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Adhesive capsulitis occurs due to thickening and fibrosis of the coracohumeral ligament (CHL), glenohumeral ligament, rotator interval (RI), and axillary joint recess.
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The condition is more common in middle-aged females with a history of diabetes mellitus but is also linked to collagen vascular disease, thyroid disease, rheumatologic disorders, trauma, and surgery.
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Course is reportedly self-limiting but may persist for up to 18 to 24 months or longer.
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If conservative measures fail, hydrodistention may be considered as a treatment option. Hydrodistention has been found to be superior to manipulation under anesthesia (MUA) in one study and superior during earlier stages of disease and treatment course.
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Recommend using high-volume saline and anesthetic rather than corticosteroid for distention due to risk of chondrotoxicity, hyperglycemia in diabetes mellitus, labile hypertension, and lack of superior benefit with addition of steroids.
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Use a 20- to 25-gauge 3.5-inch or 10-cm needle for an out-of-plane approach to the glenohumeral joint (GHJ) during injection (authors’ preferred method due to decreased tissue disruption).
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Perform preprocedure and postprocedure shoulder joint range of motion testing.
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Perform proprioceptive neuromuscular facilitation (PNF) and active release therapy (ART) immediately following the procedure and start physical therapy (PT) within 2 to 4 hours after procedure for maximal sustained benefit of capsular distention.
Anatomy
The glenohumeral joint (GHJ) is a diarthrodal joint, stabilized by the capsule, glenohumeral and coracohumeral ligaments (CHLs), glenoid labrum, and rotator cuff musculature. The rotator interval (RI) is a tendinous triangular gap covered exclusively by capsular tissue. It is bordered by the supraspinatus tendon superiorly, subscapularis tendon inferiorly, and coracoid process medially. The RI contains the long head of the biceps tendon. The joint capsule is reinforced by the CHL and superior glenohumeral ligament (SGHL) in this location, forming the “biceps pulley.” The RI contributes to stabilization of the joint and the biceps tendon. The inferior portion of the GHJ capsule is termed the “axillary recess” and lies between the anterior and posterior bands of the inferior glenohumeral ligament (IGHL) ( Fig. 25.1A ) .
Common Pathology
Adhesive capsulitis (AC), or “frozen shoulder,” can be a debilitating condition, affecting 2% to 5% of the population, middle-aged females more than males. Risk factors include diabetes mellitus (13.4% prevalence of AC), thyroid disease, rheumatologic disorders, collagen vascular disease, and Parkinson disease. Secondary AC often results from surgery or trauma. The course of AC is typically self-limiting but may persist upward of 18 to 24 months or longer for full resolution through the three characteristic phases: freezing stage, frozen stage, and thawing phase. In addition, it has been suggested that there is a higher incidence of contralateral AC in the future in younger patients (<50 years old) and those with diabetes.
Arthroscopic findings in AC include replacement of the subscapularis recess with scar tissue, tightened axillary recess, reduced joint fluid volume, and contracture of RI and CHL. Histopathologic appearance demonstrates tissue similar to that found in Dupuytren contracture, consisting of dense type III collagen, fibroblasts, contractile myofibroblasts, and neovascularization. Clinically, external rotation is typically affected first and progresses to include limitations in flexion, abduction, and internal rotation.
Imaging
Magnetic resonance imaging (MRI) or ultrasound (US) imaging is preferred over x-ray to rule out significant rotator cuff tear or other pathology prior to interventional treatment. MRI and MR arthrography (MRA) can demonstrate thickening of the CHL, thickening and reduction in the size of the axillary recess or RI, and obliteration of the subcoracoid fat triangle. Similar pathologic thickening may be seen on US (higher sensitivity with US arthrography than US alone) as well as hypoechoic soft tissue and hypervascular synovium on power Doppler within the RI. ,
Treatment Options
Typically, the first-line treatment for AC is physical therapy (PT), including strengthening, stretching, mobilization, US, and medications such as nonsteroidal antiinflammatory drugs (NSAIDs) or oral steroids. , The authors recommend pursuing injection therapy after at least 6 weeks of conservative measures and advanced imaging. Although hydrodistention has shown improved efficacy in the earlier stages of treatment, it may not be approved by insurance prior to a course of conservative treatment. RI, subacromial, and intra-articular steroid injections can also be performed. , There is no proven difference in outcome after subacromial versus intra-articular injection. ,
