Hydrodilatation in the management of shoulder capsulitis

Functional Outcome of Hydrodilation in Adhesive Capsulitis of Shoulder

Introduction

Adhesive capsulitis, or frozen shoulder, is a painful and disabling condition characterized by progressive restriction of shoulder movement. Hydrodilatation, a minimally invasive procedure involving joint capsule distension, has been proposed as an effective treatment option. This study evaluates the functional outcomes of hydrodilatation in patients with adhesive capsulitis using the Constant-Murley score (CMS) and American Shoulder and Elbow Surgeons (ASES) score, along with pre- and post-procedure range of motion (ROM) assessments.

Materials and Methods

A prospective observational study was conducted on 30 patients diagnosed with adhesive capsulitis who underwent hydrodilatation. Functional and ROM improvements were assessed at baseline, post-procedure, 1 month, 3 months, 6 months, and 1 year. Data were analyzed using paired t-tests, and P < 0.05 was considered statistically significant.

Results

The mean age of participants was 47.7 ± 9.8 years. The study population comprised 14 males (46.7%) and 16 females (53.3%), indicating a slightly higher prevalence among females. Significant improvements were observed in active and passive abduction, adduction, forward flexion, and external rotation (P < 0.001). Internal rotation restriction reduced from 59.1% to 40.9% (P < 0.001). Functional scores (ASES and CMS) showed progressive improvement, with ASES increasing from 41.1 ± 6.1 to 65.9 ± 8.4 and CMS from 44.4 ± 5.8 to 64.8 ± 9.1 at 1 year (P < 0.001).

Conclusion

Hydrodilatation is an effective and well-tolerated intervention for improving shoulder function in adhesive capsulitis, with sustained benefits up to 1 year. Future studies should focus on standardizing treatment protocols and optimizing patient selection criteria.

Hydrodilatation: a comparison between diabetics and non-diabetics with adhesive capsulitis

PURPOSE

The primary aim of this retrospective study is to compare the short and medium-term outcomes for shoulder hydrodilatation for treatment of shoulder AC between diabetic and non-diabetic patients, to evaluate if there were better outcomes amongst non-diabetic patients.

METHODS

Patients with clinical or radiological diagnosis of AC and who underwent fluoroscopic guided shoulder hydrodilatation in our local institution from January 2021 to June 2022 were included in this study. Clinical outcomes were measured with visual analog scale (VAS) for pain and passive range of motion consisting of forward flexion (FF) and external rotation (ER) at pre-hydrodilatation, one month and six months post hydrodilatation.

RESULTS

A total of 163 shoulders were included, corresponding to 156 patients consisting of 47 diabetics, 109 non-diabetics and seven bilateral shoulders (3 diabetics and 4 non-diabetics). At the time of presentation, there was no significant difference in VAS, FF or ER between diabetics and non-diabetics. From pre-hydrodilatation to 1-month post-hydrodilatation and one month to six months post-hydrodilatation, there was significant improvement in VAS, FF and ER for both groups. Comparing diabetics vs. non-diabetics, the non-diabetic group had significantly better FF (p < 0.01) at one month post hydrodilatation. At 6 months post-hydrodilatation, non-diabetic group also had significantly better outcomes including VAS score (p = 0.02), FF (p < 0.01) and ER (p = 0.02).

CONCLUSION

Hydrodilatation is an effective treatment option in the short and medium term in both diabetics and non-diabetics with adhesive capsulitis, with good relief of pain and improvement in shoulder range of motion. Diabetic patients have significantly less improvement in range of motion and pain compared to non-diabetics at six months post hydrodilatation.

What volume of injection should be used in hydrodilatation for frozen shoulder? A prospective cohort study

This study evaluated the outcome and recurrence rates after hydrodilatation (HD) in patients with frozen shoulder (FS), comparing the effects of injecting 25 mL or more of fluid versus lower volumes. A total of 132 shoulders (130 patients) were treated at a shoulder clinic between August 2019 and February 2023. HD was performed under ultrasound guidance, injecting a combination of 40 mg Triamcinolone, 10 mL of local anaesthetic, and saline to a total volume of 10 to 40 mL based on patient tolerance. The results were analysed based on the volume of fluid injected and whether patients were diabetic. The overall failure or recurrence rate (FRR) was 24% after a minimum of 1 year. Non-diabetic patients injected with ≥25 mL had a significantly lower FRR (9%) compared to those injected with <25 mL (30%, p = 0.006). Diabetic patients had a much higher FRR of 52%, compared to 17% in non-diabetics (p = 0.0002). The study concluded that injecting patients with ≥25 mL of fluid had a significantly lower FRR than those injected with <25 mL at a minimum of 12 months follow-up (9% vs 30%, p = 0.006). Diabetic patients experienced a higher rate of recurrence, suggesting the need for patient counselling about the increased likelihood of failure.

Does the intervention for adhesive capsulitis in patients with diabetes differ from that for patients without diabetes?: A systematic review

BACKGROUND

Adhesive capsulitis (AC) is often accompanied by pain and restriction in range of movement, which long lasting symptoms often have negative impact on patients' work and lives. Since diabetes mellitus (DM) is an independent risk factor for developing AC, and AC with DM have more limitations of joint motion than general people.

AIMS

The aim of the present study is to evaluate the difference of clinical efficacy between diabetes and non-diabetes, and to explore whether AC with diabetes need special intervention compared to non-diabetes.

METHODS

Pubmed NCBI and Embase were searched for studies published in the last 30 years. We conducted a literature search for terms regarding AC and DM on Pubmed NCBI and Embase.

RESULTS

A total of 9 studies eligible for inclusion. The affected shoulders in these studies ranged from 26 to 135, 460 shoulders (551 participants) in total, including 166 shoulders in diabetic group and 394 shoulders in non-diabetic/idiopathic group. Interventions included shock wave therapy, hydrodilatation, arthroscopic capsular release, manipulation under cervical nerve root block. Evaluation indicators included pain, certain shoulder questionnaires, range of motion. Positive clinical efficacy were emerged after interventions between the 2 groups. The studies that better improvement of pain in non-diabetic/idiopathic group were 2 of 6, that of certain shoulder questionnaires were 4 of 8, that of range of motion were 3 of 6.

