Adhesive capsulitis, or frozen shoulder is a condition of the shoulder which results in the formation of inflammation and the subsequent production of scar like tissue in the shoulder joint to result in pain, stiffness and debility. The condition is common in diabetics and in this particular group, it may be recalcitrant, often requiring several injections.
Adhesive capsulitis of the shoulder
Adhesive capsulitis has been reported to be a self limiting disease, meaning that untreated, it will eventually spontaneously improve, however this may take up to 2 years.
In its early phase, the disease may result in vague shoulder pain which mimics other causes of shoulder pain. The diagnosis is often suggested at the time of ultrasound evaluation, when patients are unable to move their shoulder in the necessary positions required for the scan. An ultrasound also yields important information, as it may diagnose the underlying cause that resulted in the patient developing adhesive capsulitis in the first instance.
Common causes of adhesive capsulitis
The cause of adhesive capsulitis is often not known. However, when known, common causes include:
- Rotator cuff tendinosis/tendon tears
- Subacromial Bursitis
- Shoulder surgery
- Trauma Shingles
- Heart attack, chest surgery and stroke
Treatment of adhesive capsulitis.
In mild cases, adhesive capsulitis usually responds to rehabilitation. If the condition progresses, often an injection, called a hydrodilatation (or hydrodilation) using cortisone and saline is required to suppress the inflammation and thus target the underlying disease process.
The joint is then stretched with approximately 20-40mls of saline, often resulting in a popping sensation. It is debatable whether stretching the capsule with the addition of saline is of additional benefit and makes the procedure more painful. It is felt that the stretching part of the procedure tears the scarred capsule of the joint to improve mobility. Whether this is of additional long term benefit is as yet unproven, however stretching the capsule can often result in immediate improvement of a patient’s range of motion.
Patients may require several injections to treat the condition, however if this is unresponsive, then another option includes manipulation under general anesthesia and surgery.
CT Guided Hydrodilatation.
The skin is marked for accurate needle placement (image 1 of 9), with a needle then introduced into the shoulder joint.
Gas is then introduced into the joint to confirm position, with the medication then injected to relieve the patient of their adhesive capsulitis (frozen shoulder).
Diagnostic &/or pain relieving procedure.
An arthrogram is a procedure performed at Melbourne Radiology Clinic where imaging guidance (with either an ultrasound or CT) is used to guide a needle into a joint for the purposes of injecting X-ray and/or MRI dye (contrast). The contrast in the joint then preferentially fills different parts of the joint and may give further clues as to the source of the patient’s symptoms, such as pain. Typically large joints, such as the hip and shoulder undergo evaluation with an arthrogram, especially following surgery.
If used solely as a pain relieving procedure, local anaesthetic and cortisone may be injected, or other healing medications, such as glucose (prolotherapy), Autologous Blood Injection (ABI) or Platelet Rich Plasma (PRP).
An arthrogram may also be of diagnostic use. Pain that disappears following an injection of local anaesthetic into a joint usually confirms that the joint injected is the source of the patient’s pain. As groin pain has many causes, this technique is commonly used in deciding whether the hip joint is the cause of a patient’s groin pain. Though this may narrow the source of the patient’s pain, it does not determine the exact cause. For this, further imaging is usually required, such as an MRI (Magnetic Resonance Imaging) or CT (Computed Tomography) scan. If these scans are to be performed on the same day as the arthrogram, the fluid and dye injected into the joint not only may relieve the patient’s pain, but also distends the joint and makes subtle problems more evident, such as a cartilage tear.
- Tveit EK, Tariq R, Sesseng S, Juel NG, Bautz-Holter E. Hydrodilatation, corticosteroids and adhesive capsulitis: a randomized controlled trial. BMC Musculoskelet Disord 19;9:53 2008
- Bell S, Coghlan J, Richardson M. Hydrodilatation in the management of shoulder capsulitis. Australas Radiol 47(3):247-51, 2003
- Watson L, Bialocerkowski A, Dalziel R, Balster S, Burke F, Finch C. Hydrodilatation (distension arthrography): a long-term clinical outcome series. Br J Sports Med 41(3):167-73, 2007
Referring doctors are welcome to discuss with our radiologists the imaging and interventional radiology needs of their patients and whether a hydrodilatation or arthrogram is suitable for their patient’s medical condition.