“Frozen shoulder,” most often caused by adhesive capsulitis, is frequently treated with intraarticular steroid injections, physical therapy, and surgical manipulation under anesthesia. These therapies provide limited benefits. Hydraulic distension of the shoulder joint capsule (hydroplasty) has potential to provide rapid relief of pain and immediate improvement of shoulder function for patients with adhesive capsulitis. We performed 21 hydroplasty procedures on 16 patients over a 4-year period. Ninety-four percent (17/18) of the procedures improved patients’ measured mobility immediately after the procedure. Fifty-three percent (10/19) of the procedures produced immediate, short term, and sustained improvement in comfort and function. No significant complications of the procedure were detected. Our series suggests that the hydroplasty procedure should be further evaluated.
“Frozen shoulder” is a clinical diagnosis frequently made for patients with shoulder pain and limited motion. Adhesive capsulitis is the most likely cause of the frozen shoulder syndrome in middle-aged adults.1 This pathophysiologic process involves joint capsular contraction from intraarticular adhesion of synovial folds. The medical literature frequently regards frozen shoulder and adhesive capsulitis as synonyms.
Although many treatment options have been proposed for the frozen shoulder syndrome, each has limitations. Home exercises may not improve the rate of natural recovery.2,3 Benefits from intensive physical therapy are slow.4 Manipulation while anesthetized can be effective, but significant complications have been documented and publications report protracted recovery.5 Injection of intraarticular steroids may benefit some patients, but this hypothesis is based on few quality studies.4,6 Arthroscopic release done under general anesthesia is invasive and few patients’ outcomes are reported.7,8
An infrequently cited option is hydraulic joint capsule distension under local anesthesia (hydroplasty). This is an office technique without arthrography, and was initially reported by Fareed and Gallivan9 in a case series of 20 patients. The patients in this report noted immediate pain resolution, return to normal sleep, and return of normal function. Benefits persisted for up to 10 years. Variations of this intervention are described in the orthopedic literature and results are favorable.10,11 We found no publications addressing the use of hydroplasty in a primary care office. In this study, we performed this procedure on a series of patients in a family medicine residency clinic.
Methods
Enrollment and data collection
We offered hydroplasty to a group of patients suffering from stiff and painful shoulders with limited range of motion (ROM) in a capsular pattern (reduced external rotation, abduction, and internal rotation) and pain in the C5 dermatome that had persisted for at least 1 month.12 Informed consent was obtained from patients who underwent the procedure.
Demographic and medical information was collected for all participants. One of the authors (RM) or a trained associate systematically measured pre-and post-procedure ROM on 18 of 21 procedures. Because of scheduling difficulties, 3 patients were not measured immediately before and after the procedure. Hydroplasty procedures were performed or supervised by the other author (LH). Subsequent information was collected during consultations after the procedure. Prior to this report, current shoulder status was assessed by telephone.
Hydroplasty technique
The hydroplasty procedure we used was adapted from Fareed.9 The anterior shoulder is prepped with the patient in a supine position. The affected humerus is externally rotated as tolerated. The glenohumeral crease is palpated to identify a subcoracoid window to enter the joint space. The skin is anesthetized using 1% lidocaine. The joint space is entered with an 18-gauge 1.5-inch needle angling slightly medially and superiorly, pointing toward the presumptive center of the glenoid fossa. Once the joint space is entered, approximately 5 ml of 1% lidocaine is injected. Minimal plunger resistance during this injection helps ensure joint space entry. With a severely contracted joint capsule, more plunger resistance may be encountered. One ml of triamcinolone (40 mg) is injected. Then up to 40 ml of sterile, chilled saline are forcibly injected into the joint space using 10-ml increment syringes. Clear fluid efflux from the needle is usually seen when syringes are changed. A sensation of reduced resistance to injection during saline injection suggests capsular distension or rupture.
Results
The hydroplasty procedure was offered and performed on 21 shoulders of 16 patients over 4 years. Subjects ranged in age from 37 to 76 years. Eleven female and 10 male shoulders were treated. Two patients had both shoulders treated, and 3 patients had the same shoulder treated on 2 separate occasions. One or both of the authors reevaluated 15 of 16 patients approximately 1 week (range 1 to 6 weeks) subsequent to the procedure.
ROM increased immediately post-procedure in 17 of 18 procedures in which measurements were recorded. The sum of changes in external rotation and internal rotation is reported in the Table. One patient experienced decreased ROM following a painful injection, but return to baseline of pain, motion, and function occurred within 24 hours.