcomes: Summary
 A guided injection is more accurate. Patients prefer ultrasound to
fluoroscopy and there is added benefit of no radiation, no
claustrophobia, lower cost and decreased procedure time.
 Hydrodilatation distension with or without steroid has an additional
benefit to steroid alone.
 Hydrodilatation capsule preservation versus capsule rupture. It is not
necessary to rupture the capsule during procedure.
 There is a place for surgical intervention but in view of the possible
complications and need for general anaesthesia to perform this
procedure this should be reserved for patients who not respond to intra-
articular steroid injection and hydrodilatation.
 It should also be remembered that capsulitis can co-exist with
subacromial/subdeltoid bursitis so this may also account for some of the
response.
 Diabetes mellitus (DM). Hydrodilatation may be less beneficial in
diabetic patients.
Gina Allen 2018
Again, it is essential to engage with physiotherapy following this injection to
restore full range of movement and strength in the shoulder.
Technique
 Full shoulder scan to check integrity of the rotator cuff
as procedure may be not appropriate in patients with
full thickness tear.
 Posterior Approach
 Patient side lying on opposite shoulder
 Lidocaine and steroid single syringe – 10 ml
 Saline second syringe – 30 ml or 40 ml
 Capsule stretching or rupture (feel pressure) – until no
further distention is achieved.
Inclusion
 Frozen shoulder – Adhesion
 Diagnosed clinically
 Normal X-RAY (no fracture or AVN)
 Ultrasound to check for subacromial/subdeloid burisitis to
extend the procedure
 Ultrasound to check for full thickness tear of supraspinatus
tendon (patients with a proven full thickness rotator cuff
tear were excluded because hydrodilatation is not
effective in this group) Sinha 2017
Exclusion
 Anticoagulation therapy
 Systemic sepsis
 Joint infection
 Allergies to steroid or local anaesthetic
 Acute trauma
 Unable to consent
 Serious mental illness
 Age <18
 Diabetes Mellitus
 Allergies to injection procedures – needles,
needlephobia
Post procedure care and
complications
 Bleeding (haemathrosis)
 Infection (septic arthritis).
 Care should be taken for the first 48 hours with no heavy or
overhead lifting.
 Rupture of the capsule can occur with this procedure and is
felt as a sudden loss of resistance to injection. Any adverse
reactions that occurred during the procedure were recorded.
Discussion
 Outpatient procedure
 Local Anaesthetic
 No adverse events
 Generally well tolerated
Thank You
 Questions?
References
 Gina Allen 2018.
https://www.csp.org.uk/system/files/documents/2019-
12/frozen_shoulder_corticosteroid_vs_hydrodilatation_o
r_surgery.pdf
 Maund E, Craig D, Suekarran S et-al. Management of
frozen shoulder: a systematic review and cost-
effectiveness analysis. Health Technol Assess. 2012;16
(11): 1-264. doi:10.3310/hta16110 - Pubmed citation
 Buchbinder R, Green S, Youd JM et-al. Arthrographic
distension for adhesive capsulitis (frozen shoulder).
Cochrane Database Syst Rev. 2008; (1):
CD007005. doi:10.1002/14651858.CD007005 - Pubmed
citation

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Shoulder Hydrodistention or Hydrodilatation

  • 1. Ultrasound Guided Hydro-dilatation for Frozen Shoulder AAMIR SAFDAR-KHAN Advance Musculoskeletal Practitioner Diagnostic & Interventional MSK Sonographer
  • 2. AIMs and Procedure Adhesive capsulitis is considered a self-limiting disease with the aim of hydrodilatation to reduce the duration of pain and limited range of motion in the short- and medium- term. Glenohumeral joint hydrodilatation is an established treatment for adhesive capsulitis and can be performed using ultrasound.  Local anesthesia to offer pain relief  Steroid provides anti-inflammatory effect  Saline stretches the contracted joint capsule Procedure is performed in the outpatient Total volume: 40-50 ml 9 ml local anethesias, 1 ml of steroid and 30-40 ml of saline
  • 3. • The articles assessed types of procedure, technique of procedure, complications and the success rate for each procedure according to pain response and improvement in both movement and function. • Hydrodilatation with/without steroid versus intra-articular steroid. • Hydrodilatation capsule preservation versus Capsule rupture • Meta-analyses. Published evidence so far supports the effectiveness of the procedure despite  Techniques used  Sample size  Outcome measures  Length of follow-up  Physiotherapy input Gina Allen 2018 and Wei-Ting Wu et al 2017 Evidence
  • 4. Ladermann 2021  Summarised Meta-analysis of RCTs  Compared conservative treatment options for frozen shoulder.  Out of 319 studies only 8 meta-analysis were included.  Physiotherapy, intra-articular and subacromial corticosteroid injection (CSI), and guided hydrodilatation with corticosteroid.  Concluded: Hydro-dilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to CSI or physiotherapy.
