Indications for hydrodilatation for frozen shoulder

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.

Sonographically-navigated frozen shoulder release (S-FSR): A modified technique for sonographically-navigated, in-office hydrodilatation of adhesive capsulitis

We describe a new technique for hydrodilatation of the frozen shoulder, which we coined 'Sonographically-Navigated Frozen Shoulder Release (S-FSR)' or 'Dr Gonzalez's technique.' Traditional treatments include a combination of conservative and surgical modalities, such as non-steroidal anti-inflammatories, physical therapy, and open capsular release. We describe a modification to hydrodilatation of the frozen shoulder. Our technique describes the gradual dilation of the glenohumeral (GH) capsule with the goal of seeing a gentle release of the frozen shoulder. Furthermore, we outline our protocol for patient preparation with preprocedural diazepam 5 mg and Hydrocodone 5 mg-Acetaminophen 325 mg, one tablet each. During the procedure, we inject a solution of 10 mL lidocaine mixed with 2 mL of 40 mg/mL triamcinolone acetonide injection (80 mg total) through an anterior approach at the level of the rotator interval for pain control. Following this injection, we proceed to fenestrate the superior glenohumeral ligament (SGHL) in the process. We conclude the procedure with hydrodilatation of the GH joint (GHJ) through the posterior approach with approximately 50 mL of 0.9% normal saline, or until an expansion and release of the GH joint is visualized under ultrasound visualization. A full instruction video can be found at: https://www.youtube.com/watch?v = ZNB0R0hkeok&ab_channel = DrJorgeA.Gonzalez.

Factors associated with frozen shoulder in adults: a retrospective study

OBJECTIVE

This study aims to explore the risk factors associated with frozen shoulder patients and further analyze the relationship between gender and diabetes with frozen shoulder.

METHOD

We have reviewed the data of 1205 frozen shoulder patients in China's Xinjiang region from 2018 to 2023. The collected information included patients' gender, occupation, place of origin, marital status, age, the season of disease onset, duration of illness, etiology, surgical history, hypertension, diabetes, respiratory diseases, knee joint disease, hyperlipidemia, cardiovascular diseases, cervical spondylosis, lumbar disc herniation, rheumatoid arthritis, hyperuricemia, sleep quality, smoking and alcohol consumption, and constipation. We have used multifactor logistic regression analysis to identify the risk factors for a frozen shoulder.

RESULTS

Single-factor logistic regression analysis showed that the number of females, patients with diabetes, knee joint disease, constipation, and patients with poor sleep quality in the observation group are higher than in the control group (P < 0.05). There were no statistically significant differences between the two groups in terms of occupation, place of origin, marital status, age, season of disease onset, duration of illness, etiology, surgical history, hypertension, respiratory diseases, hyperlipidemia, cardiovascular diseases, cervical spondylosis, lumbar disc herniation, rheumatoid arthritis, hyperuricemia, smoking, and alcohol consumption history (P > 0.05). Multivariate analysis showed that the final model included four variables: gender, diabetes history, sleep, and constipation. Among them, the OR values of gender and diabetes history were more significant than 1, indicating that they were independent risk factors for frozen shoulder, while the OR values of sleep and constipation were less than 1, suggesting that they were negatively associated with the occurrence of frozen shoulder.

CONCLUSION

The results of this study suggest that gender and diabetes are independent risk factors for frozen shoulder. Additionally, poor sleep quality and constipation also can be correlated with the occurrence of a frozen shoulder.

Additional Effect of Extracorporeal Shockwave Therapy with Lidocaine Injection on Clinical and MRI Findings in Frozen Shoulder: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Trial

INTRODUCTION

Frozen shoulder is a very common musculoskeletal condition and the evidence related to the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in individuals with frozen shoulder is rare. Therefore, this study aims to compare and investigate the additional effects of extracorporeal shockwave therapy (ESWT) with intra-articular (IA) lidocaine injection in a frozen shoulder.

METHODS

Sixty eligible participants with frozen shoulder were included and the active group (n = 30, age 52.12 ± 5.2 years) received a lidocaine injection (1% lidocaine (Xylocaine) and 2cc (80 mg) methylprednisolone acetate) with active ESWT (3.5 bar air pressure and 2000 pulses with an energy flux density (EFD) ¼ 0.16 mJ/mm2) three sessions a week for 4 weeks. The placebo group (n = 30, age 53.56 ± 5.5 years) received lidocaine injection with placebo treatment (a special head that blocked the shock waves) three sessions a week for 4 weeks. Both groups received progressive resistance exercises (PRE) to the shoulder muscles. The primary outcome was pain intensity, measured with the visual analogue scale. The other outcome measures were the thickness of the coracohumeral ligament (CHL) measured by magnetic resonance imaging (MRI), abduction, and lateral rotation range of motion (ROM), functional disability, kinesiophobia, depression status, and quality of life. Participants were assessed at baseline, after 4 weeks, 8 weeks, and at 6-month follow-up.