CONCLUSIONS

Whether AC combined with DM or not, the current treatment could achieve positive clinical effectiveness and there is some statistical evidence show that the curative effect of AC combined with DM is worse than non-diabetic. In other words, the available evidence suggests that patients with DM might require additional rehabilitation measures with routine glycemic control.

Ultrasound-guided hydrodilatation for adhesive capsulitis: capsule-preserving versus capsule-rupturing technique

OBJECTIVE

To compare the clinical efficacy of capsule-rupturing versus capsule-preserving ultrasound-guided hydrodilatation in patients with shoulder adhesive capsulitis (AC). To determine potential factors affecting the outcome over a 6-month follow-up.

MATERIALS AND METHODS

Within a 2-year period, 149 consecutive patients with AC were prospectively enrolled and allocated into (i) group-CR, including 39 patients receiving hydrodilatation of the glenohumeral joint (GHJ) with capsular rupture and (ii) group-CP, including 110 patients treated with GHJ hydrodilatation with capsular preservation. Demographics, affected shoulder, and AC grade were recorded. Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and visual analog scale (VAS) were used for clinical assessment at baseline/1/3/6 months. Comparisons were performed with Mann-Whitney U test and Kolmogorov-Smirnov test. Linear regression was used to identify predictors of outcome. P value < 0.05 defined significance.

RESULTS

DASH and VAS scores in both groups improved significantly compared to baseline (P < 0.001) and were significantly lower in the CP compared to CR group at all time-points following intervention (P < 0.001). Capsule rupture was a significant predictor of DASH score at all time-points (P < 0.001). DASH scores correlated to initial DASH score at all time-points (P < 0.001). DASH/VAS scores at 1 month were correlated to the AC grade (P = 0.025/0.02).

CONCLUSION

GHJ hydrodilatation results in pain elimination and functional improvement till the mid-term in patients with AC, with improved outcome when adopting the capsule-preserving compared to the capsule-rupturing technique. Higher initial DASH score is predictive of impaired functionality in the mid-term.

Recurrence of the frozen shoulder after hydrodilatation, what is the true incidence?

Purpose of the study

To assess the outcome and recurrence rates of frozen shoulder treated by hydrodilatation in an independent hospital setting.

Method

Patients presenting to a shoulder clinic from August 2019 to July 2021 with a diagnosis of frozen shoulder were offered hydrodilatation. Data included primary or secondary frozen shoulder, length of symptoms, and diabetic status. An Oxford Shoulder Score was completed prior to hydrodilatation. Using ultrasound guidance, 40 mg Triamcinolone and local anaesthetic (10-25 mL depending on patient tolerance) were injected into the rotator interval. At a mean of 9 months, patients recorded their tolerance of the procedure, subsequent progress, the need for further treatment, and their current Oxford Shoulder Score.

Results

From 55 shoulders, six patients had a failure to improve and 10 patients had a transient improvement followed by recurrence (29%). 2/21 (9.5%) patients had 25 mL injected compared to 14/34 (41%) who had < = 20 mL (p = 0.012). 14/43 (33%) of primary frozen shoulder patients had a recurrence, compared with 2/12 (16%) secondary frozen shoulder patients, p = 0.019.

Conclusion

Further treatment was indicated in 14/34 (41%) of patients who underwent hydrodilatation in the frozen stage of frozen shoulder and could not tolerate more than 20 mL of injection, and was more commonly required in primary (33%) versus secondary (16%) frozen shoulder.

Suprascapular nerve block is faster and as effective as hydrodistension in relieving frozen shoulder-associated pain and disability: A prospective, single-blind observational study with a follow-up of 24 weeks

Background and Aims

Hydrodistension (HD) and suprascapular nerve block (SSNB) have been shown to reduce pain and improve shoulder function in frozen shoulder (FS). The aim of this study was to compare the efficacy of HD and SSNB in the treatment of idiopathic FS.

Material and Methods

This was a prospective observational study. A total of 65 patients with FS were treated with SSNB or HD. The functional outcome was evaluated by Shoulder Pain and Disability Index (SPADI) score and active shoulder range of motion (ROM) measured at 2 weeks, 6 weeks, 12 weeks, and 24 weeks. Parametric data were analyzed using an independent sample T-test. Nonparametric data were analyzed using the Mann-Whitney test and Wilcoxon test. A P value less than 0.05 was considered significant.

Result

At the end of 24 weeks, the two-group improved significantly from the baseline and the improvement was comparable between the two groups. ROM also improved significantly in both groups. At 2nd week, SPADI score was significantly less in SSNB group (P < 0.05). About 43% of patients considered HD extremely painful.

Conclusion

Both HD and SSNB are almost equally effective in reducing pain and improving shoulder function. However, SSNB leads to a faster improvement.

Influence of diabetes on response to ultrasound guided hydrodistension treatment of adhesive capsulitis: a retrospective study

BACKGROUND

Diabetes is associated with microvascular and macrovascular complications. Although it is less recognized, diabetes also has an important role in the development of musculoskeletal disorders. Our objective was to evaluate the effect of type 2 diabetes (T2D) on the severity of adhesive capsulitis of the shoulder (AC) and on the efficacy of ultrasound guided hydrodistension treatment.

METHODS

We conducted a retrospective longitudinal observational study, of patients with AC who underwent ultrasound guided hydrodistension at our Centre. Severity was measured with DASH (Disabilities of Arm, Shoulder and Hand) score and pain was evaluated with a score between 0 and 10. The association of T2D with baseline characteristics of AC, and with outcomes at 6-12 months was analyzed using linear and logistic regression models.

RESULTS

We evaluated 120 ultrasound guided hydrodistension treatments of AC, 85 in patients without diabetes and 35 in patients with T2D. Patients with diabetes had a higher prevalence of dyslipidemia, hypertension and higher HbA1c values. The average duration of diabetes was 4.8 years (2.0, 7.9). The baseline characteristics of AC were not significantly different between patients with and without diabetes. Patients with T2D relapsed more frequently and required more reinterventions than patients without diabetes (20.0% vs 4.7%, p = 0.008), had higher post-intervention pain scale values [4.0 (0.0-5.0) vs 0.0 (0.0-5.0), p = 0.022] and higher post-intervention DASH score [0.8 (0.0-1.8) vs 0.0 (0.0-0.8), p = 0.038].

CONCLUSION

Although baseline characteristics of AC in patients with diabetes were similar to those without diabetes, patients with diabetes had a worse response to treatment, more frequent relapses and a greater need for new interventions.

