Capsular Distension for Adhesive Capsulitis
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
Image 1. Illustration of adhesive capsulitis (courtesy of AAOS.org)
Capsular Distension (Hydrodilation)
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).
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).
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