Glenohumeral joint hydrodilatation

Glenohumeral joint (shoulder) hydrodilatation or tension arthrography is an established treatment for adhesive capsulitis of the shoulder (frozen shoulder) and can be performed using a variety of modalities. 

Indications

• adhesive capsulitis of the shoulder

Contraindications

• anticoagulation/coagulopathy
• systemic sepsis
• allergies to contrast, steroid or local anesthetic
• acute trauma

Procedure

Preprocedure evaluation

• history and examination, particularly noting the range of movement of the affected shoulder
• informed consent
• review prior imaging

Equipment

Equipment, set up and positioning is as per routine glenohumeral joint injection.

Injectate

Typically a normal shoulder will accommodate 8-15 mL of fluid, however, in adhesive capsulitis that amount will be reduced to below 7 mL. As such it is difficult to predict how much volume is required. A variety of formulations and sequence of administration of the injectate vary among practitioners. 

A typical combination would be as follows: 

1. 2 mL of undiluted contrast to confirm intra-articular location
2. steroid and local anesthetic mixture
   • 1-2 mL of long-acting steroid (e.g. triamcinolone, methylprednisolone, betamethasone)
   • 8-10 mL of long-acting local anesthetic (e.g. bupivacaine, ropivacaine)
3. normal saline +/- additional contrast if additional volume is required 

Technique

A routine glenohumeral joint injection is performed. Following confirmation of intra-articular position with a small amount of contrast (avoid over-injecting as there may not be enough room for the steroid and local anesthetic), the glenohumeral joint is maximally distended, first using steroid/long-acting local anesthetic mixture followed by injection of additional normal saline if the joint volume is large. 

The volume injected is generally accepted as maximally tolerated by pain, until capsule rupture or full distension of subscapular bursa ¹. It is important to note that although initial research suggested that capsular rupture had to be achieved for effect ³, this is no longer believed to be the case ⁸. 

Postprocedural care

The patient should be assessed in regards to their range of motion, which should be improved. Care should be taken for the first 48 hours with no heavy or overhead lifting. Follow-up should be with referring doctor and physiotherapist. 

Complications

Bleeding (hemarthrosis) and infection (septic arthritis).

Outcomes

Adhesive capsulitis is considered a self-limiting disease with the aim of hydrodilatation to reduce the duration of pain and limited range of motion in the short- and medium-term.

The benefit of shoulder hydrodilatation compared to steroid injection alone or other conservative treatment has not been established with several studies demonstrating mixed results ^5,6.