1 81

2 82
3 83
4 84
5 85
PM R XXX (2017) 1-13
6 www.pmrjournal.org 86
7 87
8 Analytical Review 88
9 89
10 90
11
12
Hydrodilatation With Corticosteroid for the Treatment of 91
92
13
14
Adhesive Capsulitis: A Systematic Review 93
94
15 95
16 96
17 Q16 Michael Catapano, BHSc, MD, Nimish Mittal, MBBS, MD, 97
18 98
19 John Adamich, BHSc, MD(C), Dinesh Kumbhare, MD, MSc, FRCPC, DABPMR, 99
20 100
21
Harpreet Sangha, MD, FRCPC, Dip CSCN (EMG) 101
22 102
23 103
24 104
25 105
26 106
Abstract
27 107
28 108
29 Background: Current evidence suggests that corticosteroid injection alone expedites the recovery of pain-free range of motion 109
30 (ROM) in patients with adhesive capsulitis compared to physiotherapy or placebo. However, it remains unclear whether the 110
31 111
32 addition of hydrodilatation with corticosteroid provides improvement in pain-free ROM as well as pain relief. 112
33 Objective: A review of the literature was conducted to determine whether the combined intervention of hydrodilatation and 113
34 corticosteroid injection expedites restoration of pain-free ROM compared to a control treatment of corticosteroid injection in 114
35 115
36
patients with adhesive capsulitis. 116
37 Methods: EMBASE, MEDLINE, and CINAHL were searched from database inception to January 2017. Relevant studies were 117
38 determined as randomized controlled trials written in English, comparing the outcomes of hydrodilatation and corticosteroid 118
39 injection to a control group treated with corticosteroid injection alone in patients with adhesive capsulitis. Two independent 119
40 120
41 reviewers assessed manuscripts for study inclusion and extracted data. 121
42 Results: A total of 2276 studies were identified through the search, of which 6 randomized controlled studies (involving 410 122
43 shoulders) met criteria for inclusion in this review. Mean age ranged from 51-61 years, with mean symptom duration of 4-9 123
44 124
45
months. Studies varied significantly regarding the volume of injectate, anatomical injection approach, symptom duration, and the 125
46 method of glenohumeral capsule distension (capsular rupture versus preservation). Two studies demonstrated clinically and 126
47 statistically significant improvement in the combination group at 3-month follow-up, and one study demonstrated clinically 127
48 128
significant improvement only in ROM and/or pain/functional scales, compared to 3 studies demonstrating no benefit when
49 129
50 compared to corticosteroid injection alone. 130
51 Conclusion: Combining hydrodilatation with corticosteroid injection potentially expedites recovery of pain-free ROM. The 131
52 greatest benefit is experienced within the first 3 months of intervention. Differences in hydrodilatation techniques, inclusion of 132
53 133
54 capsular preservation, anatomical approach, and length of symptoms may explain the variability in efficacy demonstrated. 134
55 Further trials using larger sample sizes, better anatomical approaches, image guidance, and hydrodilatation techniques are 135
56 required to determine the true nature of benefits of hydrodilatation with corticosteroid injection. 136
57 137
Level of Evidence: To be determined.
58 138
59 139
60 140
61 141
62 142
63 143
64 Introduction are otherwise active and healthy [4]. Persistent func- 144
65 tional limitations and pain at longer follow-up periods 145
66 146
67
Adhesive capsulitis affects 2%-5% of the population [5] have been reported, suggesting that a significant 147
68 [1] and is a difficult condition to treat, resulting in sig- portion of patients may be left with residual deficits [6]. 148
69 nificant patient morbidity [2,3]. Adhesive capsulitis is Despite the prevalence of adhesive capsulitis, the 149
70 150
71 characterized by severe pain that is associated with pathologic response and biochemical progression of 151
72 both active and passive reduction in passive range of disease within the glenohumeral joint remains uncer- 152
73 153
74 motion (ROM) of the glenohumeral joint [2]. Patients are tain. Current research has demonstrated that pain and 154
75 typically symptomatic ranging from 6 months to 2 years limited ROM are due to a reduction in capsular volume 155
76 156
77
during their fifth or sixth decade of life, whereas they of the glenohumeral joint from a healthy volume of 157
78 158
79 1934-1482/$ - see front matter ª 2017 by the American Academy of Physical Medicine and Rehabilitation 159
80 https://doi.org/10.1016/j.pmrj.2017.10.013 160

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 2 Hydrodilatation for Adhesive Capsulitis Q1

161 28-35 mL to about 5-10 mL in the diseased state [7]. The Meta-analysis (PRISMA) guidelines. MEDLINE, EMBASE, 241
162 242
163 initial painful stage is characterized by hypertrophic, and CINAHL were searched from database inception to 243
164 vascularized synovitis without adhesions or capsular January 1, 2017, for articles addressing hydrodilatation 244
165 245
166
contracture [8]. Synovial biopsy findings have added for adhesive capsulitis of the shoulder. The search 246
167 significantly to our understanding by demonstrating an criteria were adapted from previously published sys- 247
168 inflammatory profile, including chronic inflammatory tematic reviews to be more inclusive [17]. The search 248
169 249
170 infiltrate, absence of a synovial lining, moderate to clause for EMBASE is presented in Figure 1. Systematic 250
171 extensive subsynovial fibrosis, and perivascular lym- article screening was performed independently and in 251
172 252
173
phocytic reaction [9]. Capsular contracture appears to duplicate, from titles through to full text by 2 of the 253
174 be the hallmark of the frozen stage, the second stage of authors (M.C. and J.A.) and recorded in Covidence 254
175 adhesive capsulitis, characterized histologically by (2016). Only articles published in English were included. Q2 255
176 256
177 deposition of disorganized collagen fibrils with hyper- Criteria for inclusion were as follows: Level I evidence; 257
178 cellular collagenous tissue, patchy synovial thickening, hydrodilatation with corticosteroid injection group; and 258
179 259
180 and loss of axillary recess with absence of inflammatory intra-articular corticosteroid injection control group. 260
181 infiltrates [8]. Exclusion criteria were systematic reviews; Level II ev- 261
182 262
183
Adhesive capsulitis is often managed conservatively, idence or lower; and animal models or cadaveric 263
184 with an approach that may include pain management and studies. Throughout the title and abstract screening 264
185 physiotherapy [10]. However a multitude of interventions stages, any article with discordance between reviewers 265
186 266
187 have been trialed to expedite recovery, including intra- was included to ensure that no relevant articles were 267
188 articular corticosteroid injection, manipulation under prematurely excluded. The reviewers discussed any 268
189 269
190
anaesthesia, arthroscopic release, suprascapular nerve disagreements at the full-text stage and if consensus 270
191 blocks, and hydrodilatation [8]. Intra-articular cortico- was not reached, a third reviewer provided input 271
192 steroid injections into the glenohumeral joint have been regarding each article’s eligibility. The reference lists of 272
193 273
194 definitely demonstrated, in multiple randomized all included studies were additionally screened to 274
195 controlled trials, to result in early return of pain-free obtain more relevant articles. Data extraction was done 275
196 276
197
ROM compared to both placebo and conservative treat- in duplicate. The PEDro Scale [18] was used to assess the 277
198 ment [11-16]. The addition of hydrodilatation to the quality of the included studies. This scale has been 278
199 standard of care (ie, corticosteroid injection) may work validated in the evaluation of multiple physical medi- 279
200 280
201 synergistically to improve adhesive capsulitis outcomes cine interventions using an 11-point criterion. Clinical 281
202 by providing an immediate expansion of the capsule that trials are scored based on clarity of eligibility criteria, 282
203 283
204 can be maintained through either sustained hydraulic allocation, equivalency of baseline demographics be- 284
205 pressure or physiotherapy [17]. Currently it is very diffi- tween groups, blinding, and completeness of follow-up 285
206 286
cult to quantify the proportion of patients left with re- and outcome measures. High-quality evidence has
207 287
208 sidual deficits; however, the combination of been defined as scores between 6 and 10, fair quality 288
209 hydrodilatation and corticosteroid injection may also defined as scores between 4 and 5, and poor quality 289
210 290
211 reduce the prevalence of long-term deficits [17]. defined as scores below 3. (For further details about 291
212 The aim of this systematic review was to analyze PEDro, the reader is referred to reference 18.) 292
213 293
214
current available randomized controlled trials to 294
215 determine whether there is a synergistic effect of Results 295
216 corticosteroid injection and hydrodilatation in the 296
217 297
218 treatment of adhesive capsulitis compared to standard- After duplicates were removed, 2276 were included Q3
298
219 of-care corticosteroid injection. This systematic review in the title and abstract screening phase. Following the 299
220 300
221
builds on the previous Cochrane Review by Buchbinder title and abstract screen, 151 studies progressed to full 301
222 et al [17] by further elucidating whether hydrodilatation text review. A total of 146 studies were removed by the 302
223 with corticosteroid injection is better than the alter- full text review, leaving 5 articles to be included for 303
224 304
225 native intervention of corticosteroid injection alone, by analysis, with the addition of one article found via 305
226 the inclusion of recently published randomized reference searches (Figure 2). PEDro scale scores were 306
227 307
228 controlled trials and refined trial inclusion criteria with above 7 for all included studies. As a physician admin- 308
229 appropriate control groups. istering the procedure cannot be blinded, no study was 309
230 310
231
able to obtain a score of 11. The majority of studies did 311
232 Methods not clearly blind subjects to group allocation. Table 1 312
233 and 2 provide descriptive characteristics of the studies 313
234 314
235 Search Strategy and Assessment of Study included, and Table 3 lists the respective outcome 315
236 Eligibility measures and main results. 316
237 317
238
Jacobs et al [19] conducted a randomized control 318
239 This review was formatted and based upon Preferred trial of 50 shoulders randomized to receive hydro- 319
240 Reporting Items for Systematic Review and dilatation, corticosteroid injection, or hydrodilatation 320

