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Hydrodistension – The Indian Summer for a Frozen Shoulder

Published 25 May 2017

Frozen shoulder- the condition

Frozen shoulder is a common problem suffered by approximately 2-5% of the population.1 The actual cause and reason some people suffer a frozen shoulder compared to others is unknown. It is however known that diabetic patients and patients who have suffered a stroke resulting in a loss of movement of the arm are more likely to be effected. It can also be related to an underlying problem within the shoulder but any of us could however wake up one morning with an excruciating shoulder that won’t move. The exact reason for this is still not fully understood.2

A frozen shoulder results in restricted movement of the shoulder with extreme pain which impacts upon a sufferer’s ability to carry out previously simple tasks as part of everyday daily activity such as putting on a jacket, pushing up to stand from a chair or washing their hair. The person may have never had any shoulder problems in the past, being previously fit and well. The new onset of an inability to lift their arm above head height is therefore greatly worrying and disabling.

Three phase to developing a frozen shoulder is thought to exist:

Freezing phase – in which pain in the shoulder and upper arm is experienced with gradual loss of shoulder movement in all directions.

Frozen phase in which stiffness reaches its maximum and the third and final phase being

_Thawing pha_se when range of movement returns to normal and pain finally subsides.3 4

Frozen shoulders most commonly occur in the 6th decade of life with females affected more than men. It may occur acutely or have a gradual onset with a minor injury seemingly triggering the process.5 Despite frozen shoulders being considered self-limiting, only approximately 50% of people have a full resolution of symptoms after 4 years.1 5 Despite most remaining symptoms being considered mild, loss of function is still experienced5 and 6% of sufferers have been found to have long term severe symptoms with those patients with most severe symptoms at onset suffering for a  longer period of time.5

What is Hydrodistension?

Many treatment options exist but no one treatment is universally accepted to restore all patients  range of motion and relieve pain.l1 The medical profession however continues to strive to discover a treatment which increases the functional capacity of the individual in the long term.6

Hydrodistension of the shoulder was first described in 1965 7 and since then many studies of the procedure have been undertaken. The procedure is also referred to as hydrodilatation, distension arthrography or hydrodistension and is considered a therapeutic intervention for a frozen shoulder.6 The treatment involves an injection of a large volume of saline (sterile salt water) to distend and rupture capsular adhesions.8 One theory as to how it decreases the pain is by stretching pain receptors in the shoulder rendering them less sensitive to pain9. A further theory is that the capsule is ruptures allowing better movement of the previously restricted joint.

Numerous different injection techniques have been used with the majority of research carried out so far involving imaging such as ultrasound to confirm that the needle is in the correct position within the shoulder joint.10. The volume of saline injected has varied within research between 10 to 90ml6 8 10-12 with better results being found when more than 15ml was injected.

A steroid injection is often offered for most patients with a frozen shoulder when physiotherapy fails to give sufficient benefit. Despite hydrodistension being used over half a century ago it is still not routinely carried in the UK with very few doctors trained to carry out the procedure. Thankfully in Newcastle and Sunderland, Dr Rae from www.SportsMedicineNE.com is one doctor who is able to offer the treatment.

Success of Hydrodistension

Hydrodistension has been compared to surgery for frozen shoulder with very favourable results. Hydrodistension avoids the need for an admission to hospital and risks associated with a general anaesthetic.10 A significantly greater improvement in the range of movement (ROM) of the shoulder and greater reduction in pain has been discovered following hydrodistension compared to manipulation under anaesthetic surgery8 10

Evidence suggests that a combination of physiotherapy following hydrodistension helps to reduce the pain and improve the range of movement compared to physiotherapy or hydrodistension alone16 17.

No significant complications or infections were reported in trials reviewed2 12 or procedures carried out by Dr Rae. It has been stated in some medical evidence that hydrodistension was more painful than a simple steroid injection.15 Dr Rae’s own anecdotal experience from carrying out the procedure over a number of years is that a hydrodistension injection is only mildly more uncomfortable than a steroid injection. Complications from the procedure are not considered to be any different to a routine steroid injection.9

Most studies evaluated patients up to 3 months following hydrodistension but Watson et al6 were able to confirm the effectiveness up to 2 years following the procedure,

Shoulder hydrodistension has been described as an “office procedure” which gives dramatic and immediate relief to patients suffering from a frozen shoulder.11 Medical evidence confirms that the procedure is relatively low-risk6 and effective treatment with earlier rather than later intervention resulting in a more favourable outcome.10

Dr Rae’s recent research, currently awaiting publication, confirms a statistically significant improvement in all movements of the shoulder following a hydrodistension injection. It also confirmed a 96% improvement in pain suffered at rest and 70% decrease in maximum pain experienced before hydrodistension compared to afterwards. All of the subjects had already failed to improve sufficiently with exercises and at least one standard steroid injection prior to trying hydrodistension procedure from Dr Rae

Dr Rae’s protocol at Sports Medicine NE

  1. Full assessment with Dr Rae in clinic to confirm or diagnose a frozen shoulder and discuss treatment options available.