Expert clinical consensus in the delivery of hydrodilatation for the management of patients with a primary frozen shoulder

Aims

To achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation.

Methods

We conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional.

Results

Between 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating).

Conclusion

In the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation.

Cite this article: Bone Jt Open 2022;3(9):701–709.

Effects of Hydrodilatation With Corticosteroid Injection and Biomechanical Properties in Patients With Adhesive Capsulitis After Breast Cancer Surgery

Objective

To compare the biomechanical properties of the glenohumeral joint capsule between adhesive capsulitis (AC) after breast cancer surgery and idiopathic AC and demonstrate the effects of hydrodilatation (HD) with corticosteroid injection for AC after breast cancer surgery.

Methods

Twenty-three prospective patients with AC after breast cancer surgery (BC group) and 44 retrospective patients with idiopathic AC without breast cancer (CON group) underwent HD with corticosteroid injection and home exercise training. We compared their biomechanical characteristics (capsular capacity, maximal pressure, and capsular stiffness). In the BC group, the passive range of motion (ROM) of the affected shoulder and a questionnaire (Shoulder Pain and Disability Index [SPADI]) were evaluated at baseline and 2 and 4 weeks after treatment.

Results

The BC group showed higher biomechanical characteristics (maximal pressure and capsular stiffness) than did the CON group. The mean maximal pressure and capsular stiffness were 519.67±120.90 mmHg and 19.69±10.58 mmHg/mL in the BC group and 424.78±104.42 mmHg and 11.55±7.77 mmHg/mL in the CON group (p=0.002 and p=0.001, respectively). And, the BC group showed significant improvements in all ROMs (abduction, flexion, and external rotation) and the SPADI pain and disability sub-scores following the treatment.

Conclusion

The glenohumeral joint capsular stiffness was greater in the patients with AC after breast cancer surgery than in those with idiopathic AC. HD with corticosteroid injection was effective in treating AC after breast cancer surgery.

Diabetes as a Prognostic Factor in Frozen Shoulder: A Systematic Review

•

People with diabetes may experience worse outcomes from frozen shoulder than those without diabetes; however, the certainty in evidence was moderate to low.

•

If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term.

Objective

To summarize evidence from longitudinal observational studies to determine whether diabetes (types 1 and 2) is associated with the course of symptoms in people with frozen shoulder.

Data Sources

A systematic literature search of 11 bibliographic databases (published through June 2021), reference screening, and emailing professional contacts.

Study Selection

Studies were selected if they had a longitudinal observational design that included people diagnosed with frozen shoulder at baseline and compared outcomes at follow-up (>2wk) among those with and without diabetes at baseline.

Data Extraction

Data extraction was completed by 1 reviewer using a predefined extraction sheet and was checked by another reviewer. Two reviewers independently judged risk of bias using the Quality in Prognostic Factor Studies tool.

Data Synthesis

A narrative synthesis, including inspection of forest plots and use of the prognostic factor Grading of Recommendations, Assessment, Development and Evaluations framework. Twenty-eight studies satisfied the inclusion criteria. Seven studies were judged to be at a moderate risk of bias and 21 at a high risk of bias. Diabetes was associated with worse multidimensional clinical scores (moderate certainty in evidence), worse pain (low certainty in evidence), and worse range of motion (very low certainty in evidence).

Conclusions

This review provides preliminary evidence to suggest that people with diabetes may experience worse outcomes from frozen shoulder than those without diabetes. If high-quality studies can confirm the findings of this review, then clinicians should monitor patients with frozen shoulder with diabetes more closely and offer further treatment if pain or lack of function persists long-term.

Effectiveness of surgical and non-surgical interventions for managing diabetic shoulder pain: a systematic review

PURPOSE

This systematic review evaluated and compared the effectiveness of non-surgical and surgical interventions for managing shoulder pain in patients with diabetes.

METHODS

PubMed, Scopus, CINAHL, EMBASE, Sport Discus, and Cochrane library were searched for studies published in the last 20 years. Randomized clinical trials (RCTs) and cohort studies that assessed shoulder pain in patients with diabetes and implemented one or a combination of non-surgical and surgical interventions were eligible for inclusion. The quality of the included studies was assessed using the Structured Effectiveness Quality Evaluation Scale (SEQES) tool. Data extracted from the eligible studies included study design, patient characteristics, duration of symptoms, type of interventions, outcome measures used to assess pain, follow-up intervals, and research findings.

RESULTS

A narrative synthesis with effect sizes (ES) or between-group differences was conducted. A total of 25 (14 non-surgical and 11 surgical) studies met the inclusion criteria. Six studies addressed physiotherapeutic interventions (three RCTs and three cohorts - ES = 0.07-1.3), three studies assessed the effect of steroid injections (two RCTs and one cohort - ES = 0.2-0.4), two cohorts addressed arthrographic capsular distension (between-group difference of 1.1 on Visual Analogue Scale), two cohorts addressed MUA, and one RCT addressed suprascapular nerve block (ES = 1-6). For the surgical studies, six cohorts addressed arthroscopic capsular release (ES = 0.2), three cohorts addressed arthroscopic rotator cuff repair (ES = 0.05-0.5), and one cohort addressed arthroplasty (ES = 0.3).

CONCLUSION

Moderate- to very-low-quality evidence suggests large effects of physiotherapy modalities plus exercise and suprascapular nerve block, and trivial to small effects for surgical interventions for improving shoulder pain in patients with diabetes. Future well-designed studies are needed to provide accurate estimates of the true effects of these interventions on improving shoulder pain in patients with diabetes.Implications For RehabilitationShoulder pain may lead to disability in patients with diabetes.We recommend the use of physiotherapy interventions to reduce shoulder pain.Corticosteroid injections are recommended for short-term shoulder pain relief.

Intra-articular steroid for adhesive capsulitis: does hydrodilatation give any additional benefit? A randomized control trial

OBJECTIVES

To assess the benefit offered by capsular hydrodilatation in addition to intra-articular steroid injections in cases of adhesive capsulitis, assess outcomes in diabetic patients with capsular hydrodilatation as compared to non-diabetics and correlate duration of symptoms with outcome based on the type of intervention given.

