Capsular Distension for Adhesive Capsulitis

Adhesive capsulitis (AC), often termed ‘frozen shoulder’, is a disease where the shoulder capsule forms scar tissue or adhesions across the joint causing stiffness, pain and dysfunction. It affects between 2-5% of the population and as much as 11-20% of diabetic patients. The purpose of this article is to briefly review AC and then discuss hydrodilation and the evidence supporting its use.

Generally, the cause of AC is unknown or idiopathic without a clear inciting event. Risk factors for developing it include caucasian, female gender, age 40-60s. Systemic diseases such as diabetes mellitus, hyperlipidemia, hypertension, and thyroid dysfunction also increase your risk. A history of trauma or immobilization following surgery can also lead to AC. Propionibacterium (P.) acnes has been linked to AC as a possible infective aetiology of the disease (Bunker, 2014).

Case Vignette

You are evaluating a 45 year old white female with right shoulder pain for about 6 months. She suffers from diabetes and hypothyroidism. Her shoulder pain has been insidious in onset without trauma or injury. At this time, she has pain and decreased range of motion affecting her activities of daily living. On exam her external rotation is asymmetric and her pain is moderate. According to Naviaser et al, which stage of frozen shoulder is she in?

A) Stage I: Freezing, painful
B) Stage II: Frozen, stiff
C) Stage III: Global loss of ROM, extreme pain
D) Stage IV: Persistent stiffness, no pain

By history, the onset is usually insidious with a slow onset. As many as 90% of patients develop shoulder pain before restrictions in range of motion (Boyle-Walker 1997). On physical exam, external rotation is most commonly affected. Pain is worse at extremes of range of motion. Firm endpoints suggest a possible mechanical block rather than soft end-points seen in pain-related restriction of AC.

Evaluation often starts with standard radiographs of the shoulder, which are most often normal. MRI can be used but is not required to make the diagnosis. Findings include thickening of the coracohumeral ligament which is fairly specific, subcoracoid fatty infiltration, thickening of the capsule and reduced joint volume of 5-8 mL (normal 13-15 mL) (Mengiardi 2004). Ultrasound is also useful diagnostically, demonstrating thickening of the joint capsule and is reported to be 91% sensitive, 100% specific (Ryu 1993).

Image 1. Illustration of adhesive capsulitis (courtesy of AAOS.org)

AC can be classified into stages based on symptoms. Stage I is the early freezing and painful stage in which motion is still preserved (6 weeks – 9 months). In stage II, the shoulder becomes frozen and stiff, with loss of range of motion affecting activities of daily living (4-9 months). Stage III results in a global loss of range of motion and worsening pain. In stage IV, AC is now considered chronic with persistent stiffness and an absence of pain. From stage IV, patients can “thaw” out gradually which takes 5 to 26 months.

AC is considered a self limited disease that will usually spontaneously resolve in 1-3 years, however 20-50% of patients may have longer lasting symptoms (Binder 1984). For this reason, treatment is generally non-surgical. First line treatment includes physical therapy, medications, and corticosteroid injections. Hyaluronic acid and suprascapular nerve block has also been suggested. Rarely, patients may require manipulation under anesthesia (MUA) by an orthopedic surgeon in the operating room.

Capsular Distension (Hydrodilation)

Capsular distension, also termed ‘hydrodilation’ or ‘distension arthrography’, is a therapy for frozen shoulder which involves injecting a large volume of saline containing some combination of steroid and local anesthetic into the glenohumeral joint. In some cases, contrast material is also injected if an MRI is planned. This can be performed under either ultrasound or fluoroscopic guidance. The volume can be as high as 30 mL, which is about 10 fold more than would be in a routine corticosteroid injection. In some studies, the authors distend the capsule until rupture is noted radiographically, while in others this is not the case.

How does capsular distension work? This is debated among orthopedists. Most agree that capsular rupture contributes to a mechanical resolution of shoulder stiffness. What is less clear is whether dilation, slow capsular deformation and/or capsular rupture are the key elements. In a study of manipulation under general anesthesia (MUA), the authors found no correlation between the tactile sensation of tearing the capsule to the patients final outcome (Dodenhoff 2000). Another proposed mechanism is reversal of the myofibroblastic activity that occurs by joint distension.

Image 2. Ultrasound image of posterior joint capsule pre-procedure (courtesy of Dr Troyer and Dr Concepcion)

How effective is capsular distension? A 2008 Cochrane review evaluated capsular distension across 5 trials with 196 patients. They conclude there is “silver” level evidence that arthrographic distension with saline and steroid provides short‐term benefits in pain, range of movement and function in adhesive capsulitis (Buchbinder 2008).

