Hydrodistention is a treatment for frozen shoulder (FS) that is gaining popularity again. However, no large, long-term outcome data has been published yet. Our aims were to evaluate hydrodistension for the treatment of primary frozen shoulder (FS) in a large cohort of patients with long follow-up period. We present a case series of eighty-nine patients (36 males and 53 females) with a mean age of 52 years (33-73). Eleven (12.4%) had disease associations. We excluded post-operative secondary stiff shoulders. The mean volume injected was 33.7ml (16-66). 36/89 (40%) had capsular rupture. Six (6.7%) had adverse effects. The mean follow-up was 104.5 weeks (8-238). Mean improvement in forward flexion was 165.4, abduction 111.6, external rotation was hand above head with elbow back (and internal rotation in extension to T12. Mean improvement in quickDASH score was 17.1 (p<0.001) and Constant Score was 70.0 (p<0.001). Mean improvement in VAS was 7.3 (p<0.001). No patients had night pain (p<0.001). Eighty-eight (99%) returned to their previous occupation. Seventy-six (85%) returned to their previous level of sport. Gender, previous intra-articular steroid injection, volume of the injectate, type of steroid used, capsular rupture and underlying aetiology had no impact on outcome.

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Hydrodistension
for
Primary Frozen Shoulder
Lennard Funk
Abbas Rashid
Jeremy Granville-Chapman
Emma Torrance

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Hydrodistension (HD)
• Indication: painful FS
• Described by Andren & Lundberg (1965)
• Radiologic guidance
• Saline, LA, steroid, contrast, air
Andren & Lundberg. Treatment of rigid shoulders by joint distention during arthrography. Acta
Orthop Scand. 1965;36:45-53.
Reported Adverse Effects
• Pain during procedure
• Pain after procedure
• Claustrophobia
• Fluid noises
• Facial flushing
• CVA

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Evidence
Recent Evidence (2006-2014)
• Capsule rupture = no rupture
• Benefit maintained at one year
• PROMS: diabetic = non diabetics
• HD as effective as MUA
Clemet et al. Frozen shoulder : long-term outcome following arthrographic distension. Acta Orthop Belg.
2013 Aug;79(4):368-74.
Bae et al. Randomized controlled trial for efficacy of capsular distension for adhesive capsulitis:
fluoroscopy-guided anterior versus ultrasonography-guided posterolateral approach. Ann Rehabil Med.
2014 Jun;38(3):360-8. doi: 10.5535/arm.2014.38.3.360. Epub 2014 Jun 26.
NG et al. A propsective RCT comparing MUA and capsular distention for the treatment of adhesive
capsulitis.. Shoulder & Elbow. 4(2)05-99.2012
• HD vs. sham
- 3 months: improvement in PET
• HD/PT vs. PT
- 8 weeks: improvement in ROM
• HD vs. steroid injection
- 3 months: no difference in pain, ROM
Elleuch et al. The contribution of capsular distension to the treatment of primary adhesive capsulitis
of the shoulder: a comparative study versus rehabilitation. Ann Readapt Med Phys. 2008 Dec;51(9):
722-8. doi: 10.1016/j.annrmp.2008.08.008. Epub 2008 Sep 20.
Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database of
Systematic Reviews 2003, Issue 2.
Koh et al. Changes in biomechanical properties of glenohumeral joint capsules with adhesive
capsulitis by repeated capsule-preserving hydraulic distensions with saline solution and
corticosteroid. PM R. 2012 Dec;4(12):976-84.
Cochrane Review (1992-2006)

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•Assess functional outcomes of Hydrodistension
•Primary & Secondary frozen shoulder
•Large cohort
•Long follow-up
Study Aims

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• Retrospective
• 2010-2015
• Case notes review
• Pre & post HD:
- VAS, ROM, qDash, Constant Score
- return to occupation
- return to sport
• Subgroup Analysis:
- gender
- previous steroid injections
- capsular rupture
- volume of injectate
- content of injectate
Study Design

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• 3 Radiologists
• X-Ray guided
• Anterior approach
• Contrast, Bupivacaine, Steroid, Saline
• Recorded
- Capsular rupture
- Adverse effects
Technique

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• 350 referrals with FS
• 323 had HD
• Cohort = 89 (with 2 year f/u)
• M 36 : F 53
• Mean age 52years (33-73)
0-2 previous injections
11/89 (12.4%) disease association
- 6 Diabetes Mellitus
- 5 Thyroid dysfunction
24/89 (27.0%) secondary FS
- 9 Trauma
- 7 SA Impingement
- 4 Cuff tear
- 3 Calcific tendinopathy
- ACJ pathology
Results - Cohort

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350 FS
323 Hydrodistension
27 inject + Physio
89 w/ 2yr FU
M 36 : F 53Age: 52 (33-73)
11/89 (12.4%) disease association
- 6 Diabetes Mellitus
- 5 Thyroid dysfunction
24/89 (27.0%) secondary FS
- 9 Trauma
- 7 SA Impingement
- 4 Cuff tear
- 3 Calcific tendinopathy
- ACJ pathology

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• Mean vol. injected 33.7ml
(16-66)
• 36/89 (40%) capsular rupture
• Adverse Effects 6/89 (6.7%)
- x4 pain
- dizziness
- hyperventilation
• Mean f/u 104.5 weeks (8-238)
• Numbers requiring surgery
- 20/323 (6.8%)
- 2/89 (2.2%)
Results - Intervention

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Pre HD Post HD
161.5
49.9
166.9
61.5
Forward Flexion
Abduction
Rotation ER IR
Pre HD
Hand behind
head – elbow
forward
Buttock
Post HD
Hand above
head – elbow
back
T12
• All differences significant (p<0.001)
Objective Outcomes

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Pre HD Post HD
81.1
11.1
25.9
43
qDASH
Constant
VAS Satisfaction
Pre HD Post HD
9.1
1.8
• All differences significant (p<0.001)
• 88/89 (99%) returned to previous occupation
• 76/89 (85%) returned to previous level of sport
Night Pain
Pre HD Sometimes
Post HD No
Patient-reported Outcomes

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Gender
Previous
steroid
injections
Volume
injected
Type of steroid
Capsular
rupture
Primary or
secondary FS
M:F 0,1,2
33.7mls
(16-66mls)
Kenalog vs.
Triamcinolone
Yes 40%
No 60%
Primary 73%
Secondary 27%
Mann-
Whitney
Mann-Whitney
Mann-
Whitney
Spearmans
Correlation
Kruskal-
Wallis
Mann-
Whitney
no influence no influence no influence no influence no influence No influence
Subgroup Analysis

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• Significant improvements in objective and patient-
reported outcomes
• Effect maintained beyond two years
• Regardless of:
- gender
- primary or secondary aitiology
- previous injections
- volume & content of injectate
- capsular rupture
Discussion

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Strengths
✓ Large series
✓ Subgroup analysis
✓ Longest f/u
Weaknesses
x Retrospective
x Multiple radiologists
• ?variation in technique
Limitations

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➢Effective in primary & secondary frozen shoulder
➢Maintained in medium term
➢Well-tolerated outpatient procedure
➢Our first-line treatment for painful frozen shoulder
Conclusions

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THANK YOU
Thanks to Our Amazing Radiologists:
Jonathan Harris, Sarah Jackson, Waqar Bhatti,
Naveen Vasireddy, Andrew Dunn, David
Temperley, Sheila Augustine, Shub Bassu