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Effective Treatment for Frozen Shoulder: Ultrasound-Guided Hydrodilatation Explained

Frozen shoulder, also known as adhesive capsulitis, is a condition that leads to significant pain and restricted movement in the shoulder joint. This condition can severely impact a person’s ability to perform daily activities and maintain their quality of life. One effective treatment option for frozen shoulder is shoulder hydrodilatation, a minimally invasive procedure that involves injecting a saline solution into the shoulder joint to stretch the joint capsule, reduce pain, and improve mobility.


Ultrasound-guided hydrodilatation enhances the accuracy of this shoulder injection, ensuring that the treatment is administered precisely where it is needed. This technique has shown excellent results in relieving the symptoms of frozen shoulder and helping patients regain their range of motion.





Understanding Adhesive Capsulitis

Adhesive capsulitis, commonly referred to as frozen shoulder, is a condition characterised by stiffness and pain in the shoulder joint. This condition progresses through three distinct stages:

  1. Freezing Stage: During this initial stage, pain increases gradually, and shoulder movement becomes more restricted. This phase can last from six weeks to nine months.

  2. Frozen Stage: In this stage, pain may begin to diminish, but the shoulder remains stiff. Daily activities can become increasingly difficult. This phase typically lasts from four to six months.

  3. Thawing Stage: The final stage involves a gradual improvement in shoulder movement and a decrease in pain. Full recovery can take anywhere from six months to two years.


Adhesive capsulitis can occur without any apparent cause, but it is more common in individuals with certain risk factors, including diabetes, thyroid disorders, and a history of shoulder injuries or surgeries. The condition can also develop after periods of shoulder immobility, such as following a fracture or surgery around the shoulder.


The impact of frozen shoulder on daily life can be profound. Simple tasks such as dressing, reaching for objects, or even sleeping can become challenging due to the pain and limited range of motion. It is essential for individuals experiencing these symptoms to seek medical advice to manage the condition effectively.





What is Ultrasound-Guided Hydrodilatation for Frozen Shoulder?

Ultrasound-guided hydrodilatation is a minimally invasive procedure designed to treat adhesive capsulitis for persistent stiffness and pain. This technique involves the precise injection of a saline solution, often mixed with a corticosteroid, into the shoulder joint to stretch the joint capsule, relieve pain, and improve mobility.


How the Procedure Works

  1. Ultrasound Guidance: The procedure begins with the use of an ultrasound machine to visualise the shoulder joint. This imaging technique allows your doctor to scan the structures around the shoulder joint and accurately locate the joint space to ensure precise needle placement.

  2. Injection Process: Once the joint space is identified, a local anaesthetic is usually administered to numb the area. A needle is then inserted into the shoulder joint under continuous ultrasound guidance. The saline solution, often combined with a corticosteroid, is injected into the joint capsule. The injected fluid helps to expand and stretch the capsule, breaking down adhesions and scar tissue that contribute to the stiffness of frozen shoulder.

  3. Immediate Effect: Patients may experience immediate relief from pain due to the numbing effect of the anaesthetic. The corticosteroid helps reduce inflammation, while the saline solution stretches the capsule, improving the range of motion.




Comparison with Other Treatments

  • Physical Therapy: While physical therapy is often the first line of treatment for frozen shoulder, it can be a slow process and may not always provide adequate relief. Hydrodilatation can offer faster and more significant improvements in shoulder mobility.

  • Corticosteroid Injections Alone: Traditional corticosteroid injections can reduce inflammation but do not address the physical restriction caused by the tight joint capsule. Hydrodilatation combines the anti-inflammatory benefits of corticosteroids with the mechanical stretching of the capsule, providing a more comprehensive treatment.

  • Surgery: In severe or resistant cases of frozen shoulder that do not respond to other treatments, surgery (Arthroscopic Arthrolysis) may be considered. However, hydrodilatation is a less invasive option with fewer risks and a shorter recovery time.




Indications for Hydrodilatation

Ultrasound-guided hydrodilatation is primarily indicated for patients suffering from frozen shoulder who have not responded adequately to conservative treatments such as physical therapy, pain medications, or corticosteroid injections alone. The procedure is also suitable for individuals who want to shorten the course of the condition.


Ideal Candidates for Hydrodilatation

  1. Persistent Symptoms: Patients with persistent shoulder pain and restricted movement lasting more than three months despite conservative treatments are ideal candidates.

  2. Limited Range of Motion: Those with a severely limited range of motion in the shoulder, making it difficult to perform everyday tasks, can benefit significantly from hydrodilatation.

  3. Non-Surgical Preference: Patients who prefer a non-surgical approach to manage their frozen shoulder, avoiding the risks and recovery time associated with surgery.

  4. Underlying Conditions: Individuals with conditions like diabetes or thyroid disorders, which increase the risk of developing frozen shoulder, may also be considered for this procedure if they exhibit severe symptoms.


Contraindications

While ultrasound-guided hydrodilatation is a safe and effective treatment, it may not be suitable for everyone. Contraindications include:

  1. Infection: Active infection in or around the shoulder joint.

  2. Allergy to Injectables: Allergies to the medications used in the procedure, such as corticosteroids or local anaesthetics.

  3. Severe Osteoarthritis: Patients with advanced osteoarthritis in the shoulder may not respond well to this treatment as the cause for pain and stiffness could be osteoarthritis rather than frozen shoulder.


Before proceeding with hydrodilatation, a thorough assessment by your doctor is essential to determine if this treatment is appropriate for the patient’s specific condition and medical history.



Procedure Details

Pre-Procedure Preparations

Before undergoing ultrasound-guided hydrodilatation, patients should follow these preparatory steps:

  1. Medical Evaluation: A thorough medical history and physical examination are conducted to confirm the diagnosis of frozen shoulder and assess suitability for the procedure.

