Sonographically-navigated frozen shoulder release (S-FSR): A modified technique for sonographically-navigated, in-office hydrodilatation of adhesive capsulitis

Abstract

We describe a new technique for hydrodilatation of the frozen shoulder, which we coined ‘Sonographically-Navigated Frozen Shoulder Release (S-FSR)’ or ‘Dr Gonzalez's technique.’ Traditional treatments include a combination of conservative and surgical modalities, such as non-steroidal anti-inflammatories, physical therapy, and open capsular release. We describe a modification to hydrodilatation of the frozen shoulder. Our technique describes the gradual dilation of the glenohumeral (GH) capsule with the goal of seeing a gentle release of the frozen shoulder. Furthermore, we outline our protocol for patient preparation with preprocedural diazepam 5 mg and Hydrocodone 5 mg-Acetaminophen 325 mg, one tablet each. During the procedure, we inject a solution of 10 mL lidocaine mixed with 2 mL of 40 mg/mL triamcinolone acetonide injection (80 mg total) through an anterior approach at the level of the rotator interval for pain control. Following this injection, we proceed to fenestrate the superior glenohumeral ligament (SGHL) in the process. We conclude the procedure with hydrodilatation of the GH joint (GHJ) through the posterior approach with approximately 50 mL of 0.9% normal saline, or until an expansion and release of the GH joint is visualized under ultrasound visualization.

A full instruction video can be found at: https://www.youtube.com/watch?v = ZNB0R0hkeok&ab_channel = DrJorgeA.Gonzalez

Introduction

Adhesive capsulitis, colloquially known as ‘frozen shoulder’ (FS), most commonly affects individuals between the ages of 40–59 years old. ¹ It is more common in females and has a high correlation with diabetes mellitus and thyroid dysfunction. The incidence of FS is approximately 3–5% of the general population; however, the incidence of FS in patients with diabetes can climb as high as 20%. ¹ Other risk factors for developing FS include age over 40 years old, previous trauma to the shoulder, and prolonged immobilization of the shoulder. ¹ Pathologically, adhesive capsulitis was first described as hypertrophy and contraction of the shoulder capsule. ² Clinically, Cho et al. describe FS as a spontaneous onset of insidious pain with marked reduction in glenohumeral range of motion, both passively and actively. ³ When considering the etiology of FS, there are two main categories to consider, primary FS vs. secondary FS.

Primary FS, also known as idiopathic FS, occurs spontaneously, without injury or provocation. ¹ One theory suggests an imbalance between matrix metalloproteinases ultimately leading to disruption in the production, remodeling, and degradation of extracellular proteins. ¹ On the other hand, secondary FS is often a consequence of traumatic injury, such as periarticular fractures and/or dislocations or complications from surgical procedures involving the shoulder, such as shoulder arthroplasty, rotator cuff repair, and even arthroscopic debridement.^1,4,5

One study conducted by Koorevaar et al. evaluated 505 patients who underwent some type of surgical intervention to the shoulder. Of the 505 patients, 11% developed post-operative frozen shoulder. ⁶ McAlister et al. proposes the FS to be a consequence of tissue reorganization that takes place following traumatic injuries or invasive interventions. ⁴ Local and inflammatory cells secrete various growth factors and cytokines, such as transforming growth factor-β (TGF- β) and Platelet-derived growth factor (PDGF), for example. An imbalance of these growth factors and cytokines ultimately lead to an excess deposition of restrictive matrix proteins, such as Type I, Type III, and Type V collagen, along with fibroblast proliferation. ⁴

When examining the pathophysiology of adhesive capsulitis, there are three main phases to consider: the freezing or inflammatory phase, the frozen phase, and the thawing phase. The duration of each phase, along with the goals of therapy, can be seen in Figure 1.

Figure 1.

Phases of adhesive capsulitis and goals of therapy.

Freezing phase: The freezing phase typically lasts approximately 10–36 weeks. ³ It is characterized by a spontaneous onset of pain, with marked reduction in both active and passive range of motion. ⁷ Treatment modalities should be focused on pain management.

Frozen phase: The freezing phase typically occurs between 4 to 9 months from onset of symptoms. It is characterized by gradual reduction in pain, with persistent reduction in passive and active range of motion. ⁷ Treatment modalities should be focused on pain management, while increasing range of motion.

Thawing phase: The thawing phase typically occurs between 12 to 42 months from onset of symptoms. It is characterized by minimal or complete resolution of pain, but persistent reduction in passive and active range of motion. ⁷ Treatment modalities should be focused on increasing passive and active ROM, along with restoration of lifestyle. ⁷

Diagnosing the frozen shoulder

Diagnosing FS relies on patient history and physical examination, with imaging used to rule out alternative causes of the patient's symptoms.^1,8 FS is primarily a diagnosis of exclusion, characterized by significantly reduced range of motion, especially during the freezing and frozen phases. In most cases, pain precedes the loss of motion. ⁹ A common physical exam finding is limited external rotation, which, when normal, can exclude FS as a cause of the patient's symptoms.