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 M. Catapano et al. / PM R XXX (2017) 1-13 3

321 Database: Embase Classic+Embase <1947 to 2016 March 03> 401

322 402
323
Search Strategy: 403
324 -------------------------------------------------------------------------------- 404
325 1 shoulder pain/ (11441) 405
326 2 rotator cuff/ (4656) 406
327 407
328
3 bursi s/ (4665) 408
329 4 frozen shoulder/ (1564) 409
330 5 humeroscapular periarthri s/ (1773) 410
331 6 supraspinatus muscle/ (507) 411
332 412
333 7 shoulder impingement syndrome/ (1984) 413
334 8 rotator cuff injury/ (1302) 414
335 9 ((shoulder* or rotator cuff) adj5 (bursi s or frozen or impinge* or tendini s or tendoni s or pain*)).mp. 415
336 (21096) 416
337 417
338 10 rotator cuff.mp. (11436) 418
339 11 capsuli *.mp. (1116) 419
340 12 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 (33495) 420
341 421
13 dilata on/ (12206)
342 422
343 14 arthrography/ (6092) 423
344 15 (dilatat* or distension).mp. (153707) 424
345 16 hydrodilat*.mp. (43) 425
346 426
17 intraar cular drug administra on/ (6783)
347 427
348 18 13 or 14 or 15 or 16 or 17 (166313) 428
349 19 12 and 18 (1748) 429
350 20 (exp animals/ or exp animal experimenta on/ or nonhuman/) not ((exp animals/ or exp animal 430
351 431
352
experimenta on/ or nonhuman/) and exp human/) (6206037) 432
353 21 19 not 20 (1736) 433
354 22 exp embryo/ or exp fetus/ or exp juvenile/ (3516029) 434
355 23 exp adult/ (6116305) 435
356 436
357
24 22 not (22 and 23) (2403377) 437
358 25 21 not 24 (1711) 438
359 26 limit 25 to embase (1472) 439
360 440
361 Figure 1. Search strategy (Embase). 441
362 442
363 443
364 444
365 with corticosteroid injection performed via a landmark- with lidocaine and triamcinolonhexetonide to tri- 445
366 446
367
based posterior approach [19]. Participants were amcinolonhexetonide alone via a landmark-based pos- 447
368 offered a total of 3 injections at 6-week intervals unless terior approach [20]. Hydrodilatation was confirmed via 448
369 they either refused or had a dramatically improved ultrasound demonstrating enlarged joint space 449
370 450
371 range of movement and no pain. Injections consisted of compared to preinjection images. Capsular preserva- 451
372 hydrodilatation (bupivacaine with air; total volume 9 tion was not directly commented on during ultraso- 452
373 453
374
mL); corticosteroid injection
only group (triamcinolone nography. Patients were offered injections once per 454
375 acetonide; total volume 1 mL); and corticosteroid in- week for a maximum of 6 weeks or until no symptoms 455
376 jection and hydrodilatation group (triamcinolone ace- remained, and were asked to record daily analgesic use 456
377 457
378 tonide, bupivacaine and air; total volume 10 mL). and pain at rest and with function on a visual analog 458
379 Patients were followed up at baseline and at 6, 12, and scale (VAS). An impartial physician who was not 459
380 460
381
16 weeks postintervention. Three patients dropped out involved in treatment administration and was unaware 461
382 of the study between the fourth and eighth weeks for of the treatment that each patient received examined 462
383 reasons unrelated to the study, and one patient was patients at inclusion and at 3, 6, and 12 weeks. Of the 463
384 464
385 unable to continue due to a cerebrovascular accident. 20 patients included in the analysis, patients treated 465
386 At the end of 16-week period, patients receiving with hydrodilatation and corticosteroid injection ach- 466
387 467
388 hydrodilatation with corticosteroid injection achieved ieved non
statistically significant pain relief with a 468
389 the greatest overall improvement in ROM, with VAS scores at 12 weeks of 2 and 0 compared to 1 and 3 469
390
391
improvement of 4.3 , 3.6 , and 2.1 per week, in the controls at rest and with function, respectively. 470
471
392 compared to the corticosteroid injection group of 3.4 , Analgesic consumption (P ¼ .008), flexion (not re- 472
393 3.3 , and 1.7 per week in abduction, flexion, and ported), extension ROM (P ¼ .03), external rotation 473
394 474
395 external rotation, respectively. However, although this ROM (P ¼ .01), and physician impression of symptom 475
396 improvement was clinically significant, it was not sta- severity (P ¼ .002) all demonstrated significant benefit 476
397 477
398
tistically significant. in the population receiving hydrodilatation and corti- 478
399 Gam et al [20] conducted a randomized controlled costeroid injection as compared to the corticosteroid 479
400 trial comparing the combination of hydrodilatation injection
only group. 480

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 4 Hydrodilatation for Adhesive Capsulitis