RESULTS

The post-intervention at 4 weeks showed an improvement of 2.0 (CI 95% 1.71-2.28) in the active group compared to the placebo group. Similar effects were noted after 8 weeks (2.2) (CI 95% 1.91-2.48) and at the 6-month (1.9) (CI 95% 1.61-2.18) follow-up. Similar improvements were also found in the thickness of the CHL ligament (0.6) (CI 95% 0.46-0.73), abduction and lateral rotation (ROM) (- 23.6) (CI 95% - 27.47 to -19.72), (- 18.10) (CI 95% - 19.72 to - 16.47), functional disability (16.2) (CI 95% 14.85-17.54), kinesiophobia (11.0 (CI 95% 10.21-11.98), depression status (4.4) (CI 95% 4.03-4.76) and quality of life (0.9) (CI 95% 0.79-1.00) (p = 0.001) at the 6-month follow-up period, where mean estimates and their confidence intervals all included worthwhile effects. There were no adverse reactions or side effects noted in either the active or placebo groups during and after the treatment.

CONCLUSIONS

The study concluded that the addition of extracorporeal shockwave therapy after intra-articular lidocaine injection improves pain, functional disability, range of motion, kinesiophobia, depression status, and quality of life in people with frozen shoulder.

TRIAL REGISTRATION

https://ctri.nic.in , identifier; CTRI/2020/04/024834 prospectively registered on 24/04/2020.

Evidence for Combining Conservative Treatments for Adhesive Capsulitis

Background: Adhesive capsulitis, also known as frozen shoulder, is a challenge to treat clinically. Common first-line treatment options are suprascapular nerve block (SSNB), intra-articular corticosteroid (IACS) injection, hydrodilatation, and physical therapy. This literature review summarizes each of these conservative treatments and discusses the evidence base for combining treatment options for potential additive benefits to improve patient outcomes (ie, pain, range of motion [ROM], and shoulder function). Methods: The PubMed and Google Scholar databases were searched using the search terms "adhesive capsulitis," "frozen shoulder," "corticosteroids," "physical therapy," "suprascapular nerve block," "hydrodilatation," and "conservative care." Pertinent articles were identified and synthesized to provide a comprehensive review of 4 common conservative treatments for adhesive capsulitis. Results: Combining SSNB with physical therapy and/or IACS injection and combining IACS injection with physical therapy have support in the literature for improving shoulder pain, ROM, and function, while hydrodilatation and physical therapy seem to offer some additive benefits for improving shoulder ROM when used as adjunct treatments for adhesive capsulitis. Conclusion: Adhesive capsulitis remains a challenge to treat clinically with much still unknown regarding treatment optimization. For the foreseeable future, first-line conservative management will continue to be the mainstay of managing adhesive capsulitis. Thus, knowing how to best use and optimize these various options-both individually and in combination-is vital for effective treatment.

Adhesive capsulitis after COVID-19 vaccine injection: a peculiar case treated with combined bursa distention and glenohumeral capsular hydrodilatation

Frozen shoulder is a common and self-limiting condition affecting the soft tissues of the shoulders, characterized by severe pain, impaired range of motion (ROM) and limitation of daily activities. Its prevalence is 5% and it occurs most commonly in the fifth and sixth decades of life; women are more affected [DePalma in Clin Orthop Relat Res 466:552-560, 2008]. It can be idiopathic or associated with other conditions such as metabolic disorders, diabetes, thyroid diseases, prolonged immobilization, trauma [DePalma in Clin Orthop Relat Res 466:552-560, 2008], or complications after vaccine administration known as SIRVA (Shoulder injury related to vaccine administration). SIRVA is not caused by the vaccine itself but by inappropriate vaccination techniques [Martín Arias et al. in Vaccine 35:4870-4876, 2017]. The natural history of the frozen shoulder is a progression through three stages based on clinical and arthroscopic presentations: freezing, frozen and thawing [DePalma in Clin Orthop Relat Res 466:552-560, 2008; Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. The onset is characterized by disabling pain, that worsens at night; it is induced by inflammation and hypervascularity and lasts from 10 to 36 weeks [Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. The second stage is predominated by stiffness and severe reduction of ROM. This phase typically lasts from 9 to 12 months [Do et al. in Orthop J Sport Med 9:232596712110036, 2021]. Eventually, a recovery phase occurs, with a gradual recovery of the ROM that can last between 12 and 42 months. Ultrasound is an emerging diagnostic tool that contributes to differential diagnosis and treatment [Zappia et al. in Insights Imaging 7:365-371, 2016; Ricci et al. in J Ultrasound Med 39:633-635, 2020]: signs of adhesive capsulitis consist of thickening of the inferior recess of the glenohumeral joint capsule, thickening of the coracohumeral ligament and soft tissue structures in the rotator cuff interval, with hypervascularity. An unspecific sign is increased fluid in the tendon sheath of the long head of the biceps [Martín Arias et al. in Vaccine 35:4870-4876, 2017; Tandon et al. in J Ultrasound 20:227-236, 2017].