  2. An X-ray prior to the procedure is recommended to rule out other possible coexisting conditions which may affect the success of the procedure. If this has already been carried out please bring a copy of the report with you.

  3. Planned appointment with Dr Rae for an ultrasound guided hydrodistension procedure. The procedure is carried in clinic under local anaesthetic. The procedure takes no longer than 15 minutes once all paper work and setting up of the equipment has been completed.

  4. Exercises should start within a few hours of the procedure to gain maximum benefit. Paracetamol or co-codamol analgesia is advised following the procedure.

  5. An appointment within 24 hours with the physiotherapist is essential to maximise the benefit of  the procedure. Follow up with the physiotherapists will be made depending upon the result gained.

  6. Review with Dr Rae 6 weeks post procedure is highly recommended

To book a consultation contact either Sports Medicine NE clinic at Newcastle or Spire Washington

Medical References

  1. Favejee MM, Huisstede BM, Koes BW. Frozen shoulder: the effectiveness of conservative and surgical interventions–systematic review. Br J Sports Med 2011;45(1):49-56.

  2. Bell S, Coghlan J, Richardson M. Hydrodilatation in the management of shoulder capsulitis. Australas Radiol 2003;47(3):247-51.

  3. Reeves B. The natural history of the frozen shoulder syndrome. Scand J Rheumatol 1975;4(4):193-6.

  4. Hannafin JA, Chiaia TA. Adhesive capsulitis. A treatment approach. Clin Orthop Relat Res 2000(372):95-109.

  5. Hand C, Clipsham K, Rees JL, Carr AJ. Long-term outcome of frozen shoulder. J Shoulder Elbow Surg 2008;17(2):231-6.

  6. Watson L, Bialocerkowski A, Dalziel R, Balster S, Burke F, Finch C. Hydrodilatation (distension arthrography): a long-term clinical outcome series. Br J Sports Med 2007;41(3):167-73.

  7. Andren L, Lundberg BJ. Treatment of Rigid Shoulders by Joint Distension during Arthrography. Acta Orthop Scand 1965;36:45-53.

  8. Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the frozen shoulder. A randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br 2007;89(9):1197-200.

  9. Jacobs LG, Barton MA, Wallace WA, Ferrousis J, Dunn NA, Bossingham DH. Intra-articular distension and steroids in the management of capsulitis of the shoulder. BMJ 1991;302(6791):1498-501.

  10. Sharma RK, Bajekal RA, Bhan S. Frozen shoulder syndrome. A comparison of hydraulic distension and manipulation. Int Orthop 1993;17(5):275-8.

  11. Halverson L, Maas R. Shoulder joint capsule distension (hydroplasty): a case series of patients with “frozen shoulders” treated in a primary care office. J Fam Pract 2002;51(1):61-3.

  12. Buchbinder R, Green S, Forbes A, Hall S, Lawler G. Arthrographic joint distension with saline and steroid improves function and reduces pain in patients with painful stiff shoulder: results of a randomised, double blind, placebo controlled trial. Ann Rheum Dis 2004;63(3):302-9.

  13. Rizk TE, Pinals RS, Talaiver AS. Corticosteroid injections in adhesive capsulitis: investigation of their value and site. Arch Phys Med Rehabil 1991;72(1):20-2.

  14. Tveita EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord 2008;9:53.

  15. Gam AN, Schydlowsky P, Rossel I, Remvig L, Jensen EM. Treatment of “frozen shoulder” with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial. Scand J Rheumatol 1998;27(6):425-30.

  16. Khan AA, Mowla A, Shakoor MA, Rahman MR. Arthrographic distension of the shoulder joint in the management of frozen shoulder. Mymensingh Med J 2005;14(1):67-70.

  17. Buchbinder R, Youd JM, Green S, Stein A, Forbes A, Harris A, et al. Efficacy and cost-effectiveness of physiotherapy following glenohumeral joint distension for adhesive capsulitis: a randomized trial. Arthritis Rheum 2007;57(6):1027-37.

  18. Vad VB, Sakalkale D, Warren RF. The role of capsular distention in adhesive capsulitis. Arch Phys Med Rehabil 2003;84(9):1290-2.

  19. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term follow-up. J Bone Joint Surg Am 1992;74(5):738-46.