481 561
482 Medline: 966 Ar cles 562
483 563
484 Embase: 1,472 Ar cles 564
485 565
486 CINAHL: 1,910 Ar cles 566
487 567
488
Total: 4,348 Ar cles 568
489 569
490 570
491 571
492 572
493
Duplicates Removed: 573
494 574
495 2,072 Ar cles 575
496 576
497 577
498 578
499 579
500 Title Screen: 2276 Ar cles 580
501 Removed at Title Screen: 581
502 582
503 583
504 2125 Ar cles 584
505 585
506 586
507 587
508 588
509 589
510 Full Text Screen: 151 Ar cles 590
511 Removed at Full Text Screen: 591
512 592
513
146 Ar cles 593
514 - Inappropriate controls 594
515 595
516 - Wrong pa ent popula on 596
517 597
518 - Not in English 598
519 599
520 600
521 601
522 Manual Search from 602
523 Reference Lists: 603
524 604
525 605
526 1 Ar cle 606
527 607
528 6 Ar cles Included 608
529 609
530 610
531 Figure 2. Screening process. Q13 611
532 612
533 613
534 614
535 Tveita et al studied 76 shoulders that were random- difference between groups in passive or active ROM in 615
536 ized to receive hydrodilatation with corticosteroid in- abduction, forward flexion, or external or internal 616
537 617
538 jection consisting of contrast medium, triamcinolone rotation. 618
539 acetonide, bupivacaine, and saline solution or intra- Reza et al conducted a randomized controlled trial of 619
540 620
541
articular injection alone with contrast medium, triam- 100 shoulders equally randomized to receive either 621
542 cinolone acetonide, and bupivacaine [21]. Patients hydrodilatation with saline solution, contrast material, 622
543 received 3 injections at 2-week intervals administered lidocaine, and triamicinolone acetonide or tri- 623
544 624
545 via an anterior approach under fluoroscopy using a amicinolone acetonide alone [22]. Injections were per- Q4
625
546 Kay
Schneider technique. Capsular rupture was formed under fluoroscopic guidance via an 626
547 627
548 ensured in dilatation patients with continual injection anteriorelateral approach, and all patients were given a 628
549 until there was a recorded loss of resistance, and program of active home exercises focusing on active 629
550 630
551
contrast leakage was identified by fluoroscopy. Patients shoulder ROM for 1 week. Patients were assessed at 631
552 were followed up at 6 weeks after their last appoint- inclusion and at 2 days and 12 weeks after intervention 632
553 ment with Shoulder Pain and Disability Index (SPADI) with VAS and active ROM. The patients receiving 633
554 634
555 scores and active and passive ROM. Both groups had hydrodilatation demonstrated significant improvement 635
556 significant improvement; however there was a small in VAS scores (P ¼ .002) and ROM in flexion (P ¼ .009), 636
557 637
558
observed difference in DSPADI scores of 3 favoring the abduction (P ¼ .005), and internal rotation (P ¼ .027) at 638
559 dilatation group, although this was not significant 12 weeks, with the majority of change occurring within 639
560 (confidence interval ¼
5 to 11). There was no the first 2 days. 640

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 M. Catapano et al. / PM R XXX (2017) 1-13 5

641 Yoon et al conducted a controlled trial of 90 shoul- 721

Follow-up (wk)
642 722
643 ders randomized to either hydrodilatation with corti- 723
644 costeroid injection of triamcinolone, lidocaine, and 724
645 725
646
normal saline solution under fluoroscopic guidance or 726

12
24
6
16

52
12
647 corticosteroid injections of triamcinolone alone into the 727
648 subacromial space or glenohumeral joint [23]. Patients 728
649 729
received one injection and were evaluated at inclusion
Symptom Duration, mo,

650 730
651 and at 1, 3, and 6 months after treatment using a VAS 731
652 732
653
score, Simple Shoulder Test (SST), Constant score, and 733
Cases/Controls

654 passive shoulder ROM (forward flexion and external and 734
655 internal rotation). At 1 month, patients receiving 735
656 736
7.5/7.0

657 hydrodilatation and corticosteroid injection had signifi- 737

5/4.5

3.7/4

658 cantly greater improvement in VAS score (P ¼ .035), SST 738

9/9
7/7
8/6

659 739
660 (P ¼ .02), forward flexion (P ¼ .009), and external 740
661 rotation (P ¼ .05) than patients treated with both 741
% Women, Cases/Controls

662 742
663
methods of corticosteroid injections. However, except 743
664 for SST and Constant score (between the HD and IAI 744
665 group) that were maintained at 3 months (P ¼ .05), Q5 745
666 746
667 there was no significant improvement in any other 747
668 measured outcome at 3 and 6 months. 748
669 749
Sharma et al demonstrated in 106 shoulders that
67/62.5

670 750
62/68
67/51
50/69

58/62
50/50

671 hydrodilatation with triamcinolone, lidocaine, and so- 751

672 dium chloride for a total injectate volume of 8-20 mL 752
673 753
674 was not superior at the 4-week, 8-week, or 12-month 754
Age, y, Cases/Controls

675 follow-up compared to intra-articular injection of 755

676 756
677
triamcinolone and lidocaine [24]. Patients in both 757
678 intervention groups received injections via a landmark- 758
679 based posterior approach on the day of randomization 759
680 760
681 and after 7, 17, and 31 days from the start, with 761
53.5/47

682 outcome measured being evaluated by a blinded 762

53/54
52/51
55/52

52/53
61/58

683 763
684 assessor at 4 weeks and 8 weeks. In addition, the SPADI 764
685 was re-administered via mail at 12 months post- 765
686 766
intervention. The investigators did not demonstrate any
Cases/Controls (n)

687 767
688 difference between intervention groups with a calcu- 768
689 lated effect size for SPADI from baseline to be 0.0 and 769
690 770
691 0.1 between the interarticular injection and hydro- 771
692 dilatation group at 8 weeks and 12 months, respectively. 772
28/29
38/37
18/16

32/34
50/50
12/8

693 773
694
Moreover, there was no statistically difference between 774
695 group differences in change in the SPADI, numeric pain 775
696 rating scale (NPRS), or ROM in abduction, external Q6 776
PEDro Scale
Score (/11)

697 777
698 rotation, internal rotation, or hand behind back at 4 and 778
699 8 weeks in an analysis of covariance. 779
700 780
8
7
8

10
8
8

701 781
702 Discussion 782
703 783
2016
2008
1991

2016
2013
1998
Year

704 784
705 Hydrodilatation with corticosteroid injection has 785
706 786
RCT ¼ randomized controlled trial.

gained popularity due to its theoretical benefit of

Demographics of included studies

707 787
simultaneous treatment of the inflammatory reaction
Denmark

708 788
Country

Norway

Norway

709 and constricted glenohumeral joint. Current random- 789

Korea

Iran

710 790
ized controlled trials have produced conflicting results
UK

711 791
712 as to whether this theoretical benefit translates to 792
713 clinically evident improvements compared to cortico- 793
Sharma et al [24]
Jacobs et al [19]

714 794
Tveita et al [21]

steroid injection alone. Two studies, by Reza et al [22]

Yoon et al [23]

Reza et al [22]
Gam et al [20]

715 795
716 and Gam et al [20], demonstrated significant improve- 796
717 797
ment in pain and function in patients receiving the
Table 1