  2. Imaging Studies: Imaging studies, such as X-rays, ultrasound or MRI scans, may be performed to rule out other shoulder conditions.

  3. Medication Review: Patients should inform their healthcare provider about all medications and supplements they are taking, as some may need to be paused before the procedure such as anticoagulants.



Step-by-Step Description of the Hydrodilatation Procedure

  1. Positioning and Sterilisation: The patient is positioned comfortably, usually sitting or lying down, with the affected shoulder exposed. The skin over the shoulder is thoroughly cleaned and sterilised to minimise the risk of infection.

  2. Ultrasound Guidance: An ultrasound probe is used to visualise the shoulder joint. The real-time imaging helps in locating the exact point for needle insertion, ensuring accuracy.

  3. Local Anaesthetic: A local anaesthetic is administered to numb the skin and deeper tissues, minimizing discomfort during the procedure.

  4. Needle Insertion: Under continuous ultrasound guidance, a fine needle is carefully inserted into the shoulder joint. The ultrasound ensures the needle is accurately positioned within the joint capsule.

  5. Injection: The saline solution, often combined with a corticosteroid, is slowly injected into the joint capsule. Patients may feel pressure or mild discomfort as the fluid is introduced. The solution helps to stretch the joint capsule, breaking down adhesions and scar tissue.

  6. Monitoring: Throughout the injection, the healthcare provider monitors the procedure via ultrasound to ensure proper distribution of the fluid and to avoid complications.



Post-Procedure Care

  1. Observation: Patients are observed for a short period after the procedure

  2. Pain Management: Mild pain or discomfort at the injection site is common and can be managed with over-the-counter pain relief and ice packs.

  3. Activity Restrictions: Patients are typically advised to avoid strenuous activities involving the shoulder for a few days following the procedure.

  4. Physical Therapy: Engaging in a structured physical therapy programme is crucial to maximise the benefits of the procedure. Stretching and strengthening exercises help maintain the improved range of motion and prevent recurrence.


Expected Outcomes

Patients can expect to experience immediate pain relief due to the local anaesthetic, with further improvement over the following days as the corticosteroid reduces inflammation. The stretching effect of the saline solution leads to gradual restoration of shoulder mobility. Most patients notice significant improvement within a few weeks, allowing them to return to their regular activities with less pain and more shoulder movement.



Benefits and Risks

Benefits of Ultrasound-Guided Hydrodilatation

  1. Improved Accuracy: The use of ultrasound guidance ensures precise placement of the needle, enhancing the effectiveness of the hydrodilatation procedure.

  2. Immediate Pain Relief: The injection often includes a local anaesthetic, providing immediate pain relief.

  3. Enhanced Mobility: By stretching the joint capsule, hydrodilatation helps restore shoulder movement, making daily activities easier and less painful.

  4. Minimally Invasive: The procedure is less invasive compared to surgical options, reducing the risks associated with surgery and promoting faster recovery.

  5. Reduced Inflammation: The corticosteroid component of the injection helps reduce inflammation, contributing to long-term pain relief.

  6. Short Procedure Time: The entire process is typically completed within 30 minutes to an hour, allowing patients to return home the same day.


Risks and Complications

  1. Infection: Although rare, there is a small risk of infection at the injection site. Proper sterilization techniques minimise this risk.

  2. Bleeding and Bruising: Some patients may experience minor bleeding or bruising at the injection site.

  3. Pain or Discomfort: Temporary pain or discomfort during and after the injection is possible but usually subsides within a few days.

  4. Allergic Reactions: Allergic reactions to the injected substances, such as corticosteroids or anaesthetics, can occur but are uncommon.

  5. Nerve Damage: There is a minimal risk of nerve damage due to the needle insertion, especially if not guided accurately.

  6. Ineffectiveness: In some cases, the procedure may not provide significant relief, and additional treatments or alternative therapies might be required.

  7. Joint Instability: Rarely, overstretching the joint capsule can lead to temporary joint instability.


Mitigating Risks

To minimise the risks associated with ultrasound-guided hydrodilatation, it is crucial to:

  • Choose a doctor with the skill and experience in ultrasound-guided injections.

  • Follow post-procedure instructions

  • Monitor for signs of complications



Long-Term Recovery and Rehabilitation

  1. Physical Therapy: Engaging in a structured and tailored exercise programme focusing on stretching and strengthening the shoulder muscles is crucial for maximising the benefits of the procedure.

  • Stretching Exercises: Gentle stretching exercises help maintain the improved range of motion and prevent stiffness from recurring.

  • Strengthening Exercises: Building shoulder strength is important for overall joint stability and function.

  1. Follow-Up Appointments: Regular follow-up appointments with your doctor are important to monitor progress and adjust the treatment plan as necessary.

  2. Monitoring Symptoms: Patients should keep track of their symptoms and report any persistent or worsening pain, swelling, or reduced mobility to their healthcare provider.


Conclusion

Ultrasound-guided hydrodilatation is an effective treatment for frozen shoulder, offering pain relief and improved mobility. Patients not responding to conservative treatments can benefit greatly. Ultrasound guidance enhances injection accuracy, ensuring optimal results and minimising risks. Structured physical therapy post-procedure is essential to maintain range of motion and prevent frozen shoulder recurrence. Regular follow-up appointments are crucial to monitor progress and address issues promptly.


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About the Author: Dr. Mustafa Alnaib MBChB, MRCS, MSc, FEBOT is an orthopaedic surgeon, musculoskeletal doctor and Clinic Director at ACTIVATE Musculoskeletal Clinic in Kent


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