  • 5. Makki 2021  Study assessed clinical outcome of glenohumeral hydrodilatation in three cohorts of patients with adhesive capsulitis.  Stiffness, idiopathic and post-surgical and post-trauma  Outcome measures: Pain and ROM  Retrospective study.  Procedures were performed under guidance  Solution: CS, anesthesia and Saline – Overall 35 ml  Results show hydrodilatation resulted in an improvement in pain and ROM; however, especially those with diabetes, needing further procedures or showing no improvement in range of motion and pain.
  • 6. Rex 2021  Systematic review  Multicentred RCTs  Compared the effectiveness of physiotherapy techniques with a steroid injection (PTSI), manipulation under anaesthesia (MUA) with a steroid injection, and guided capsular release/hydrodilitation (ACR).  Nine RCTs were included.  Patient-reported shoulder function at long-term follow- up (> 6 months and ≤ 12 months)  Findings provided the strongest evidence that, when compared with each other, neither PTSI, MUA, nor ACR are clinically superior.
  • 7. Evidence Outcomes: Summary  A guided injection is more accurate. Patients prefer ultrasound to fluoroscopy and there is added benefit of no radiation, no claustrophobia, lower cost and decreased procedure time.  Hydrodilatation distension with or without steroid has an additional benefit to steroid alone.  Hydrodilatation capsule preservation versus capsule rupture. It is not necessary to rupture the capsule during procedure.  There is a place for surgical intervention but in view of the possible complications and need for general anaesthesia to perform this procedure this should be reserved for patients who not respond to intra- articular steroid injection and hydrodilatation.  It should also be remembered that capsulitis can co-exist with subacromial/subdeltoid bursitis so this may also account for some of the response.  Diabetes mellitus (DM). Hydrodilatation may be less beneficial in diabetic patients. Gina Allen 2018 Again, it is essential to engage with physiotherapy following this injection to restore full range of movement and strength in the shoulder.
  • 8. Technique  Full shoulder scan to check integrity of the rotator cuff as procedure may be not appropriate in patients with full thickness tear.  Posterior Approach  Patient side lying on opposite shoulder  Lidocaine and steroid single syringe – 10 ml  Saline second syringe – 30 ml or 40 ml  Capsule stretching or rupture (feel pressure) – until no further distention is achieved.
  • 9. Inclusion  Frozen shoulder – Adhesion  Diagnosed clinically  Normal X-RAY (no fracture or AVN)  Ultrasound to check for subacromial/subdeloid burisitis to extend the procedure  Ultrasound to check for full thickness tear of supraspinatus tendon (patients with a proven full thickness rotator cuff tear were excluded because hydrodilatation is not effective in this group) Sinha 2017
  • 10. Exclusion  Anticoagulation therapy  Systemic sepsis  Joint infection  Allergies to steroid or local anaesthetic  Acute trauma  Unable to consent  Serious mental illness  Age <18  Diabetes Mellitus  Allergies to injection procedures – needles, needlephobia
  • 11. Post procedure care and complications  Bleeding (haemathrosis)  Infection (septic arthritis).  Care should be taken for the first 48 hours with no heavy or overhead lifting.  Rupture of the capsule can occur with this procedure and is felt as a sudden loss of resistance to injection. Any adverse reactions that occurred during the procedure were recorded.
  • 12. Discussion  Outpatient procedure  Local Anaesthetic  No adverse events  Generally well tolerated
  • 14. References  Gina Allen 2018. https://www.csp.org.uk/system/files/documents/2019- 12/frozen_shoulder_corticosteroid_vs_hydrodilatation_o r_surgery.pdf  Maund E, Craig D, Suekarran S et-al. Management of frozen shoulder: a systematic review and cost- effectiveness analysis. Health Technol Assess. 2012;16 (11): 1-264. doi:10.3310/hta16110 - Pubmed citation  Buchbinder R, Green S, Youd JM et-al. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2008; (1): CD007005. doi:10.1002/14651858.CD007005 - Pubmed citation