718 798
Study

719 combined intervention of hydrodilatation compared to 799

720 corticosteroid injection alone at 1-month and 3-month 800

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 844
868

866

864

849
848

806

804
880
879
878

875

869

865

863
862

860
859
858

856
855
854
853
852

850

846
845

843
842

840
839
838

836

834

832

830
829
828

826
825

823
822

820

809
808

805

803
802
877

870

867

835

833

824

807
873
872

827
871

861

857

837

801
876

847

831

821

812
841
851

819

816
815
814
813

810
874

818
817

811
Table 2

6
Descriptions of included studies
Amount of
Prior Conservative Injectate Injectate
Study Diagnostic Criteria Treatment(s) Comparison Group(s) Intervention direction (Capsular Effect)
Yoon et al [23] Patients included consisted of those Patients included within Intra-articular injection: 1 mL Single injection under Injectate was - 1 mL (40 mg)
(2016) with limited active and passive ROM the study were not triamcinolone 40 mg, 4 mL fluoroscopy, using an directed triamcinolone
in at least 2 directions (abduction allowed to have previous 2% lidocaine, and 5 mL of anterior approach posteriorly, - 4 mL 2%
and forward flexion <100 , external treatments of normal saline solution in whereby needle slightly lidocaine
rotation <20 , or internal rotation/ manipulation under the glenohumeral joint placement was medial superiorly, - 40 mL normal
Apley’s Test score <L3), pain or anaesthesia, using an anterior approach to the head of the and laterally. saline solution
discomfort for 6 months to 1 year, a suprascapular nerve with patients in the supine humerus and (Capsule
current VAS score of <7 of 10 for injection, or have position approximately 1 cm ruptured)
pain, and more severe pain at night received a steroid Subacromial injection: 1 mL lateral to the coracoid
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than during the day. Those with
radiographic or ultrasonographic
evidence of rotator cuff tear or
calcific tendinitis, glenohumeral
arthritis, or trauma were excluded
injection within the 6
months prior to
enrollment. Prior use of
other conservative
therapy was not
triamcinolone 40 mg, 4 mL process.
2% lidocaine, and 5 mL of
normal saline solution into
the subacromial bursa using
a posterior approach under

Hydrodilatation for Adhesive Capsulitis

from the study. reported. ultrasound guidance
Tveita et al [21] Included patients consisted of those Prior to inclusion, some Intra-articular injection: 3-4 Arthrograms were Needle was - 4 mL of contrast
(2008) with limitation of passive movement patients were taking mL contrast medium, 2 mL performed according to directed medium
in the glenohumeral joint of >30 for oral medication for (20 mg) triamcinolone, and the Kaye-Schneider posteriorly - 2 mL (20 mg)
at least 2 ranges of forward flexion, shoulder pain including 3-4 mL of 5 mg/mL technique and injected and slightly triamcinolone
abduction, or external rotation acetaminophen or bupivacaine was injected using fluoroscopy and an superiorly and - 4 mL 5 mg/mL
compared to the unaffected side, various NSAIDs, and a using fluoroscopy and an anterior approach with medially as bupivacaine
pain predominantly in one shoulder few were receiving anterior approach with needle placement at described by - 10 mL saline
lasting >3 months and <2 years. physiotherapy. Patients needle placement at about about the junction of the Kay- solution
Those with a clinical history of were excluded if they the junction of the middle the middle and lower Schneider (Capsule
diabetes mellitus, trauma to the were taking oral and lower third of the third of the technique ruptured)
shoulder in the past 6 months corticosteroids. Patients glenohumeral joint space. glenohumeral joint
requiring hospital care, serious were not instructed to space.
mental illness, cancer, glenohumeral attend physiotherapy
arthritis, glenohumeral dislocations, but were allowed to
or full-thickness rotator cuff tears proceed with their
with displacement of the humeral current treatment
head were excluded from the study. program if they wished.
Jacobset al [19] Included patients consisted of those Prior use of conservative Hydrodilatation without Injections were preformed Needle was - 1 mL (40 mg)
(1991) with abduction and forward flexion therapy was not corticosteroid: injection of via a posterior approach positioned triamcinolone
<90 , external rotation <20 , intact reported. All patients 6 mL 0.25% bupivacaine and using a landmark-based anterior and - 6 mL 0.25%
rotator cuff via clinical testing, and were given an 3 mL air via a landmark- technique with the superiorly, bupivacaine
normal shoulder radiographs. information sheet with a based posterior approach infiltration of the directed - 3 mL air
Patients were included regardless of home exercise program; that was identical to the capsule through the toward the (Inferred capsule
severity of pain when using the limb, however, compliance hydrodilatation with posterior corner of the coracoid preservation)
at rest or at night, history of trauma, was not assessed. corticosteroid technique. acromion and the process.
or duration of symptoms. Patients Intra-articular injection: 1 mL needle held horizontally
with diabetes mellitus or a triamcinolone (40 mg) via a toward the coracoid.
myocardial infarction were excluded landmark-based posterior
from the study. approach that was identical
to the hydrodilatation with
900 corticosteroid technique.
944
949
948

906

904
960
959
958

956
955
954
953
952

950

946
945

943
942

940
939
938

936

934

932

930
929
928

926
925

923
922

920

909
908

905

903
902

899
898

896
895
894
893
892

890
889
888
887
886
885
884
883
882
881
935

933

924

907
927

897
957

937

901

891
947

931

921
941
951

912
919

916
915
914
913

910
918
917

911
 1000
1006

1004
1009
1008

1005

1003
1002
1007
1040
1039
1038

1036

1034

1032

1030
1029
1028

1026
1025

1023
1022

1020

1001
1035

1033

1024
1027
1037

1031

1021

1012
1019

1016
1015
1014
1013

1010
1018
1017

1011

968

966

964
999
998

996
995
994
993
992

990
989
988
987
986
985
984
983
982
981
980

969

965

963
962
967
997

979
978

975
991

977

970

961
973
972
971
976

974
Gam et al [20] Included patients consisted of those Those included in the Intra-articular injection: 1 mL Injection was carried out Needle - 19 mL 1%-2%
(1998) referred with a diagnosis of adhesive study had no other (20 mg) of triamcinolone via a posterior approach placement lidocaine
capsulitis of 6 wk or more duration treatment for adhesive alone via a posterior verified by ultrasound. was directed - 1 mL (20 mg)
and nocturnal accentuation of pain, capsulitis other than approach identical to that The treatment was anteriorly triamcinolone
50% or less passive range of motion analgesics in the study use for the hydrodilatation repeated once/wk for a with a 1.5- (Inferred capsular
in external rotation compared to the period. Prior treatment technique. The treatment maximum of 6 wk or inch needle preservation)
contralateral shoulder, no for adhesive capsulitis in was repeated once/wk for a until no symptoms were perpendicular
glenohumeral effusion, normal this patient population maximum of 6 wk or until no present. to the
shoulder x-rays, normal ESR, was not reported. symptoms were present scapulae
hemoglobin, leukocytes, alkali spine.
phosphatase, and negative IgM
rheumatoid factor, no history of
significant shoulder trauma in the
last 6 months that resulted in pain or
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restricted movement of the shoulder

(minor trivial injuries accepted), and
no diabetes.
Sharma et al Patients included in the study were Not reported Intra-articular Injection: 1 ml Injections were carried Needle - 1 mL (20 mg)