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.

Long-Term Outcomes of Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: A Prospective Observational Study

Ultrasound-guided hydrodistention has been established as an effective minimally invasive treatment option for glenohumeral joint adhesive capsulitis (AC). Nonetheless, the long-term outcomes of the procedure have not yet been established. A total of 202 patients with AC were prospectively recruited and followed up for a total of 2 years. Pain and functionality were assessed with the use of the visual analogue scale (VAS) and the disabilities of the arm, shoulder, and hand (DASH) score, respectively, at the beginning and the end of the follow-up period. The relapse of AC over the 2-year period and the effect of diabetes were also evaluated in the treatment cohort. The Mann-Whitney U test was used to compare mean scores at the two time points, and Cox survival analysis and χ2 test were used to assess the effect of diabetes on AC relapse. VAS and DASH scores were significantly lower at 2 years compared with the beginning of the follow-up period (p < 0.001). Diabetes was diagnosed in 38/202 patients (18.8%) and was found to be significantly associated with recurrence of the disease (p < 0.001). In conclusion, in this observational study, we have demonstrated that ultrasound-guided hydrodistention is linked to excellent long-term outcomes for the treatment of AC, which are significantly worse in patients with diabetes.

Effectiveness of ultrasound-guided fascia hydrorelease on the coracohumeral ligament in patients with global limitation of the shoulder range of motion: a pilot study

We conducted a prospective single-arm interventional study of the treatment efficacy of ultrasound-guided fascia hydrorelease (US-FHR) on the coracohumeral ligament (CHL) of patients with global limitation of shoulder range of motion (ROM) without local inflammation. The primary outcome was the change in passive ROM (pROM) of external rotation (ER) after first US-FHR. Secondary outcomes included the change in pROM of other directions from baseline, the pain visual analogue scale (pVAS) at the timepoints after each procedure (first, second US-FHR and rehabilitation) as well as the change in the Shoulder Pain and Disability Index (SPADI) from the first to the second visit. Eleven patients underwent US-FHR. The pROM of ER after the 1st US-FHR changed by a median of 7.1° (p < 0.01). There was a statistically significant improvement in the pROM of flexion, extension, abduction, external rotation, and internal rotation from baseline to each timepoints. The pVAS at rest showed no significant improvement, although the pVAS at maximal ER showed a trend towards improvement. The SPADI score decreased by a median of 13.4 (p < 0.01). No adverse events were observed. US-FHR on the CHL with or without rehabilitation might be an effective, less invasive treatment for patients with global limitation of shoulder ROM.

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.

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.

Management of Patients with Adhesive Capsulitis via Ultrasound-Guided Hydrodilatation without Concomitant Intra-Articular Lidocaine Infusion: A Single-Center Experience

Considering the potential chondrotoxic effects of lidocaine, this retrospective study aimed to examine whether ultrasound-guided hydrodilatation without concurrent lidocaine infusion can still provide comparable treatment benefits for patients with adhesive capsulitis (AC). Outpatient data from 104 eligible AC patients who received ultrasound-guided hydrodilatation between May 2016 and April 2021 were reviewed. A total of 59 patients received hydrodilatation with diluted corticosteroid only, while 45 patients received treatment with mixed, diluted corticosteroid and 1% lidocaine. The overall treatment outcome was documented as the percentage of clinical improvement, ranging from 0% to 100% compared to baseline, and it was ranked into poor, moderate and good treatment outcomes. The results show no significant group-wise difference in demographics, overall treatment outcome, and number of hydrodilatations, while most patients showed moderate and good treatment outcomes. Patients with lidocaine infusion did not show greater treatment benefit. Our results suggest that ultrasound-guided hydrodilatation without concurrent lidocaine infusion can still deliver good treatment benefits for AC patients, and the findings are supportive of a modified approach toward careful intra-articular local anesthetic use during management of AC in the primary care setting.

