Ultrasound Guided Hydro-distention or Hydro-dilatation for Frozen Shoulder.
Basics for advance practitioners who wanted to learn and improve or add into the shoulder procedures. Other healthcare professionals can also benefit such as sonographers, osteopath, chiropractors.
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.