MATERIALS AND METHODS

This prospective double-blinded randomized control trial included patients presenting with clinical features of adhesive capsulitis with no evidence of rotator cuff pathology and randomized them into two groups-intra-articular steroid with hydrodilatation (distension group) and only intra-articular steroid (non-distension group) with intervention being performed as per the group allotted. Primary outcome measure was Shoulder Pain and Disability Index (SPADI) scores which were taken pre-intervention, at 1.5, 3 and 6 months post-intervention, which were assessed by generalized linear model statistics and Pearson correlation.

RESULTS

Although there was statistically significant drop in SPADI in both groups over time [F(1.9, 137.6) = 112.2; p < 0.001], mean difference in SPADI between the 2 groups was not statistically significant (1.53; CI:-3.7 to 6.8; p = 0.56). There was no significant difference between both groups among diabetics [F(1,38) = 0.04; p = 0.95] and no significant difference between diabetic and non-diabetic patients who received hydrodilatation [F(1.8, 60) = 2.26; p = 0.12]. There was no significant correlation between the reduction in SPADI scores and duration of symptoms in any subset of the study population.

CONCLUSION

Shoulder joint hydrodilatation offered no additional benefit compared to intra-articular steroid injections for shoulder adhesive capsulitis. Outcome for diabetics and non-diabetics were similar and there was no correlation between duration of symptoms and outcome.

Distension arthrogram in the treatment of adhesive capsulitis has a low rate of repeat intervention

AIMS

The primary aim of this study was to evaluate the efficacy of distension arthrography in the treatment of adhesive capsulitis of the shoulder. The secondary aim was to assess which patient and procedural factors predicted the recurrence of symptoms after the procedure.

METHODS

All patients referred to our shoulder clinic over a ten-year period, between 2008 and 2018, with a clinical diagnosis of capsulitis and symptoms persisting for more than six months, were offered treatment with a distension arthrogram. All procedures were performed by one of five musculoskeletal radiologists, with a combination of steroid, local anaesthetic, and a distention volume of 10 ml, 30 ml, or 50 ml. Patient demographics, procedural details, recurrence of symptoms, and the need for further intervention were evaluated.

RESULTS

A total of 2,432 distension arthrograms were performed during the study period. The mean time between arthrography and analysis was 5.4 years (SD 4.4; 1 to 11). Recurrent symptoms occurred in 184 cases (7.6%), all of whom had a repeat distension arthrogram at a median of nine months (interquartile range (IQR) 6.0 to 15.3). The requirement for further intervention for persistent symptoms following arthrography was significantly associated with diabetes (p < 0.001) and bilateral capsulitis (p < 0.001). The volume of distension, either with air or saline, showed a dose-dependent advantage. Distension of 50 ml versus 30 ml showed a significantly decreased odds ratio for recurrence of 2.2 (95% confidence interval (CI) 1.6 to 3.0; p < 0.001). Capsule rupture (p = 0.615) or steroid dose (p = 0.275) did not significantly affect the rate of recurrence. There were no infections or neurovascular injuries. Following the second distension arthrogram, the symptoms resolved in 137 cases (74.5%) with no further intervention being required. An arthroscopic capsular release was ultimately required in 41 cases, comprising 1.7% of the entire cohort.

CONCLUSION

We found a low rate of repeat intervention following distension arthrography in patients with adhesive capsulitis of the shoulder, at long term follow-up. Greater volumes of distension are associated with lower rates of recurrence independent of capsule rupture. Cite this article: Bone Joint J 2020;102-B(5):606-610.

Definition, Diagnosis, Treatment, and Prognosis of Frozen Shoulder: A Consensus Survey of Shoulder Specialists

Background

The objective of this study was to identify a consensus on definition, diagnosis, treatment, and prognosis of frozen shoulder (FS) among shoulder specialists.

Methods

A questionnaire composed of 18 questions about FS—definition, classification, utilization of diagnostic modalities, the propriety of treatment at each stage, and prognosis—was sent to 95 shoulder specialists in Korea. Most questions (15 questions) required an answer on a 5-point analog scale (1, strongly disagree; 5, strongly agree); three questions about the propriety of treatment were binary.

Results

We received 71 responses (74.7%). Of the 71 respondents, 84.5% agreed with the proposed definition of FS, and 88.8% agreed that FS should be divided into primary and secondary types according to the proposed definition. Only 43.7% of the respondents agreed that FS in patients with systemic disease should be classified as secondary FS. For the diagnosis of FS, 71.9% agreed that plain radiography should be used and 64.8% agreed ultrasonography should be used. There was a high consensus on proper treatment of FS: 97.2% agreed on education, 94.4%, on the use of nonsteroidal anti-inflammatory drugs; 76.1%, on intra-articular steroid injections; and 97.2%, on stretching exercise. Among all respondents, 22.5% answered that more than 10% of the patients with FS do not respond to conservative treatment.

Conclusions

The survey revealed a general consensus among shoulder specialists on the definition and treatment of FS. However, classification of FS was found controversial.

Short-Term Outcome Predictors in Patients With Primary Adhesive Capsulitis Treated With Ultrasound-Guided Hydrodilatation With Corticosteroids

OBJECTIVE

Glenohumeral joint hydrodilatation with corticosteroids has been proposed as an effective secondary therapeutic procedure for primary adhesive capsulitis. However, little is known about which subgroup of patients would benefit from this procedure. This study aimed to identify covariates associated with improved prognosis in patients receiving ultrasound-guided hydrodilatation with corticosteroid injection.

DESIGN

This was a cohort study. Data on baseline demographic characteristics, disease status, past medical conditions, and initial ultrasonographic findings were collected. Linear and logistic regression analyses were performed to determine the prognostic factors associated with better clinical outcomes.

RESULTS

Fifty-three patients (54 shoulders) were included. Linear regression analysis showed that coracohumeral ligament thickness of less than 3 mm, use of analgesics before hydrodilatation, and female sex were associated with good improvement in the Shoulder Pain and Disability Index score. Multivariate logistic regression analysis showed that coracohumeral ligament thickness of less than 3 mm on ultrasound was associated with a strong tendency (P = 0.054) of reaching the minimal detectable change. In addition, capsule rupture did not play a role in determining the clinical efficacy of hydrodilatation.

CONCLUSIONS

In patients with primary adhesive capsulitis, coracohumeral ligament thickness of less than 3 mm is correlated with greater short-term improvement in the Shoulder Pain and Disability Index score after ultrasound-guided hydrodilatation with steroid injection is performed.