The role of suprascapular nerve block in hydrodilatation for frozen shoulder

Introduction: Frozen shoulder is a debilitating problem that requires comprehensive diagnosis and management. Patients usually recover, but the possibility of not reobtaining a full range of motion exists. Thus, early shoulder exercises are necessary to achieve their full range of motion. This study aims to understand the effects of suprascapular nerve block (SSNB) augmentation at the spinoglenoid notch in hydrodilatation to treat frozen shoulder to facilitate early shoulder exercises. Methods: The current study retrospectively observed 31 patients, including 40–60-year-old patients diagnosed and treated with primary frozen shoulder. The participants were divided into groups A (hydrodilatation) and B (hydrodilatation and the augmentation of an SSNB). Shoulder function and pain scores were assessed before, during, and after the intervention (at months 1 and 6). Results: The result of this study shows that suprascapular nerve block plays a role in decreasing pain in intraintervention (0.69 vs. 5.73; p < 0.05), month 1 of follow-up (3.44 vs. 6.40; p < 0.05), but not significant on month 6 of group A and B after intervention (5.88 vs. 7.20; p > 0.05). Better delta functional scores were noted in the therapy group during month 1 of the follow-up (delta American shoulder and elbow surgeons [ASES]: 19.29 vs. 34.40, p < 0.05; delta disabilities of the arm, shoulder, and hand [DASH]: 17.88 vs. 38.15, p < 0.05). The difference in functional score on month 6 between both groups was not significantly different (delta ASES: 31.97 vs. 30.31, p > 0.05; delta DASH: 36.63 vs. 38.92, p > 0.05). Discussion: One rationale for using an SSNB augmentation at spinoglenoid notch in hydrodilatation for treating frozen shoulder was to obtain pain relief immediately to facilitate early manual exercise. SSNB has positive effects on short-term evaluation of shoulder pain and function after glenohumeral hydrodilatation, but not in the long term.

The Efficacy of Manipulation with Distension Arthrography to Treat Adhesive Capsulitis: A Multicenter, Randomized, Single-Blind, Controlled Trial

Objective

To determine whether arthrographic distention combined with manipulation for frozen shoulder provides additional benefits.

Methods

A total of 180 participants from five clinical centers with pain and stiffness in predominantly 1 shoulder for >3 months entered the study, and 165 completed the study. The control group was treated with arthrographic distention alone, and the treatment group underwent manipulation after resting for 5 minutes following arthrographic distention. Patients were followed up at the one and two weeks and at three and six months. For the clinical evaluation, shoulder-specific disability measure (SPADI) score, the visual analog scales (VASs) for pain, and range of active motion were used.

Results

83 patients out of 90 in the treatment group and 82 out of 90 in the control finished the entire study period. SPADI, VAS, Constant-Murley (CM), and range of motion (ROM) were improved after treatments in both groups. The statistical differences were not observed in the CM, adduction, internal rotation, and posterior extension function between groups (P > .05) after the first treatment. And the statistical differences were not observed in the internal rotation, the extorsion, and posterior extension function (P > .05) after the second treatment.

Conclusion

Distention arthrography plus manual therapy provided faster pain relief, a higher level of patient satisfaction, and an earlier improvement in AROM of the shoulder than distention arthrography alone in patients with frozen shoulder.

Ultrasonography-Guided Common Musculoskeletal Interventions from Head to Toe: Procedural Tips for General Radiologists

The expanding scope of interventional musculoskeletal procedures has resulted in increased pressure on general radiologists. The confidence of general radiologists in performing ultrasound-guided musculoskeletal procedures varies with their clinical exposure. This didactic review provides a methodologically and clinically oriented approach to enhancing user understanding and confidence in performing ultrasound-guided musculoskeletal procedures. The body of the text is accompanied by figures depicting the procedural approach, injection site, and labeled ultrasonography images. This paper aims to provide a teaching and bedside aid for education on and the execution of musculoskeletal procedures to ensure the provision of quality health care.