Capsular hydrodistention under pressure has long been regarded as an effective treatment option to rapidly improve range of motion (ROM) in AC by stretching or rupturing the contracted joint capsule. There is no consensus on the inclusion of corticosteroid within the injectate. In some studies, hydrodilation with cortisone has been shown to have better outcomes in pain and ROM compared with intra-articular or subacromial steroid injections or hydrodilation alone. However, the study that found dilation to be inferior to intra-articular corticosteroid only used a volume of 9 mL for dilation, which is inadequate to cause capsular distention. Although the use of corticosteroid may aid in reducing inflammation due to capsular stretch during hydrodistention and reduce risk of recontracture of the capsule, , the authors have had very successful results with use of anesthetic and saline alone and prefer to avoid the chondrotoxic effects of steroid when possible. , In addition, avoiding steroid is essential in the setting of poorly controlled diabetics, labile hypertension, and steroid sensitivity. Dilation of the joint capsule with the goal of capsular rupture is controversial because there is no evidence that rupture is required for desired outcome. Some studies have even shown that capsular preservation may actually result in increased ROM and decreased pain in the short term. , The volume used for hydrodilation has widely ranged from 10 to 90 mL, most commonly in the 25- to 50-mL range. , , , The authors recommend avoiding intentional capsular rupture by monitoring for backflow of injectate in the syringe and patient’s tolerance to pressure during injection. Another described hydrodilation approach is via the rotator cuff interval. One study by Yoong et al. showed good results in the treatment of AC with rotator cuff interval hydrodilation with 21 mL of combination of local anesthetic and steroid; however, the authors have not had clinic experience with this technique. Orthobiologic treatments such as platelet-rich plasma (PRP), platelet lysate, and platelet-poor plasma (PPP) can also be considered as dilation solutions due to antiinflammatory and chrondroprotective cytokines, and one study showed that intra-articular PRP injection had better results for AC compared with steroid injection. , Although there is a paucity of data for use in AC, the editors have had good success using platelet lysate and PPP to replace saline for dilation solution in practice.
Another option if conservative measures fail is manipulation under anesthesia (MUA), which has been found to be inferior to hydrodistention in regards to pain and ROM in one study. , MUA should be avoided in elderly osteoporotic patients due to the risk of fracture. If MUA fails, arthroscopic capsular release of the CHL, anterior capsule, and subscapularis bursa can be pursued. This technique may be challenging with tighter capsular contracture due to difficulty inserting the arthroscope. Although arthroscopic capsular release has been shown to have slightly better outcomes than hydrodistention, both arthroscopy and MUA require general anesthesia, increasing the risk of adverse outcomes in certain populations.
Indications for High-Volume Ultrasound-Guided Injection for Adhesive Capsulitis
Patient Selection
Candidates for capsular hydrodistention or high-volume ultrasound-guided injection (HVUGI) are those with AC who fail at least 6 weeks of conservative PT, modalities, and medication management, unless conservative measures are contraindicated or there are severe functional limitations. Hydrodistention has been found to have improved efficacy in the early stages and in those with less severe limitations in ROM at the time of procedure (“freezing” rather than “frozen” stage) but may not be approved by insurance prior to a trial of conservative treatment. Long-term outcomes with HVUGI may be less favorable in diabetic patients.
Authors’ preferred diagnostic criteria for AC include greater than 25% reduction of passive ROM in two or more of the four cardinal shoulder motions (internal rotation, external rotation, abduction, and extension) without another explanation for the loss of motion, such as GHJ osteoarthritis or impingement. Preprocedurally, we test and record the degree of shoulder motion in abduction, external rotation, internal rotation, and extension, as well as the Apley scratch test. We perform GHJ ROM testing with the scapula fixed and shoulder in 90 degrees of abduction (or at end range if patient cannot achieve 90 degrees) and elbow in 90 degrees of flexion. Normal ROM in this position is at least 45 degrees of internal rotation, 90 degrees of external rotation, 90 to 110 degrees of abduction (isolated GHJ), and 45 to 60 degrees of extension.
Equipment
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Musculoskeletal US machine with a high-frequency linear or curvilinear array transducer (10 to 18 MHz preferred)
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Sterile probe cover and sterile US gel (entirely sterile procedure recommended)
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Sterile gloves
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ChloraPrep cleansing solution sticks × 2
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Two extension tubing sets
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Syringes: 10 mL, 20 mL, 60 mL
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Needles: 18-gauge 1.5-inch needle (to draw medications); 25-gauge 1.5-inch needle (for local anesthesia); 20- to 25-gauge 3.5-inch or 20-gauge 10-cm Chiba (Cook Medical, Bloomington, IN) or 2- to 3.5 inch spinal needle (for injectate)
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Injectate:
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Up to 12 mL of local anesthetic for the skin and extra-articular soft tissue such as 1% lidocaine without epinephrine.
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10 mL of preferred intra-articular anesthetic
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Recommend use of ropivacaine 0.5% over bupivacaine and especially lidocaine due to risk of chondrotoxicity with intra-articular injection.
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50 mL of preservative-free 0.9% normal saline solution or preferred dilation solution (connected to tubing and primed, Fig. 25.2B )
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