Frozen Shoulder: Hydrodistention & Steroid Injections

Hydrodilatation (Hydrodistension) Frozen shoulder

What is a Frozen Shoulder?

What is a frozen shoulder?

Frozen shoulder (sometimes called adhesive capsulitis) refers to inflammation and stiffness of the shoulder joint capsule. The shoulder joint is a ball and socket type of joint. The ball is the humeral head (the upper end of the arm bone), and the glenoid is the part of the shoulder blade that articulates with the humerus. The natural anatomy of the shoulder joint gives it a significant degree of mobility to accommodate a wide range of movement. The shoulder joint is surrounded by a thin layer of tissue (joint capsule). The inflamed and stiff joint capsule in the frozen shoulder will restrict shoulder movement. The condition is usually associated with shoulder pain significantly interfering with activities and sleep.

What are the causes/risk factors for frozen shoulder?

The cause and mechanism for frozen shoulder are not clear. It can be seen following:

Shoulder injury, including shoulder fracture dislocation and rotator cuff injury.
Shoulder surgery
It is also more common in diabetic patients with inflammatory arthritis and Dupuytren’s contracture.
It can be seen without an obvious reason.

What are the stages of frozen shoulder?

Routinely, there are three stages in a frozen shoulder. However, each can vary in duration, and a frozen shoulder generally can last up to 2 years.

Painful stage. The shoulder feels painful, with a gradual increase in shoulder stiffness.
Stiff stage. The shoulder becomes very stiff, significantly limiting shoulder movement
Unfreezing (thawing) stage. The shoulder pain starts to ease gradually, and the movement is regained.

The whole cycle of a frozen shoulder may take months (or years), and one study suggested that only around 60% of patients would regain their baseline function after four years.

What are the symptoms of frozen shoulder?

The features of a frozen shoulder depend on the stage of the condition and usually consist of pain and significant restriction of shoulder movement.

How is a frozen shoulder diagnosed?

Frozen shoulder is mainly a clinical diagnosis. So, the diagnosis is usually established based on the clinical findings. Imaging is primarily used to rule out other causes of shoulder pain, like rotator cuff tear, shoulder osteoarthritis and shoulder calcification (calcific tendonitis). An X-ray will be normal in a frozen shoulder, but it is useful in ruling out osteoarthritis (wear and tear changes to the shoulder joint). MRI can be helpful for the assessment as it can show signs suggestive of frozen shoulder changes like capsular thickening and inflammation. Ultrasound also can show features of shoulder inflammation (capsulitis), but most importantly, it will assess the rotator cuff tendons and rule out an associated tear. In addition, ultrasound is beneficial when performing a hydrodilation/hydrodistension procedure. Overall, imaging assessment in suspected frozen shoulder cases consists of an x-ray to assess the shoulder joint, followed by an ultrasound examination to rule out the presence of any rotator cuff tear and evaluate for any features of capsulitis.

What are the mimics of frozen shoulder?

Other shoulder problems that can have a similar presentation and be mistaken for a frozen shoulder include:

How to treat frozen shoulder?

The treatment usually starts by doing physiotherapy. This includes stretching exercises and manual techniques to help mobilise the shoulder joint. These are particularly useful for the “stiff stage” of the frozen shoulder. Evidence shows that conservative management has limited effect during a frozen shoulder's first “painful stage”.

Management also includes education and modification of daily activities (for example, using supportive pillows under the shoulder when you sleep and taking regular breaks during the day to rest your shoulder). Anti-inflammatory tablets can also be used to help reduce the inflammation in the joint.

Do shoulder injections help with a frozen shoulder?

If the symptoms are severe and do not respond to the measures described above, particularly if the pain affects your sleep, daily activities, and sports. In that case, a frozen shoulder injection can be helpful. In frozen shoulder, patients may struggle to have efficient rehabilitation. A shoulder injection is indicated in such cases to help undertake a more effective physiotherapy program, and there is strong evidence that having a Frozen shoulder injection followed by a dedicated physiotherapy program (within a couple of weeks) is very effective. Injection therapy is particularly useful during the “painful stage” of a frozen shoulder as the pain can be severely restrictive with very little response to conservative management. Ultrasound-guided shoulder injection for managing a frozen shoulder is a well-recognized treatment option recommended by NICE guidelines.

We recommend doing shoulder injections under imaging guidance (either ultrasound or x-ray). Ultrasound is our preferred choice as it does not involve radiation and is very accurate when performed by an experienced doctor. We always recommend performing shoulder injections under ultrasound guidance to ensure accurate placement of the needle into the shoulder joint at the site of inflammation. Ultrasound guidance results in a more accurate, less painful and faster procedure, with better outcomes, than performing these injections without guidance.

What type of injection is helpful for a frozen shoulder?

Mainly, two types of injections can be used to treat a frozen shoulder.

Ultrasound-guided shoulder steroid injection

A long-acting type of cortisone (called Kenalog or triamcinolone acetonide) is injected into the shoulder under ultrasound guidance. Steroids are potent anti-inflammatory medicines and help by reducing the inflammation in the shoulder joint and shoulder capsule and give you a window of opportunity to undertake an effective physiotherapy program and achieve good recovery. The Steroid Injection For Frozen Shoulder is usually mixed with numbing medication in this procedure.

Ultrasound-guided hydrodistension (hydrosilylation)

Hydrodistension Injection is a particular procedure used to treat frozen shoulder/adhesive capsulitis. In addition to injecting cortisone and numbing medicine, a high volume of sterile (clean) water (approx. 20 MLS) will be injected inside the shoulder joint under ultrasound guidance. This aims to distend the inflamed and thickened joint capsule and reduce the inflammation via the steroid effect. To find out more, please see our article about shoulder hydrodistension.

The evidence is unclear about which injection is more effective for treating a frozen shoulder. Ultrasound-guided hydrodistension injection is increasingly used to treat frozen shoulder, particularly during the “stiff stage”, as the procedure will help stretch the thick and stiff joint capsule and reduce the inflammation. Ultrasound-guided steroid injection for frozen shoulder is considered during the frozen shoulder's initial (painful stage).

Some studies researching the effectiveness of Hydrodilatation vs. Steroid Injections have found that hydrodilatation and steroid injections are the most effective management technique for frozen shoulder.

How many injections can I have for a frozen shoulder?

Most patients notice a significant improvement from one frozen shoulder injection, followed by a dedicated physiotherapy program to treat frozen shoulders. However, in about 10% of the cases, the symptoms of a frozen shoulder are severe, and the patient can notice partial improvement. This is more commonly seen in diabetic patients. In such cases, a second injection can be considered. However, we always try to avoid a second injection, and routinely we would not consider a repeat injection until 3-4 months from the last one. To learn more, please see our article about How many frozen shoulder steroid injections can I have?

Can I get frozen shoulder twice?

It is very uncommon to have a frozen shoulder twice in the same shoulder. However, there is a possibility of having a frozen shoulder on the other side (approximately 17% within five years).

Is surgery useful for a frozen shoulder?

Nowadays, surgical treatment is rarely used for frozen shoulders. It involves cutting the thick capsule via keyhole surgery. The name of the procedure is (shoulder capsular release). There is no significant difference in the long-term outcome compared to physiotherapy and injection therapy, so surgical treatment is rarely considered.