Diabetes: a silent player in musculoskeletal interventional radiology response

Diabetes has an important role in the development of several musculoskeletal disorders, such as adhesive capsulitis of the shoulder (ACs) and stenosing flexor tenosynovitis of the finger (SfTf). The etiopathophysiology of ACs and SfTf in diabetic patients is associated with both chronic hyperglycemia, increased amounts of visceral adiposity and chronic inflammation. Chronic hyperglycemia stimulates the creation of cross-links between collagen molecules, impairing degradation and resulting in the build-up of excessive collagen deposits in the cartilage, ligaments, tendon sheaths and tendons. Increased adipocytes in diabetic patients secrete proteins and cytocines such as TNF-α, IL-6 and IL-13 which result in overproduction of pro-inflammatory factors, destruction of normal tissue architecture and fibrosis. Both hyperglycemia and adipocytes inhibit efferocytosis, limiting natural resolution. Recently, multiple image-guided interventional radiology musculoskeletal treatment options have been developed, such as ultrasound-guided glenohumeral capsule hydrodistension for ACs and ultrasound-guided percutaneous pulley release for trigger finger. Diabetes can negatively influence outcomes in patients with ACs and SfTf and may impact the decision of which specific procedure technique should be employed. Further studies are necessary to define how diabetes influences response to interventional radiology treatments of these disorders, as well as the extent to which control of blood sugar levels can contribute towards the personalization and optimization of patient follow up.

Current concepts of natural course and in management of frozen shoulder: A clinical overview

Frozen Shoulder (FS) by many specialists is still considered a benign, self-limiting condition, which usually resolves without intervention. This concept originated in the 70’, stating that FS will proceed from “the freezing” phase, with the predominance of inflammation and pain to “the frozen” phase with marked stiffness in the joint and “the thawing” phase, with a progressive return to the normal Range Of Motion (ROM) and function. Nevertheless, numerous authors have recently challenged this concept, arguing that most patients with FS will never fully recover, and suffer from residual pain and loss of function. Lack of early intervention, when a patient does not improve with conservative treatment, might lead to disability. We have discussed the recent concepts in the natural course of the disease and discussed both noninvasive and surgical methods in the treatment of FS.

Hydraulic distension as a treatment for patellofemoral pain syndrome (PFPS) non-responsive to standard rehabilitation

BACKGROUND

The occurrence of Patellofemoral Pain Syndrome (PFPS) is often found in daily medical care. Rehabilitation is usually applied with good results. However, patients often do not respond to standard rehabilitation, suggesting there may be some undetected factors that standard treatments cannot address. It is known that post-traumatic adhesive capsulitis in the knee often shows symptoms similar to those of PFPS, but idiopathic adhesive capsulitis (IAC) has seldom been mentioned as a possible cause of PFPS. Adhesive capsulitis in the shoulder joint causes frozen shoulder (FS), and hydraulic distension (HD) is often applied to FS effectively.

PURPOSE

The purpose of this study was to investigate and report on the clinical application of HD to treat PFPS non-responsive to rehabilitation treatment.

PATIENTS AND METHODS

HD was applied to 72 knees that had resisted regular conservative treatments for PFPS. Follow-up data (e.g. visual analogue scale) was collected immediately after HD, and at periods of 1, 3 and 6 months later.

RESULTS

Of the 72 patients, 64 patients obtained pain relief after HD. Pain was relieved for at least 6 months for 33 of the 64 patients. No benefit was received for 8 patients.

CONCLUSIONS

HD could be an additional conservative option for some PFPS that resisted rehabilitation. Assuming that the mechanisms of action for HD in the knee are the same as those in FS, there is evidence to suggest that IAC might play a role in the development of PFPS for some patients.

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.

Adhesive capsulitis: review of imaging findings, pathophysiology, clinical presentation, and treatment options

Adhesive capsulitis, commonly referred to as "frozen shoulder," is a debilitating condition characterized by progressive pain and limited range of motion about the glenohumeral joint. It is a condition that typically affects middle-aged women, with some evidence for an association with endocrinological, rheumatological, and autoimmune disease states. Management tends to be conservative, as most cases resolve spontaneously, although a subset of patients progress to permanent disability. Conventional arthrographic findings include decreased capsular distension and volume of the axillary recess when compared with the normal glenohumeral joint, in spite of the fact that fluoroscopic visualization alone is rarely carried out today in favor of magnetic resonance imaging (MRI). MRI and MR arthrography (MRA) have, in recent years, allowed for the visualization of several characteristic signs seen with this condition, including thickening of the coracohumeral ligament, axillary pouch and rotator interval joint capsule, in addition to the obliteration of the subcoracoid fat triangle. Additional findings include T2 signal hyperintensity and post-contrast enhancement of the joint capsule. Similar changes are observable on ultrasound. However, the use of ultrasound is most clearly established for image-guided injection therapy. More aggressive therapies, including arthroscopic release and open capsulotomy, may be indicated for refractory disease, with arthroscopic procedures favored because of their less invasive nature and relatively high success rate.