M. Catapano et al. / PM R XXX (2017) 1-13

[24] (2016) those with reduced passive range of (20 mg) triamcinolone and 3 out via a landmark- placement triamcinolone
motion more than 30% of 2 of 3 mL 10 mg/mL lidocaine for based posterior was directed - 3 mL lidocaine
shoulder movements and no normal a total of 4 mL injected into approach. Injections anteriorly - Sodium chloride
movement of shoulder abduction, the glenohumeral joint via a were given after using a 9 mg/mL to
external rotation, and internal landmark-based posterior inclusion on day 1 and landmark- total 8 to >20
rotation compared to the approach. after 7, 17, and 31 days based mL
contralateral side. Patients with Treatment-as-usual: informed from the start. injection (Unknown
diabetes or asthma, pregnant about the possibilities of technique. capsular effect)
women, and breastfeeding women optional conservative
were excluded. treatment, such as
physiotherapy or pain
medication other than
corticosteroid injections or
per oral corticosteroid
medication until 61 days
after inclusion
Reza et al [22] Patients included were those with a Not reported Intra-articular injection: Arthrographic shoulder Not reported - 1 mL [40 mg]
(2013) painful stiff shoulder for >3 months injection of 1 mL (40 mg) capsule distension was triamcinolone
without evidence of gross infection, triamcinolone was injected performed through an acetonide
inflammatory disease, space- into the shoulder joint via anterior-lateral - 2 mL 2%
occupying lesions, shoulder bony an anterior-lateral method. approach under lidocaine
lesions, or calcium deposits around A program of active home fluoroscopic guidance. - 20 mL contrast
the joint on a complete blood count exercises focusing on active Patients sat with their material
with ESR or shoulder and neck shoulder ROM for 1 wk affected arms in - 27 mL normal
radiography. Those with clinical followed the injections. maximal external saline solution
evidence of abnormal muscular mass rotated position. (Capsule
around the arm or shoulder ruptured)
suggestive of rotator cuff tendon
tearing, fever, pain on touching of
the shoulder, or history of
pregnancy, diabetes mellitus, or
polyarthritis were excluded.
ESR ¼ erythrocyte sedimentation rate; NSAIDs ¼ nonsteroidal anti-inflammatory drugs; ROM ¼ range of motion; VAS ¼ visual analog scale.

7
1044
1068

1066

1064

1049
1048
1069

1065

1063
1062

1060

1046
1045

1043
1042
1099
1098

1096
1095
1094
1093
1092

1090
1089
1088
1087
1086
1085
1084
1083
1082
1081
1080

1067

1059
1058

1056
1055
1054
1053
1052

1050
1079
1078

1075
1097

1077

1070

1061
1091

1073
1072

1057

1047
1071

1041
1076

1051
1100
1120

1074
1106

1104
1109
1108

1105

1103
1102
1107

1101
1112
1119

1116
1115
1114
1113

1110
1118
1117

1111
 1200

1144

1129
1128

1126
1125

1123
1122
1168

1166

1164

1149
1148

1124
1199
1198

1196
1195
1194
1193
1192

1190

1169

1165

1163
1162

1160
1159
1158

1156
1155
1154
1153
1152

1150

1146
1145

1143
1142

1140
1139
1138

1136

1134

1132

1130

1127
1189
1188
1187
1186
1185
1184
1183
1182
1181
1180

1167

1135

1133
1197

1121
1191

1179
1178

1175

1161

1157

1137
1177

1170

1147

1131
1173
1172

1141
1171

1151
1176

1174
Table 3

8
Study results for included studies
Study Main Results Authors’ Conclusions Q14

Yoon et al [23] VAS score: Hydrodilatation > intra-articular steroid injection and
(2016) IAI 5.6 (2.1), 4.6 (1.1), 4.4 (1.5), 1.9 (1.1) vs HD 5.8 (1.5), 3.6 (1.3), 3.4 (1.4), 2.1 (1.3) at baseline, 1 m, subacromial injection at 1 and 3 mo in terms of
3 mo, and 6 mo, respectively. functional scores. However, for VAS and ROM, the HD
Simple Shoulder Test Score: group performed better statistically at 1 month with
IAI 3.2 (1.8), 6.0 (2.5), 6.8 (1.6), 8.3 (1.2) vs HD 3.2 (2.2), 7.8 (2.0), 8.7 (3.4), 8.9 (1.2) at baseline, 1 mo, similar effects at 3 and 6 mo.
3 mo, and 6 mo, respectively. No difference between injection techniques at 6 mo.
Constant Score:
IAI 58.6 (17.1), 67.4 (19.8), 73.6 (18.1), 80.1 (14.2) vs HD 57.4 (20.0), 78.1 (16.8), 77.3 (18.1), 85.1 (11.2)
at baseline, 1 mo, 3 mo, and 6 mo, respectively.
Tveita et al [21] SPADI: No difference at 6-wk follow-up.
(2008) IAI 59 (20), 20 (17) vs HD 63 (20), 26 (19) at baseline and 6 wk, respectively.
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Passive ROM (with scapula stabilized):

aROM IAI 31 (11), 46 (13) vs HD 31 (11), 44 (12) at baseline and 6 wk, respectively
ffROM IAI 46 (17), 65 (12) vs HD 48 (14), 61 (13) at baseline and 6 wk, respectively
extROM IAI 16 (14), 29 (16) vs HD 19 (13), 27 (17) at baseline and 6 wk, respectively
intROM IAI 31 (13), 48 (15) vs HD 34 (14), 45 (12) at baseline and 6 wk, respectively

Hydrodilatation for Adhesive Capsulitis

Jacobs et al [19] ROM: Greatest improvement in passive ROM in the distension
(1991) aROM IAI 3.4 (2.4-4.5) vs HD 4.3 (3.4-5.2) in degrees/wk (95% confidence interval) at baseline and 16 wk and steroid group; however not statistically
ffROM IAI 3.3 (2.3-4.3) vs HD 3.6 (3.2-4.0) in degrees/wk (95% confidence interval) at baseline and 16 wk significantly better. Both steroid and distension and
extROM IAI 1.7 (1.2-2.3) vs HD 2.1 (1.6-2.6) in degrees/wk (95% confidence interval) at baseline and steroid group were better than distension only.
16 wk
VAS with resisted movement NR at baseline and 16 wk
Gam et al [20] VAS: Corticosteroid and distension demonstrated a
(1998) At Rest IAI 4 (2-6), 1 (0-6) vs HD 3 (2-7), 2 (0-5) at baseline and 12 wk statistically significant difference in ROM in all
With Function IAI 4 (3-7), 3 (2-8) vs HD 5 (4-5), 0 (0-1) at baseline and 12 wk directions except abduction and analgesic sparing.
Analgesic use: Clinically significant but statistically nonsignificant
IAI 1 (0-3), 0.5 (0-2) vs HD 2 (1-3), 0 (0-0) at baseline and 12 wk differences in VAS scores were reported.
Exact values for ROM were not reported. However there was significant improvement in all ROMs
(extension, forward flexion, external rotation) except abduction. Extension and external rotation was
significant from wk 7, respectively pw 0.03 and 0.01. Q15
Exact values for physician impression were not reported. However the physicians impression also showed
a significant difference in wk 7 and 12 in favor of distension, respectively pw 0.01 and 0.002.
Sharma [24] SPADI: No significant difference between hydrodilatation and
et al (2016) IAI 63.8 (16.0), 34.1 (21.4), 23.8 (22.0), 16.9 (18.9) vs HD 60.5 (16.8), 30.9 (21.0), 20.1 (18.4), 17.2 (19.8) corticosteroid compared to corticosteroid alone for
at baseline, 4 wk, 8 wk, and 12 mo, respectively any outcome measure at 4 wk, 8 wk, or 12 mo.
NPRS:
IAI 6.9 (1.4), 3.8 (2.2), 3.0 (2.3) vs HD 7.2 (1.6), 3.5 (1.7), 2.9 (1.6) at baseline, 4 wk, and 8 wk,
respectively
PROM:
aROM IAI 53.7 (13.4), 62.7 (15.6), 68.9 (15.3) vs HD 51.0 (17.8), 64.7 (17.2), 71.9 (17.0) in degrees at
baseline, 4 wk, and 8 wk, respectively
extROM IAI 19.6 (14.7), 30.1 (16.3), 38.2 (17.6) vs HD 25.2 (17.7), 35.6 (15.8), 42.7 (17.9) in degrees at
baseline, 4 wk, and 8 wk, respectively
IntROM IAI 38.8 (15.5), 49.5 (17.4), 57.2 (15.7) vs HD 41.1 (14.1), 42.7 (17.3), 59.6 (16.1) in degrees at
baseline, 4 wk, and 8 wk, respectively
1268