Watson followed patients for 2 years following hydrodilation and concluded that when combined with physical therapy, there was a significant improvement in all outcome measures including pain, function and range of motion (Watson 2007). Clement performed a similar study in 2013 following patients with AC treated with capsular distension, including diabetics, for 14 months. The found 55% had normal or near normal shoulder function at 1 month, and at 14 months that number had risen to 63% (Clement 2013).

Image 3. Ultrasound image of early capsular distension with needle in plane (courtesy of Dr Troyer and Dr Concepcion)

Image 4. Ultrasound image of late capsular distension with needle in plane (courtesy of Dr Troyer and Dr Concepcion)

How does hydrodilation compare to surgical management? Queraishi et al compared 17 patients who received shoulder MUA, to 19 patients who received hydrodilation (Quraishi 2007). They found higher Constant scores but similar range of motion at 6 months, however the hydrodilation group (94%) had a higher patient satisfaction rate compared to MUA (81%). The authors also commented on the added benefit of avoiding general anesthesia and risk of surgical injuries such as fracture or cuff injury. Currently, there are no studies comparing hydrodilation to arthroscopic arthrolysis.

Is there any value to repeating the procedure? Generally, this is unknown. Trehan performed repeat hydrodilation at 6 weeks on patients who had partial but incomplete relief from their primary procedure. They found no difference in the oxford shoulder score between the initial hydrodilation and the repeat procedure (Trehan 2010).

Stability Brace

Shoulder Sling

Shoulder Immobilizer

Heated Brace

Summary

In summary, adhesive capsulitis, or frozen shoulder, is a commonly encountered clinical entity by physicians. Treatment is generally non-operative and many patients will require one or more joint injections. Hydrodilation represents a safe and probably superior alternative to standard corticosteroid injections. Whether capsular rupture is required remains to be determined.

– More Shoulder Pain from Sports Medicine Review: https://www.sportsmedreview.com/by-joint/shoulder/

– Read More @ Wiki Sports Medicine: https://wikism.org/Hydrodilation

– Read More @ Wiki Sports Medicine: https://wikism.org/Adhesive_Capsulitis

Case Conclusion

Best answer is B. According to Neviaser et al in a paper published in 1987, adhesive capsulitis can be staged by symptoms ranging from stage I to stager IV. Stage I (Freezing/ Painful) is characterized by gradual onset of diffuse shoulder pain (6 wks to 9 mos). It is worse at night, motion is preserved, and synovitis is seen on arthroscopy. Stage II (Frozen/Stiff) is characterized by a decreased ROM affecting activities of daily living (4 to 9 mos or more). In stage two, there is early adhesion formation, capsular contraction. Stage III is notable for global loss of ROM, extreme pain. At this point, the synovitis resolved, axillary fold obliterated. Stage IV (chronic) is characterized by persistent stiffness without pain. Patients can see ‘thawing’ with a gradual return of motion (5 to 26 mos)

Neviaser RJ and Neviaser TJ. The frozen shoulder: diagnosis and management. Clin Orthop Relat Res 1987; 223: 59–64.

References

Bunker TD, Boyd M, Gallacher S, et al. Association between Propionibacterium acnes and frozen shoulder: a pilot study. Shoulder Elbow 2014;6:257-261.
Boyle-Walker KL, Gabard DL, Bietsch E, et al. A profile of patients with adhesive capsulitis. J Hand Ther 1997; 10: 222–228.
Mengiardi B, Pfirrmann CW, Gerber C, et al. Frozen shoulder: MR arthrographic findings. Radiology 2004; 233: 486–492.
Ryu KN, Lee SW, Rhee YG, et al. Adhesive capsulitis of the shoulder joint: usefulness of dynamic sonography. J Ultrasound Med 1993; 12: 445–449.
Binder AI, Bulgen DY, Hazleman BL, et al. Frozen shoulder: a long-term prospective study. Ann Rheum Dis 1984; 43: 361–364
Buchbinder, Rachelle, et al. “Arthrographic distension for adhesive capsulitis (frozen shoulder).” Cochrane Database of Systematic Reviews 1 (2008).
Watson, Lyn, et al. “Hydrodilatation (distension arthrography): a long-term clinical outcome series.” British journal of sports medicine 41.3 (2007): 167-173.
Clement RG, Ray AG, Davidson C, Robinson CM, Perks FJ. Frozen shoulder : long-term outcome following arthrographic distension. Acta Orthop Belg 2013;79:368-374.
Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the frozen shoulder: A randomised trial comparing manipulation under anaesthesia with Hydrodilatation. JBJS Br 2007;89:1197-1200
Trehan RK, Patel S, Hill AM, Curtis MJ, Connell DA. Is it worthwhile to offer repeat hydrodilatation for frozen shoulder after 6 weeks? Int J Clin Pract 2010;64:356-359
Dodenhoff RM, Levy O, Wilson A, Copeland SA. Manipulation under anesthesia for primary frozen shoulder: effect on early recovery and return to activity. J Shoulder Elbow Surg 2000;9:23-26.