The effectiveness of hydrodistension and physiotherapy following previously failed conservative management of frozen shoulder in a UK primary care centre

BACKGROUND

There is a lack of evidence on the clinical effectiveness of hydrodistension for frozen shoulder following failed conservative management.

METHODS

A total of 90 patients opted for hydrodistension following failed initial treatment which included physiotherapy and at least one corticosteroid injection. Shoulder pain and function were assessed at baseline, and 6, 12 and 24 weeks using the Shoulder Pain Disability Index (SPADI), The Upper Extremity Functional Index (UEFI) and a visual analogue scale (VAS) for pain. Active ranges of motion were assessed at baseline, post-24 hr and discharge.

RESULTS

We observed clinically important improvements in pain (VAS -5.5; 90% confidence interval [CI] -6.0 to -5.0; SPADI pain, -20; 90% CI-23 to -17) and function (UEFI 23; 90% CI 19 to 26; SPADI disability, -32; 90% CI -36 to -28) at 6 weeks. These improvements remained clearly substantial at 24 weeks. Active range of motion improved substantially post-24 hr (flexion 20, 90% CI 18 to 23; lateral rotation 14, 90% CI 12 to 16; abduction 22, 90% CI 19 to 25) and at discharge (flexion 37, 90% CI 33 to 41; lateral rotation 24, 90% CI 21 to 27; abduction 44, 90% CI 38 to 50).

DISCUSSION

This single-arm observational study suggests that hydrodistension is an effective treatment of frozen shoulder within a UK primary care setting when standard treatment has failed.

Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review

INTRODUCTION

Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis.

HYPOTHESIS

Different aetiological groups yield variable outcomes following arthroscopic capsular release.

MATERIALS AND METHODS

A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines.

RESULTS

Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) DISCUSSION: Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases.

LEVEL OF EVIDENCE

IV, systematic review.

Value of Anterior Band of the Inferior Glenohumeral Ligament Area as a Morphological Parameter of Adhesive Capsulitis

Objective

Thickened inferior glenohumeral ligament (IGHL) is considered as one of the major morphological parameters of adhesive capsulitis (AC). Previous studies reported that the anterior band of inferior glenohumeral ligament thickness (aIGHLT) is correlated with shoulder capsular contracture, luxatio erecta humeri, and AC. However, the thickness varies from the measured angle. To reduce this measurement error, we devised a new morphological parameter, called the anterior band of inferior glenohumeral ligament area (aIGHLA).

Methods

The aIGHL samples were collected from 54 patients with AC and from 50 control subjects who underwent shoulder magnetic resonance imaging (MRI) without any evidence of AC. Coronal T2-weighted MRI images were obtained at the shoulder level from each patient. We measured the aIGHLA and aIGHLT at the maximal view of the IGHL in the coronal plane using our picture archiving and communication system. The aIGHLA was measured at the whole cross-sectional area of the IGHL in the most hypertrophied segment of the coronal MR images. The aIGHLT was measured at the thickest point of the IGHL.

Results

The average aIGHLA was 55.58 ± 14.16 mm² in the control group and 83.71 ± 28.45 mm² in the AC group. The average aIGHLT was 3.47 ± 0.99 mm in the control group and 4.52 ± 1.02 mm in the AC group. AC patients showed significantly greater aIGHLA (p < 0.001) and aIGHLT (p < 0.001) than control subjects. Receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off score of the aIGHLA was 63.37 mm², with 79.6% sensitivity, 80.0% specificity, and AUC of 0.84 (95% CI, 0.76–0.92). The optimal cut-off point of the IGHLT was 3.81 mm, with 74.1% sensitivity, 74.0% specificity, and AUC of 0.77 (95% CI, 0.68–0.86).

Conclusions

Although the aIGHLA and aIGHLT were both significantly associated with AC, the aIGHLA was a more sensitive diagnostic parameter.

Can we improve the outcome of hydrodilatation for adhesive capsulitis?

BACKGROUND

Hydrodilatation (HD) has been shown to improve pain and function in patients with adhesive capsulitis (AC). There is no consensus concerning how HD should be performed or what volume should be injected. It has distinct advantages compared to surgery; however, it is a painful procedure and is often poorly tolerated.

METHODS

We retrospectively reviewed all patients referred for HD over a 2.5-year period aiming to assess whether volume injected influences outcome.

RESULTS

There were 107 patients treated with HD; of these, 76 (43 female, 32 male) had full data for analysis. The majority were classified as primary AC (n = 57) with an average age of 55.5 years. The mean improvement in Oxford Shoulder Score (OSS) was 12.1, with females (13.9) and post-traumatic cases of AC (14.1) demonstrating the best outcome. No complications were observed during the HD process. There was a negative correlation observed between volume injected and OSS improvement. Only two patients experienced a poor outcome and required further treatment with manipulation +/- arthroscopic arthrolysis.

CONCLUSIONS

The present study supports the use of HD as a first line treatment for AC regardless of the underlying cause, and also demonstrates that the volume injected does appear to influence the outcome.

Indications for hydrodilatation for frozen shoulder

Frozen shoulder causes significant functional disability and pain in a population group constituted by patients who are often middle-aged and working.

Frozen shoulder remains poorly understood. The available literature is limited and often prone to bias.

A rapid, non-surgical and cost-effective treatment that reduces pain and restores function is an attractive option.

Hydrodilatation is a potential first-line treatment of frozen shoulder in secondary care.

Cite this article: EFORT Open Rev 2017;2:462–468. DOI: 10.1302/2058-5241.2.160061

Effectiveness of Glenohumeral Joint Dilatation for Treatment of Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The objective was to explore the effectiveness of glenohumeral joint distension for the treatment of frozen shoulder. We searched electronic data sources including PubMed, Scopus, and Embase from the earliest records available to February 2017. Eleven randomized controlled trials including at least one pair of comparisons between capsular distension and a reference treatment were included, comprising 747 participants. Patients’ characteristics, details of reference treatments, aspects of capsular distension therapy, and outcome measurement were evaluated at three points in time: baseline, early following intervention, and at the trial’s end. The primary and secondary outcomes were the between-group standardized mean differences of changes in shoulder function and range of motion, respectively. Regarding the long-term primary outcome, the superiority of capsular distension to reference treatments was not identified. One secondary outcome (external rotation limitation) showed a probable early positive response to capsular distension when compared to intra-articular corticosteroid injection. Aspects of approaches, imaging guiding techniques and doses of distension were not found to modify treatment effectiveness. In conclusion, distension of the glenohumeral joint provides a similar long-term efficacy to all reference treatments. A single dose of a corticosteroid-contained regimen introduced through the ultrasound-guided posterior approach is a preferable practice of capsular distension for the management of frozen shoulder.