1266

1264

1244

1206

1204
1280

1269

1265

1263
1262

1260
1259
1258

1256
1255
1254
1253
1252

1250
1249
1248

1239
1238

1236

1234

1232

1230
1229
1228

1226
1225

1223
1222

1220

1209
1208

1205

1203
1202
1267

1246
1245

1243
1242

1240

1235

1233

1224

1207
1279
1278

1275

1227
1277

1270

1261

1257

1237

1201
1273
1272

1231

1221
1271

1247
1276

1251

1241

1212
1274

1219

1216
1215
1214
1213

1210
1218
1217

1211
 M. Catapano et al. / PM R XXX (2017) 1-13 9

1281 follow-up. This benefit was also experienced in patients 1361

VAS ¼ visual analog scale; IAI ¼ intra-articular injection of corticosteroid; HD ¼ hydrodilatation with corticosteroid; SPADI ¼ Shoulder Pain and Disability Index; aROM ¼ abduction range of
motion; ffROM ¼ forward flexion range of motion; extROM ¼ external range of motion; intROM ¼ internal range of motion; ROM ¼ range of motion; NPRS ¼ numeric pain rating scale; PROM ¼
Statistically significant difference in both active ROM and
VAS score at both 2 days and 12 wk postintervention.

1282 1362
1283 in the Jacobs et al [19] study. However, because of a 1363
1284 small sample size without adequate power, this differ- 1364
1285 1365
1286
ence failed to reach statistical significance. The im- 1366
1287 provements in pain and ROM seen in the studies 1367
1288 previously discussed was also documented by Yoon et al 1368
1289 1369
1290 [23] at 1 month; however there was no appreciable 1370
1291 improvement at long-term follow-ups of 3 and 6 months. 1371
1292 1372
1293
In contrast, Tveita et al [21] and Sharma et al [24] 1373
1294 demonstrated no difference at 1- and 2-month follow- 1374
1295 up, or at 1-year follow-up demonstrated by Sharma 1375
1296 1376
1297 et al between patients receiving the combined inter- 1377
1298 vention versus corticosteroid injection alone. One of the 1378
1299 1379
1300 reasons for this large variability in effectiveness among 1380
1301 randomized controlled trials may stem from the tech- 1381
1302 1382
1303
nique used to dilate the glenohumeral capsule in each 1383
1304 study. Each study used a unique protocol consisting of 1384
1305 varying volumes and consistencies of injectate, varying 1385
1306 1386
1307 anatomical injection approaches, and varying volumes 1387
IAI 7.46 (1.15), 6.76 (1.17), 3.57 (1.1) vs HD 7.96 (0.98), 4.33 (1.00), 3.29 (0.95) at baseline, 2 days, and

ffROM IAI 66.3 (24.2), 75 (21.7), 84.8 (21.3) vs HD 66.6 (29.5), 104.4 (32), 110.8 (33.3) at baseline, 2 days,

extROM IAI 22.7 (11.06), 28.1 (10.9), 36.2 (12.2) vs HD 20.4 (12.5), 40.9 (17.5), 50.8 (17.2) at baseline,

1308 used in the comparison groups. As such, studies were 1388

aROM IAI 65.4 (21.1), 72.6 (24.9), 82.7 (22.6) vs HD 63.8 (25.6), 102.7 (30.7), 114.4 (30.1) at baseline,

1309 1389
intROM IAI 31.5 (11.8), 36.9 (11.5), 48.4 (10.8) vs HD 33.6 (21), 48.1 (19.6), 55.4 (18.2) at baseline,

1310
evaluated individually for trends; however, we were not 1390
1311 able to combine data from each of the studies, as it 1391
1312 would not appropriately synthesize the total results. 1392
1313 1393
1314 Study protocols differed in their aim to obtain 1394
1315 capsular rupture during hydrodilatation. This variability 1395
1316 1396
1317
stems from initial theories that maximal expansion, 1397
1318 where capsular rupture was achieved, would result in 1398
1319 the greatest dilatation of the capsule and translate to 1399
1320 1400
1321 maximal clinical improvement. This theory was based on 1401
1322 studies of hydrodilatation without corticosteroid injec- 1402
1323 1403
1324 tion. In these studies, there was a small appreciable 1404
1325 clinical improvement with protocols obtaining capsular 1405
1326 1406
rupture (CR) [25-28] compared to those where there was
1327 1407
1328 capsular preservation (CP) [14,19,29]. Recently, this 1408
1329 theory was tested in a randomized, head-to-head clin- 1409
1330 1410
1331 ical trial of capsular CP versus capsular CR [30] with the 1411
1332 addition of corticosteroid. A total of 46 patients were 1412
1333 1413
1334
randomized to receive hydrodilatation with corticoste- 1414
1335 roid with the purpose of either CP and CR. Intra- 1415
1336 articular administration of 40 mg triamcinolone was 1416
1337 1417
1338 administered in both groups. The desired capsular ef- 1418
1339 fect was confirmed postintervention using ultrasound 1419
1340 1420
imaging and continued intra-articular pressure moni-
12 wk postintervention

1341 1421
1342 toring. Between-group comparison demonstrated that 1422
1343 1423
2 days, and 12 wk

2 days, and 12 wk

2 days, and 12 wk

there was a larger decrease in VAS score in patients in

VAS with function:

1344 1424
1345 the CP group compared to those in the CR group. This 1425
1346 improvement was significant at 3 days (P ¼ .032) and 1426
and 12 wk

1347 1427
1348 marginal at 1 month (P ¼ .075). There was increased 1428
1349 improvement in abduction ROM (P ¼ .035 and .011), 1429
ROM:

1350 1430
summed ROM (P ¼ .068 and .043), and Apley’s Test score
passive range of motion.

1351 1431
1352 (P ¼ .002 and .013) in patients with CP than in those 1432
1353 with CR group at 3 days and 1 month, respectively. The 1433
1354 1434
additional benefit attained by those in the CP group has
Reza et al [22]

1355 1435
1356 been proposed to be a result of maintained pressure in 1436
1357 1437
the glenohumeral joint causing continual capsular
(2013)

1358 1438
1359 distension without rupture postintervention and the 1439
1360 appropriate delivery of corticosteroid [30]. 1440

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 10 Hydrodilatation for Adhesive Capsulitis

