Fran Lowry

December 10, 2010

December 10, 2010 (Chicago, Illinois) — Injecting fluid into the shoulder joint using ultrasound to guide its placement is an effective way of relieving the pain of frozen shoulder, according to a study presented in a poster session here at the Radiological Society of North America 96th Scientific Assembly and Annual Meeting.

Frozen shoulder, or adhesive capsulitis, can be very resistant to usual treatment methods, such as physiotherapy and nonsteroidal anti-inflammatory drugs, said Mohammed Nayeemuddin, MD, from University Hospital North Staffordshire NHS Trust, Stoke-on-Trent, United Kingdom.

The painful disabling condition can be self-limiting, but approximately 15% to 50% of people will develop persistent pain and stiffness in the shoulder that does not respond to conservative treatment and requires more aggressive measures.

"Ultrasound-guided hydrodilatation for frozen shoulder was first reported in 1965, but it is not often used by many clinicians, partly because of a lack of knowledge of its benefits or its availability," Dr. Nayeemuddin told Medscape Medical News. "We wanted to show its importance and usefulness in clinical practice; hence, we did this study."

The British researchers performed 34 hydrodilatation procedures on 33 patients with frozen shoulder between July 2007 and October 2009. Five of these procedures were performed under fluoroscopic guidance; there were 2 cases of technical failure at ultrasound, 2 cases of lack of access to the ultrasound suite, and 1 case where the patient was deemed to be at high risk because of diabetes.

The mean age of the patients was 54 years (range, 36 to 71), and the average duration of symptoms was 8 months (range, 0.5 to 24.0 months).

The glenohumeral joint was distended using 30 mL of normal saline, 5 mL of 0.5% levobupivacaine, and 80 mg of triamcinolone.

There were only 21 patients available for follow-up, Dr. Nayeemuddin said; mean follow-up was 3.5 months (range, 0.5 to 13.0). At 4 weeks, 18 patients (86%) reported that they were completely free of pain. The remaining 3 patients received little or no benefit from the procedure. One of these patients underwent arthroscopic subacromial decompression; the other 2 are awaiting the same procedure, he noted.

Long-term follow-up results at 18 weeks were available for 12 patients, and 9 (75%) were completely pain free. Three had recurrent symptoms and, of these, 2 underwent arthroscopic capsular release. The other patient received physiotherapy and achieved reasonable relief from his symptoms, Dr. Nayeemuddin said.

The average passive shoulder movement improved by approximately 30 degrees in all directions and there were no complications because of hydrodilatation, he said.

"This is a relatively straightforward and simple procedure with great benefits to the selected group of patients," Dr. Nayeemuddin told Medscape Medical News. "It is more tolerable and acceptable to patients who otherwise would require manipulation under anesthesia or arthroscopic or open capsular release"

He added that long-term follow-up studies are needed to show its prolonged benefits.

Commenting on the study for Medscape Medical News, Thomas M. Link, MD, professor of radiology and chief of musculoskeletal imaging at the University of California, San Francisco, said that the technique has been used more in Australia and the United Kingdom, and not as much in the United States.

"It sounds like a very interesting concept; however, it seems that there are no large clinical trials, just smaller case series. It would be relatively easy to do, but I imagine that if you are distending the shoulder quite substantially and you are not using a lot of local anesthetic, it could be quite painful. This may be one reason why we do not use it much in the United States."

Addressing the pain issue, Dr. Nayeemuddin said that patients may feel a slight discomfort when the capsule adhesions are ruptured, but that the pain relief is immediate for most patients. "The procedure is done under local anesthesia. Most patients are able to move their shoulder straight away. This procedure may offer a cure for some patients and offer temporary pain relief for a variable period of time for others."

Dr. Nayeemuddin and Dr. Link have disclosed no relevant financial relationships.

Radiological Society of North America (RSNA) 96th Scientific Assembly and Annual Meeting: Abstract LL-MKS-TH3B. Presented December 2, 2010.

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