Recurrence of frozen shoulder after manipulation under anaesthetic (MUA)

Aims

Manipulation under anaesthetic (MUA) is a recognised form of treatment for patients with a frozen shoulder. However, not all patients benefit. Some have persistent or recurrent symptoms. There are no clear recommendations in the literature on the optimal management of recurrent frozen shoulder after a MUA. We aimed to address this issue in this study.

Patients and Methods

We analysed a prospectively collected, single-surgeon, consecutive series of patients who underwent MUA for frozen shoulder between January 1999 and December 2015. The Oxford Shoulder Scores (OSS) and range of movement were the outcome measures.

Results

A total of 730 patients (792 shoulders) underwent MUA during the study period. A further MUA was undertaken in 141 shoulders (17.8%), for which we had complete data for 126. The mean improvement in OSS for all patients undergoing MUA was 16 (26 to 42), and the mean post-operative OSS in those requiring a further MUA was 14 (28 to 42; t-test, no difference between mean improvements, p = 0.57). Improvement was seen after a further MUA, regardless both of the outcome of the initial MUA, and of the time of recurrence. Patients with type-1 diabetes mellitus were at a 38% increased risk of requiring a further MUA, compared with the 18% increased risk of the group as a whole (p < 0.0001).

Conclusion

Patients with a poor outcome or recurrent symptoms of a frozen shoulder after a MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate. Cite this article: Bone Joint J 2017;99-B:812–17.

Targeted ultrasound-guided hydrodilatation via the rotator interval for adhesive capsulitis

OBJECTIVE

To describe and evaluate ultrasound-guided hydrodilatation via the rotator interval for the treatment of adhesive capsulitis.

MATERIALS AND METHODS

Patients referred to our department with adhesive capsulitis were consented for hydrodilatation. Inclusion criteria included a failure to respond to conservative treatment and the absence of full thickness rotator cuff tear. Twenty-one milliliters of a mixture of local anesthetic and steroid was injected into the rotator interval using a 21-gauge needle. Patients were followed up at 2 weeks and 4 months, with documented pain scores from 0 to 10 on a visual analogue scale and the Oxford Shoulder Questionnaire.

RESULTS

Twenty-two patients were suitable for inclusion in the study. Nineteen were female (86 %) and three were male. The mean age was 55 years (range, 32-71 years). The duration of symptoms ranged from 4 weeks to 20 months. At 4 months, 19/22 (86 %) of patients described either complete (7/22) or good (12/22) improvement in their symptoms. The mean pain score was 8.4 prior to the procedure, 3.1 at 48 h and 1.9 at 4 months, and 20/22 (91 %) had a lower pain score after 4 months. There was a statistically significant (p < 0.05) improvement in the Oxford shoulder score, from a mean of 13.6 pre-procedure to 36.5 at 4 months.

CONCLUSIONS

The rotator interval and anterior joint capsule are strongly implicated in the symptomatology of adhesive capsulitis. The novel use of targeted ultrasound-guided hydrodilatation via the rotator interval gives good results in reducing shoulder pain and symptoms in adhesive capsulitis.

Clinical identifiers for early-stage primary/idiopathic adhesive capsulitis: are we seeing the real picture?

BACKGROUND

Adhesive capsulitis is often difficult to diagnose in its early stage and to differentiate from other common shoulder disorders.

OBJECTIVE

The aim of this study was to validate any or all of the 8 clinical identifiers of early-stage primary/idiopathic adhesive capsulitis established in an earlier Delphi study.

DESIGN

This was a cross-sectional study.

METHODS

Sixty-four patients diagnosed with early-stage adhesive capsulitis by a physical therapist or medical practitioner were included in the study. Eight active and 8 passive shoulder movements and visual analog scale pain scores for each movement were recorded prior to and immediately following an intra-articular injection of corticosteroid and local anesthetic. Using the local anesthetic as the reference standard, pain relief of ≥70% for passive external rotation was deemed a positive anesthetic response (PAR).

RESULTS

Sixteen participants (25%) demonstrated a PAR. Univariate logistic regression identified that of the proposed identifiers, global loss of passive range of movement (odds ratio [OR]=0.26, P=.03), pain at the end of range of all measured active movements (OR=0.06, P=.02), and global loss of passive glenohumeral movements (OR=0.23, P=.02) were associated with a PAR. Following stepwise removal of the variables, pain at the end of range of all measured active movements remained the only identifier but was associated with reduced odds of a PAR.

LIMITATIONS

The lack of a recognized reference standard for diagnosing early-stage adhesive capsulitis remains problematic in all related research.

CONCLUSIONS

None of the clinical identifiers for early-stage adhesive capsulitis previously proposed by expert consensus have been validated in this study. Clinicians should be aware that commonly used clinical identifiers may not be applicable to this stage.

[Association of physiotherapy under continuous brachial plexus analgesia and shoulder arthrographic-distension for treatment of resistant shoulder-hand syndrome]

OBJECTIVE

Evaluation of treatment of shoulder-hand syndromes resistant to conventional therapeutic. This approach consists of an intensive treatment based on arthrographic distension with rapid mobilization of the shoulder under general anaesthesia and on active rehabilitation under regional analgesia using infraclavicular brachial plexus catheter.

MATERIAL AND METHODS

It was a retrospective study of twenty-five consecutive patients with severe shoulder-hand syndrome treated between 2007 and 2012. Besides their persistent pain, these patients presented a functional disability of their shoulder, wrist and hand. Treatment was initiated at least three months after diagnosis. All were assessed at the admission and six months later.

RESULTS

After treatment, pain was reduced by at least three points at the NS in 64% of the patients. Twelve patients described a complete recovery of their shoulder function; eleven patients described a normal hand function recovery and six patients a partial recovery allowing regular life. Nineteen patients evaluated their functional improvement of more than 50%. Only two patients with more than one year of chronic pain reported no improvement after treatment.