1441 Those studies included in this review in which there Injection approaches varied significantly among the 1521
1442 1522
1443 can be inferred CP based upon review of study meth- studies included in this review. This may account for 1523
1444 odology reported clinically significant improvements some of the variability in outcomes, as previous cadav- 1524
1445
1446
in patient outcomes with the addition of hydro- eric [33], magnetic resonance imaging [34], and ultra- 1525 1526
1447 dilatation. Capsular preservation was not measured by sound [35] studies have shown that pathologically 1527
1448 any study; however, 2 studies [19,20] in this review contracted structures in patients with adhesive capsu- 1528
1449 1529
1450 likely maintained capsule integrity. Jacobs et al [19] litis include the anterior capsule, most notably the 1530
1451 used a total injectate volume of 10 mL, which is coracohumeral ligament and the rotator cuff interval. 1531
1452
1453
significantly below the average volume needed to Multiple approaches can been attempted to more 1532 1533
1454 achieve CR (18.5-25.8 mL) [31]. From this we have effectively target these pathological structures in pa- 1534
1455 inferred that there is likely CP in the majority of pa- tients with adhesive capsulitis as, theoretically, tar- 1535
1456 1536
1457 tients, with a small number experiencing CR, as geted increased pliability of anterior structures through 1537
1458 described to occur with volumes as low as 8 mL [30]. local dilatation and deposition of corticosteroid may 1538
1459 1539
1460 Gam et al [20] performed ultrasound evaluation provide optimal effect and, subsequently, clinical 1540
1461 postintervention to ensure appropriate anterior dila- improvement. 1541
1462
1463
tation after the infusion of 20 mL. Although we cannot Previously, Prestgard et al [36] studied the efficacy of 1542
1543
1464 ensure the capsular effect during their procedure, it corticosteroid injections directly into the anterior gle- 1544
1465 can be inferred that there is likely CP in a significant nohumeral capsule itself. This approach ensures that 1545
1466 1546
1467 portion of the population due to the moderate amount corticosteroid is injected around the pathological 1547
1468 of injectate and maintained capsular dilatation post- structures, but demonstrated no benefit when 1548
1469
1470
procedure on ultrasound. We cannot be sure how long compared to intra-articular corticosteroid injections 1549 1550
1471 the distension was maintained and whether there was alone. The lack of additional benefit seen with the 1551
1472 subsequent rupture after ultrasound evaluation, as a approach used by Prestgard et al [36] may be due to a 1552
1473 1553
1474 mean time to rupture has been reported as 400 sec- lack of dilational effects with small intra-articular vol- 1554
1475 onds [31]. This is in contrast to the 3 studies [21,22,32] umes in the patient group receiving directed injections 1555
1476
1477
reported in this review that ensured CR, of which only into the anterior capsule synovial tissue. For example, 1556 1557
1478 one study [22] demonstrated maintained benefits with in those receiving traditional intra-articular corticoste- 1558
1479 the addition of hydrodilatation. In one study, Sharma roid injections, 7 mL was injected into the glenohumeral 1559
1480 1560
Q7 et al [24] were unable to comment on the capsular joint, compared to those receiving anterior capsular 1561
1481
1482 effect due to variable and moderate injection volumes injections, who had 3.5 mL injected into the gleno- 1562
1483 1563
1484 of anywhere from 8 mL to more than 20 mL and humeral joint and 3.5 mL into the anterior glenohumeral 1564
1485 without data describing mean injectate volumes or capsule synovial tissue. The combination of localized 1565
1486
expected capsular effect. corticosteroid deposition into the anterior glenohumeral 1566
1487 1567
1488 In addition to the continual capsular distension, im- capsule with simultaneous targeted dilatation of ante- 1568
1489 provements in patients receiving hydrodilatation with rior capsular structures theoretically would have pro- 1569
1490 1570
1491 corticosteroid injection may be attributable to the vided additional benefit over localized corticosteroid 1571
1492 appropriate location of deliverance of corticosteroid. deposition into the anterior capsule. This theoretical 1572
1493
1494
CP provides continual dilatation while ensuring that benefit is demonstrated among studies in this review, 1573 1574
1495 injected corticosteroid stays within the joint capsule, with improved clinical endpoints such as increased ROM 1575
1496 where it can provide maximal anti-inflammatory ef- and pain relief when effectively combining these 1576
1497 1577
1498 fects. With CR, there is fluid extravasation that carries elements. 1578
1499 injected corticosteroid into the surrounding soft tissue, Injection approaches among studies included in this 1579
1500
1501
away from inflamed structures. In a recent case series review can be grouped into posterior approaches, direct 1580 1581
1502 by Yoon et al [32], patients receiving hydrodilatation anterior approaches, and anterior-lateral approaches. 1582
1503 with corticosteroid injection and CP demonstrated Studies using an anterior fluoroscopy technique [21,23], 1583
1504 1584
1505 marked improvement compared with previously pub- whereby the needle entered the joint at or below the 1585
1506 lished results. Mean pain scores were 8.4 at baseline, medial humeral head, did not demonstrate significant 1586
1507 1587
1508 3.4 at 24 hours, 3.1 at 48 hours, 2.1 at 2 weeks, and 1.9 benefits at final follow-up compared to standard-of-care 1588
1509 Q8 at 4 months. The mean Oxford score was 13.6 at base- corticosteroid injection. As described by both Yoon et al 1589
1510
1511
line and 36.5 at 4-month follow-up. The benefit seen [23] and Tveita et al [37], “during the injection, the 1590
1591
1512 with hydrodilatation with corticosteroid and CP in prior joint was gradually distended, making the axillary and 1592
1513 studies and in the studies included in this review in- subscapular recesses more visible,” demonstrating that Q91593
1514 1594
1515 dicates that CP may result in superior pain relief and pathologic structures experienced little to no disten- 1595
1516 clinical effect as measured by the Oxford score. This is sion. This is in contrast to studies in this review that 1596
1517 1597
1518
in contrast to previous studies of hydrodilatation used a posterior approach whereby the joint was 1598
1519 without corticosteroid injection that demonstrated su- accessed superiorly at the level of the scapular spine, 1599
1520 perior results with CR. and in which the patients demonstrated significant 1600

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 M. Catapano et al. / PM R XXX (2017) 1-13 11

