Hydrodilation Shoulder Joint

Other Names

• Capsular Distension
• Distension Arthrography

---

Background

• Description
  • Goal is to treatment adhesive capsulitis by 'distending' capsule and releasing fibrosis and adhesions
  • This procedure is performed under ultrasound guidance and alternatively, under fluoroscopic guidance
• General
  • Therapeutic and curative procedure for frozen shoulder which involves injecting a large volume of saline into the glenohumeral joint.
  • Typically also contains some combination of steroid, local anesthetic, and/or contrast material
• Other
  • In some studies, the authors distend the capsule until rupture is noted radiographically, while in others this is not the case.

Anatomy

• Structures visualized
  • Glenohumeral Joint
  • Spine of Scapula including suprascapular notch
  • Muscles: Deltoid, some degree of Infraspinatus, Supraspinatus
• Structures to avoid
  • Suprascapular Artery, Circumflex Scapular Artery, Suprascapular Nerve

---

Indications

Ultrasound of Hydrodilation

Adhesive Capsulitis

• Overall efficacy
  • Watson (2007): significant improvement in all outcome measures including pain, function and range of motion at 2 years
  • 2008 Cochrane review: “silver” level evidence that arthrographic distension with saline and steroid provides short‐term benefits in pain, range of movement and function in adhesive capsulitis
  • Clement (2013): 55% had normal or near normal shoulder function at 1 month, and at 14 months that number had risen to 63%
  • Lee (2015): In looking at other injectates that have been tested to treat adhesive capsulitis, Hyaluronic acid was not superior to corticosteroid injection or physical therapy for treatment in a recent systematic review of 4 RCT's.
• Compared to manipulation under anesthesia (MUA)
  • Queraishi (2007): compared MUA to hydrodilation. higher Constant scores in hydrodilation but similar range of motion at 6 months
    • However the hydrodilation group (94%) had a higher patient satisfaction rate compared to MUA (81%)
    • Added benefit of avoiding general anesthesia and risk of surgical injuries such as fracture or cuff injury
• Value in repeating procedure?
  • Trehan (2010): No difference in symptoms when repeat hydrodilation at 6 weeks in patients with partial relief from initial procedure

---

Contraindications

• Unknown

---

Procedure

US Demonstrating posterior approach to glenohumeral injection with needle visualized in joint

Equipment

• Basic procedural equipment
  • Syringes, Needles
• Medications (some combination)
  • Local Anesthetic
  • Injectable Corticosteroids
  • Contrast material if MRI planned
  • Sterile Saline
• Ultrasound Machine
  • Recommend ultrasound as it increases accuracy of needle placement into glenohumeral joint
  • Benefit over fluoroscopy: radiation free, offers real time needle guidance

Preparation

US demonstrating early hydrodilation with mild capsular distension

• Patient is typically lying on contralateral arm facing examiner
• Ipsilateral arm is internally rotated and adducted
• Follow all standard sterile precautions
  • Sterilize skin
  • Sterile gloves, probe cover

Posterior Approach Technique

US demonstrating post-hydrodilation with large capsular distension

• General
  • Recommended over anterior approach as it is easier, more effective
  • Less extravasation rate compared to anterior approach
• Patient positioning
  • Typically, the patient is in the lateral decubitus position on contralateral arm facing proceduralist
  • Ipsilateral arm is adducted, internally rotated resting on torso or lying against the side in neutral position.
  • Alternatively, this can be done with the patient seated upright or prone
• Pre-procedure
  • All procedural supplies should be setup prior to initiation
  • The shoulder should be sonographically evaluated as well to identify best approach and landmarks
  • Consideration for suprascapular nerve block for patient pain control during hydrodilation if goal of capsular rupture.
• Probe position
  • We recommend either a linear transducer or a curvilinear transducer depending on the body habitus of the patient
  • Position: over the long axis infraspinatus tendon to view the glenohumeral joint, all should be viewed simultaneously
  • The probe may need to be moved cranial-caudal or medial-lateral to identify best position

GIF of Hydrodilation. Note the capsule distending as more fluid is injected.

• Needle insertion
  • A 20-25 gauge needle, 2-3.5 inches is recommended; with larger gauge easier to inject large volumes
  • Needle will be oblique to probe, in plane and visualized in real time during procedure
  • It is introduced just lateral to the transducer, in an oblique lateral to medial direction, and guided into the glenohumeral joint space
  • Ideally, bevel is facing into the joint for the injection
• Injection
  • Initially, the capsule may only tolerate under 10 mL
  • After initial injection, wait 30-60 seconds and attempt to inject more
  • It takes typically somewhere between 10-55ml for rupture to occur, but can take up to 100ml in some cases.
  • No clear guidelines on whether capsular rupture is required or beneficial, although it has been hypothesized that capsular rupture helps by reducing the stretch on pain receptors in the capsule and periosteal attachments. If rupture does occur, it more often is at the subscapularis bursa, but has been seen down the bicep sheath as well
• Post-procedure
  • Remove needle
  • Tamponade any bleeding and apply bandage.

---

Aftercare

• Routine post injection care for intra-articular injections
• Continue other treatment modalities as prescribed by physician
• Consideration for close PT follow-up for manual stretching while joint is anesthetized for added tolerability with manual ROM and stretching.

---

Complications

• Persistent shoulder pain
• Need for additional treatment
• Rarely
  • Infection
  • Bleeding
  • Damage to other structures

---

See Also

• Procedures (Main)
• Shoulder Pain (Main)
• Ultrasound (Main)

---