CONCLUSION

After failure of the physiotherapy and analgesic treatment, there are no clear consensual procedures and guidelines remains discussed. The current study combined different approaches with a significant improvement of this complex regional pain syndrome called shoulder-hand syndromes.

Impact of diabetes mellitus on surgical outcomes in sports medicine

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.

Adhesive capsulitis: review of imaging and treatment

Adhesive capsulitis is one of the most common conditions affecting the shoulder; however, early clinical diagnosis can be challenging. Treatment is most effective when commenced prior to the onset of capsular thickening and contracture; consequently, the role of imaging is increasing. The aim of this review is to demonstrate the typical imaging appearances of adhesive capsulitis and to examine some of the evidence regarding each of these imaging modalities. An evaluation of the various management options available to the clinician is also presented.

Capsule preservation improves short-term outcome of hydraulic distension in painful stiff shoulder

The effect of intraarticular hydraulic distension (IHD) for a painful stiff shoulder (or adhesive capsulitis) has been affirmed, but whether rupturing the joint capsule during this process is beneficial remains controversial. By monitoring real-time pressure-volume (PV) profiles during IHD, we could infuse the largest possible volume without rupturing the capsule. Using the novel technique, we compared the short-term effects of IHD when the capsule was preserved versus when it was ruptured. Fifty-four patients with a painful stiff shoulder underwent IHDs intended to preserve or rupture the capsule and then classified into capsule-ruptured (n = 26) and capsule-preserved (n = 20) groups, based on the obtained PV profiles. Their profiles were triphasic or biphasic; eight with flat profiles were excluded from the comparison. Clinical outcomes were evaluated at 3-day and 1-month follow-ups, in terms of pain and range of motion (ROM). Although both groups showed significant increase in ROM and decrease in pain after IHD, the improvements were greater in the capsule-preserved group than in the ruptured group at both follow-up times, and in triphasic and biphasic cases. In conclusion, the therapeutic effects of IHD in short-term follow-ups were enhanced by preserving the capsule.

Multimedia article. The rotator interval: pathology and management

The rotator interval describes the anatomic space bounded by the subscapularis, supraspinatus, and coracoid. This space contains the coracohumeral and superior glenohumeral ligament, the biceps tendon, and anterior joint capsule. Although a definitive role of the rotator interval structures has not been established, it is apparent that they contribute to shoulder dysfunction. Contracture or scarring of rotator interval structures can manifest as adhesive capsulitis. It is typically managed nonsurgically with local injections and gentle shoulder therapy. Recalcitrant cases have been successfully managed with an arthroscopic interval release and manipulation. Conversely, laxity of rotator interval structures may contribute to glenohumeral instability. In some cases this can be managed with one of a number of arthroscopic interval closure techniques. Instability of the biceps tendon is often a direct result of damage to the rotator interval. Damage to the biceps pulley structures can lead to biceps tendon subluxation or dislocation depending on the structures injured. Although some authors describe reconstruction of this tissue sling, most recommend tenodesis or tenotomy if it is significantly damaged. Impingement between the coracoid and lesser humeral tuberosity is a relatively well-established, yet less common cause of anterior shoulder pain. It may also contribute to injury of the anterosuperior rotator cuff and rotator interval structures. Although radiographic indices are described, it appears intraoperative dynamic testing may be more helpful in substantiating the diagnosis. A high index of suspicion should be used in association with biceps pulley damage or anterosuperior rotator cuff tears. Coracoid impingement can be treated with either open or arthroscopic techniques. We review the anatomy and function of the rotator interval. The presentation, physical examination, imaging characteristics, and management strategies are discussed for various diagnoses attributable to the rotator interval. Our preferred methods for treatment of each lesion are also discussed.

Joint mobilization versus self-exercises for limited glenohumeral joint mobility: randomized controlled study of management of rehabilitation

To clarify the optimal management of rehabilitative intervention for limited glenohumeral joint mobility (LGHM) arising from adhesive capsulitis, particularly focusing on the frequency of sessions for joint mobilization and the self-exercise compliance, the functional results of 120 patients with LGHM were prospectively investigated as follows: Differences in improved angle of the shoulder joint (IA) and the time required to reach the range of motion plateau point (T) were compared by (1) age, (2) gender, (3) handedness, (4) duration before rehabilitative intervention, (5) frequency of sessions for joint mobilization by physical therapists in the hospital setting, and (6) self-exercise compliance in the home setting. The lengths of therapy and follow-up were 4.6 and 5.9 months, respectively. IA significantly decreased in the 71-year-old and above group. There were no significant differences in IA between male and female. IA of the dominant-handed group was significantly higher than that of the non-dominant-handed group. There were no significant differences in T in each item. IA of the group that had experienced more than 7 months of the condition was significantly low. Although the frequency of joint mobilization by physical therapists in the hospital setting showed no relationship with IA or T, IA was significantly higher and T was significantly shorter in the group that performed self-exercise every day than in the groups that performed less. In conclusion, early intervention and self-exercise in the home setting are more important factors than session frequency of joint mobilization in the hospital setting for the successful management of rehabilitation for LGHM.

Complex shoulder disorders: evaluation and treatment

Evaluation of patients with shoulder disorders often presents challenges. Among the most troublesome are revision surgery in patients with massive rotator cuff tear, atraumatic shoulder instability, revision arthroscopic stabilization surgery, adhesive capsulitis, and bicipital and subscapularis injuries. Determining functional status is critical before considering surgical options in the patient with massive rotator cuff tear. When nonsurgical treatment of atraumatic shoulder stability is not effective, inferior capsular shift is the treatment of choice. Arthroscopic revision of failed arthroscopic shoulder stabilization procedures may be undertaken when bone and tissue quality are good. Arthroscopic release is indicated when idiopathic adhesive capsulitis does not respond to nonsurgical treatment; however, results of both nonsurgical and surgical treatment of posttraumatic and postoperative adhesive capsulitis are often disappointing. Patients not motivated to perform the necessary postoperative therapy following subscapularis repair are best treated with arthroscopic débridement and biceps tenotomy.