1601 benefit [20], trend toward benefit [19], or no benefit and one demonstrated no benefit [21], compared to 3 1681
1602 1682
1603 [24]. This approach allows for more target dilatation of studies that offered a single intervention, of which one 1683
1604 the anterior-superior aspect, explaining some of the demonstrated significant benefit [22] and 2 demon- 1684
1605 1685
1606
benefit experienced by these patients. This trend is strated no benefit [23,24]. It is theorized that the lack 1686
1607 supported Reza et al, who demonstrated significant of additional benefit with repeat intervention is that the 1687
1608 maintained benefit of hydrodilatation with corticoste- capsule in these patients had progressed to a point at 1688
1609 1689
1610 roid injection using an anterior-lateral approach under which it was no longer amenable to either dilatation or 1690
1611 fluoroscopy [22]. This approach also accesses the joint anti-inflammatory medication, and repeat interventions 1691
1612 1692
1613
in the superior aspect and theoretically results in tar- could not overcome this. 1693
1614 geted dilatation of anterior capsular structures. Side effects were equal among the combined inter- 1694
1615 The use of control groups was not homogenous among vention group and controls. Approximately 15% of pa- 1695
1616 1696
1617 studies. Control groups varied from a total injectate tients in each group described transient loss of 1697
1618 volume of 10 mL in Yoon et al [23] and Tveita et al [21] sensation, motor control of the arm, flushing, nausea, 1698
1619 1699
1620 compared to 1 mL in Reza et al [22], Jacobs et al [19], dizziness, pain, and/or discomfort. These were typically 1700
1621 and Gam et al [20]. This heterogeneity makes it difficult rated as mild and spontaneously resolved completely, 1701
1622 1702
1623
to compare between-study results, as patients receiving lasting only for a short period of time. Dropout rates 1703
1624 intra-articular injections of 10 mL likely experienced were low in all studies, with no differences between 1704
1625 some amount of dilatation. In addition, this large vol- groups. 1705
1626 1706
1627 ume does not translate to clinical practice, as the ma- This systematic review builds on the 2008 Cochrane 1707
1628 jority of glenohumeral corticosteroid injections are Review [17] by further elucidating whether hydro- 1708
1629 1709
1630
significantly below 10 mL. As such, 2 of the studies dilatation with corticosteroid injection results in an 1710
1631 [21,23] reporting negative results may be confounded by expedited return of pain-free ROM compared to corti- 1711
1632 the use of a control group that received clinically sig- costeroid injection by the inclusion of recently pub- 1712
1633 1713
1634 nificant dilatation greater than seen with standard-of- lished randomized controlled trials and refined trial 1714
1635 care intra-articular injections. inclusion with appropriate control groups. From this 1715
1636 1716
1637
Differences among patient populations may explain review, we can conclude that there is silver-level evi- 1717
1638 some of the variability seen among the studies in this dence that hydrodilatation with corticosteroid injection 1718
1639 review. Patients in the earlier stages of their condition provides short-term improvements in pain-free ROM and 1719
1640 1720
1641 have a predominantly inflammatory response with a functionality in the first 1-3 months, with unclear 1721
1642 pliable capsule amenable to dilatation and the anti- benefit in long-term outcomes. 1722
1643 1723
1644 inflammatory effects of corticosteroid. As such, pa- 1724
1645 tients who receive intervention earlier in the course of Conclusion 1725
1646 1726
disease would be expected to experience greater clin-
1647 1727
1648 ical improvement. Although no study reported the pro- Hydrodilatation with corticosteroid injection for ad- 1728
1649 portion of patients in each stage of the disease, 2 hesive capsulitis remains a theoretically attractive 1729
1650 1730
1651 studies with a mean symptom duration of 5 months re- intervention due to its potential ability to simulta- 1731
1652 ported increased improvement in the combined group, neously treat the pathologic inflammatory response and 1732
1653 1733
1654
whereas studies with a mean symptom duration of more capsular contraction. However. there continues to be 1734
1655 than 7 months demonstrated no benefit. insufficient and conflicting evidence in the existing 1735
1656 Although there were a multitude of steroid types, literature as to whether there is benefit to the addition 1736
1657 1737
1658 dosages, varying numbers of injections, and cumulative of hydrodilatation to standard-of-care corticosteroid 1738
1659 hydrodilatation offered, we do not believe that these injection alone. The variability in published studies can 1739
1660 1740
1661
significantly contributed to the variability seen among be explained by the heterogeneity in injectate dose and 1741
1662 studies in this review. This is because there have been volume, intended CP or rupture, approaches for injec- 1742
1663 several studies demonstrating benefit with varying tion, and presence or absence of appropriate control 1743
1664 1744
1665 amounts of corticosteroid injection [13,14,38] and no groups. There is evidence that optimization of tech- 1745
1666 difference between high-dose and low-dose triamcino- nique may explain the synergistic effect experienced 1746
1667 1747
1668 lone acetonide observed [16]. In addition, it is not with hydrodilatation and corticosteroid injection in 1748
1669 believed that a cumulative dilatory effect played a role several studies. In the literature, there is a trend toward 1749
1670 1750
1671
in the variability seen between trials, as previous benefit of the addition of hydrodilatation to cortico- 1751
1672 studies have demonstrated no additional benefit of steroid injection, specifically in studies that targeted 1752
1673 repeat hydrodilatation [39]. In addition, there was no tight anterior capsular structures. Despite the trend 1753
1674 1754
1675 trend found among those studies that offered repeat demonstrated in the literature, there remains a lack of 1755
1676 hydrodilatation compared to those that offered a single robust data on the effect of hydrodilatation with corti- 1756
1677 1757
1678
intervention. Of the 3 that offered repeat interventions, costeroid injection via this optimized technique, as only 1758
1679 one demonstrated statistically significant benefit [20], a few studies have combined these factors. There has 1759
1680 one demonstrated only clinically apparent benefit [19], yet to be a consistent demonstration of benefit in a 1760

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 12 Hydrodilatation for Adhesive Capsulitis

1761 high-quality, published research study. Further research treatment of adhesive capsulitis of the shoulder: A placebo- 1841
1762 controlled trial. Arthritis Rheum 2003;48:829-838. 1842
1763 is warranted to better understand the factors affecting 1843
15. Juel NG, Oland G, Kvalheim S, Løve T, Ekeberg OM. Adhesive
1764 patient response to hydrodilatation with corticosteroid capsulitis: One sonographic-guided injection of 20 mg triam-
1844
1765 1845
1766
injection, and to provide reliable evidence on the ef- cinolone into the rotator interval. Rheumatol Int 2013;33: 1846
1767 fects of hydrodilatation with corticosteroid injection via 1547-1553. 1847
1768 an optimized technique. Hydrodilatation with cortico- 16. Yoon S-H, Lee HY, Lee HJ, Kwack K-S. Optimal dose of intra- 1848
1769 articular corticosteroids for adhesive capsulitis: A randomized, 1849
1770 steroid injection has not been demonstrated to hinder 1850
triple-blind, placebo-controlled trial. Am J Sports Med 2013;41:
1771 improvement or to result in an increased prevalence of 1851
1772 1133-1139. 1852
1773
side effects compared to corticosteroid injection alone. 17. Buchbinder R, Green S, Youd JM, Johnston RV, Cumpston M. 1853
1774 Due to the limited quality of the available literature, Arthrographic distension for adhesive capsulitis (frozen shoulder). 1854
1775 adhesive capsulitis continues to pose a challenge for the Cochrane Database Syst Rev 2008;1, CD007005. 1855
1776 18. Maher C, Sherrington C, Herbert R, Moseley A, Elkins M. Reliability 1856
1777 treating physician in deciding the most appropriate 1857
1778
of the PEDro scale for rating quality of randomized controlled 1858
intervention protocol. In conclusion, there is currently trials. Phys Ther 2003;83:713-721.
1779 1859
1780 conflicting high-quality evidence that hydrodilatation 19. Jacobs LG, Barton MA, Wallace WA, Ferrousis J, Dunn NA, 1860
1781 with corticosteroid injection expedites the return of Bossingham DH. Intra-articular distension and steroids in the 1861
1782 1862
1783
pain-free ROM compared to intra-articular corticoste- management of capsulitis of the shoulder. BMJ 1991;302:1498-
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roid injection alone. 1501.
1784 1864
1785 20. Gam AN, Schydlowsky P, Rossel I, Remvig L, Jensen EM. Treatment 1865
1786 of “frozen shoulder” with distension and glucorticoid compared 1866
1787 Uncited Reference with glucorticoid alone. A randomised controlled trial. Scand J 1867
1788 Rheumatol 1998;27:425-430. 1868
1789 21. Tveitå EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydro- 1869
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1791 1871
1792 controlled trial. BMC Musculoskelet Disord 2008;9:53. 1872
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1936 Q12 2021
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Disclosure 2025
1941 2026
1942 2027
M.C. Toronto Rehabilitation Institute, University Center, 550 University Ave, D.K. Division of Physical Medicine and Rehabilitation, Department of Medicine,
1943 2028
1944 Toronto, ON M5G 2A2, Canada; Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University 2029
1945 Department of Medicine, University of Toronto, Toronto, ON, Canada. Address of Toronto, Toronto, ON, Canada 2030
1946 correspondence to: M.C.; e-mail: michael.catapano@mail.utoronto.ca Disclosure: nothing to disclose 2031
1947 Disclosure: nothing to disclose 2032
1948 H.S. Division of Physical Medicine and Rehabilitation, Department of Medicine, 2033
1949 N.M. Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University 2034
1950 2035
University of Toronto, Toronto, ON, Canada of Toronto, Toronto, ON, Canada
1951 2036
1952 Disclosure: nothing to disclose Disclosure: nothing to disclose 2037
1953 Submitted for publication May 12, 2017; accepted October 25, 2017. 2038
1954 J.A. University of Toronto Faculty of Medicine, University of Toronto, Toronto, 2039
1955 ON, Canada 2040
1956 Disclosure: nothing to disclose 2041
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