Real-time pressure monitoring of intraarticular hydraulic distension for painful stiff shoulders

Intraarticular hydraulic distension (IHD) has been utilized to treat painful stiff shoulders by distending and then rupturing the joint capsules. However, no attempts have been made to optimize the capsule distension, which might give a better clinical outcome. To set up a prerequisite technique for a maximal distension without rupturing the capsule, real-time pressure monitoring of IHD procedures was performed in 16 patients, which revealed triphasic pressure-volume profiles in 10 patients and biphasic in 6 patients. The IHD procedures were terminated without rupturing the capsule by observing the real-time pressure-volume curves (N = 10) or by pain (N = 3). The pressure profiles of the 13 patients who had the infusion stopped without rupture demonstrated stress-relaxation curves of the capsules. The biphasic group showed a steeper slope of the second phase of linearly increasing pressure (p = 0.017) and higher pressure (p = 0.005) with slightly larger volume (p = 0.095) at the termination of fluid infusion than did the triphasic group. The stiffness of the glenohumeral joint capsule had a close correlation with the limitation in range of motion. Real-time pressure monitoring would be helpful to develop a novel IHD technique that could distend the glenohumeral joint as much as possible without rupturing it. The biomechanical parameters derived from the pressure-volume profiles would also be useful to characterize the properties of the joints of painful stiff shoulder patients.

Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial

BACKGROUND

Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis. Procedures described often involve the injection of corticosteroids, to which the reported treatment effects may be attributed. Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated.

METHODS

In this randomized trial, a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation. Patients were given three injections with two-week intervals, and all injections were given under fluoroscopic guidance. Outcome measures were the Shoulder Pain and Disability Index (SPADI) and measures of active and passive range of motion. Seventy-six patients were included and groups were compared six weeks after treatment. The study was designed as an open trial.

RESULTS

The groups showed a rather similar degree of improvement from baseline. According to a multiple regression analysis, the effect of dilatation was a mean improvement of 3 points (confidence interval: -5 to 11) on the SPADI 0-100 scale. T-tests did not demonstrate any significant between-group differences in range of motion.

CONCLUSION

This study did not identify any important treatment effects resulting from three hydrodilatations that included steroid compared with three steroid injections alone.

TRIAL REGISTRATION

The study is registered in Current Controlled Trials with the registration number ISRCTN90567697.

Thawing the frozen shoulder. A randomised trial comparing manipulation under anaesthesia with hydrodilatation

This study prospectively evaluated the outcome of manipulation under anaesthesia and hydrodilatation as treatments for adhesive capsulitis. A total of 36 patients (38 shoulders) were randomised to receive either method, with all patients being treated in stage II of the disease process. The mean age of the patients was 55.2 years (44 to 70) and the mean duration of symptoms was 33.7 weeks (12 to 76). Eighteen shoulders (17 patients) underwent manipulation under anaesthesia and 20 (19 patients) had hydrodilatation. There were three insulin-dependent diabetics in each group. The mean visual analogue score in the manipulation under anaesthesia group was 5.7 (3 to 8.5; n = 18) before treatment, 4.7 (0 to 8.5; n = 16) at two months (paired t-test p = 0.02), and 2.7 (0 to 9; n = 16) at six months (paired t-test, p = 0.0006). The mean score in the hydrodilatation group was 6.1 (4 to 10; n = 20) before treatment, 2.4 (0 to 8; n = 18) at two months (paired t-test, p = 0.001), and 1.7 (0 to 7; n = 18) at six months (paired t-test, p = 0.0006). The visual analogue scores in the hydrodilatation group were significantly better than in the manipulation under anaesthesia group over the six-month follow-up period (p < 0.0001). The mean Constant score in those manipulated was 36 (26 to 66) before treatment, 58.5 (24 to 90) at two months (paired t-test, p = 0.001) and 59.5 (23 to 85) at six months (paired t-test, p = 0.0006). In the hydrodilatation group it was 28.8 (18 to 55) before treatment, 57.4 (17 to 80) at two months (paired t-test, p = 0.0004) and 65.9 (28 to 92) at six months (paired t-test, p = 0.0005). The Constant scores in the hydrodilatation group were significantly better than in the manipulated group over the six-month period of follow-up (p = 0.02). The range of movement improved in all patients over the six months, but was not significantly different between the groups. At the final follow-up, 94% of patients (17 of 18) were satisfied or very satisfied after hydrodilatation compared with 81% (13 of 16) of those receiving a manipulation. Most of our patients were treated successfully, but those undergoing hydrodilatation did better than those who were manipulated.

Hydrodilatation (distension arthrography): a long-term clinical outcome series

OBJECTIVES

To describe and compare the medium to long-term effectiveness of hydrodilatation and post-hydrodilatation physiotherapy in patients with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology.

METHODS

Patients with primary and secondary glenohumeral contractures associated with rotator cuff pathology were recruited into a 2-year study. They all underwent hydrodilatation, followed by a structured physiotherapy programme. Patients were assessed at baseline, 3 days, 1 week, 3 months, 1 year and 2 years after hydrodilatation with primary outcome measures (Shoulder Pain and Disability Index, Shoulder Disability Index and percentage rating of "normal" function; SD%) and secondary outcome measures (range of shoulder abduction, external rotation and hand behind back). Comparisons in recovery were made between the primary and secondary glenohumeral contracture groups at all timeframes and for all outcome measures.

RESULTS

A total of 53 patients (23 with primary and 30 with secondary glenohumeral contractures) were recruited into the study. At the 2-year follow-up, 12 patients dropped out from the study. At baseline, the two contracture groups were similar with respect to their demographic and physical characteristics. The two groups of patients recovered in a similar fashion over the 2-year follow-up period. A significant improvement was observed in all outcomes measures over this period (p<0.01), so that both function and range of movement increased. The rate of improvement was dependent on the outcome measure that was used.

CONCLUSIONS

Hydrodilatation and physiotherapy increase shoulder motion in individuals with primary and secondary glenohumeral joint contracture associated with rotator cuff pathology. This benefit continues to improve or is maintained in the long term, up to 2 years after hydrodilatation.

Shoulder distension arthrography in adhesive capsulitis

Capsular retraction of the shoulder often occurs as a solitary pathological process; half of the cases are of primitive nature. In the past 10 years or more, distension of the shoulder joint has proven to be an efficient percutaneous treatment, and various techniques have been proposed. We report on our technique, which was performed on a series of 200 patients, and on the results observed in 27 patients with a precise evaluation of progressive changes in movements of the joint.