Treating the frozen shoulder

For some, FS typically has a self-limiting course of 1–3 years. ¹ On the other hand, it is estimated that 20%-50% of patients develop long-lasting symptoms.^10–13 In most cases requiring intervention, patients reach a point where they are no longer able to withstand the pain and disablement caused by FS. Regardless of the modality used, the primary goal of treatment for FS is to restore function to the shoulder without residual pain or limitations.^14,15

Non-steroidal anti-inflammatory drugs (NSAIDs) were first introduced into the treatment of FS in 1995. ¹⁶ Further studies indicated and supported the use of adjuvant or alternative treatments such as oral steroids, ¹⁷ corticosteroid injections, ¹⁸ hyaluronic acid injections, ¹⁹ physiotherapy, ²⁰ acupuncture, ²¹ arthrographic distension, also known as hydrodilatation, ²² manipulation under anesthesia (MUA), ²³ arthroscopic capsular release, ²⁴ and open capsulotomy. ²⁵

It is our belief and practice, that overall, physical therapy should always be one of the cornerstones of treatment. The only situations during which physical therapy can be considered a relative contraindication would be during the freezing phase; however, if the patient is in the frozen or thawing phase, physical therapy should always be combined with other modalities of treatment. The adjuvant method we are outlining and suggesting is hydrodilatation with ultrasound guidance and intraarticular corticosteroid injection.

Intraarticular corticosteroid injection

Multiple studies have shown intraarticular corticosteroid injections (CSI) to be superior to oral steroid treatments regarding symptom control and pain management.^26,27 Additional studies further indicate that methylprednisolone acetate is only effective for a maximum of 6 months, while CSI with triamcinolone may be effective for a maximum of 12 months.^28,29 However, on average, outcomes for patients treated with methylprednisolone vs. triamcinolone were equivalent at the 16-week mark. Studies have found that there is a significant improvement in restoration of shoulder function with intra-articular CSI, compared to placebo.^30–32 When evaluating improvement in range of motion (ROM), intra-articular CSI provided greater short-term and medium-term improvement compared to placebo.

Hydrodilatation

There are several varying protocols and regimens used with hydrodilatation of the FS, also known as distension arthrogram. Regardless, the principle behind any hydrodilatation technique involves the instillation of a large volume of saline, with or without local anesthesia, corticosteroid, or contrast, into the glenohumeral joint. ³³

When discussing the efficacy of hydrodilatation, various studies have looked at shoulder function and ROM as a means of determining improvement and efficacy.^25,28,31,34 Compared to CSI, hydrodilatation provides greater long-term improvement in shoulder function.^31,34 When evaluating improvement in shoulder ROM, hydrodilatation provides significant improvement in shoulder abduction, flexion, and external rotation. ³¹ Furthermore, it should be noted that hydrodilatation specifically provides greater short-term and long-term improvement in external rotation, and medium-term improvement in abduction when compared to other modalities, such as physiotherapy.^31,34

Multiple techniques for ultrasound guided hydrodilatation of the frozen shoulder have been described. The two most common techniques are based on the approach to infiltrating the GH capsule, primarily the anterior versus posterior approach.

The anterior approach

The anterior approach allows for access through the rotator interval, which consists of four components - the long head of biceps tendon, the coracohumeral ligament (CHL), the superior glenohumeral ligament (SGHL), and the rotator interval capsule. ³⁵ The floor and roof of the rotator cuff interval is formed by the SGHL and CHL, respectively. Of these components, the coracohumeral ligament is believed to be the primary culprit for restricting external rotation associated with FS and is often found to be contracted and thickened in FS.^36,37 Radiologically, it is common to find hypervascularity and hypertrophy of the rotator cuff interval and anterior GH capsule. ³⁸

With the patient positioned supine, or semi-supine, the ultrasound transducer oriented in the long-axis view of the rotator interval allows the physician to visualize the infiltration of the needle through the rotator interval, between the CHL and the biceps tendon sheath. ³⁹

The rationale behind utilizing the anterior approach is based on the concept of treating the commonly involved structures in FS. Theoretically, if the physician can inject corticosteroids around the hypervascularized and inflamed tissues in the anterior joint capsule, the cause of FS should have been addressed and soon resolved.

The posterior approach

The posterior approach only requires the physician to infiltrate the deltoid muscle and the infraspinatus muscle. ⁴⁰ With the transducer positioned in an axial-oblique orientation, the needle penetrates the skin just lateral to the transducer, which is then advanced in an oblique, lateral to medial direction into the GHJ. ⁴¹

One of the benefits with the posterior approach is that there is less chance for extravasation of the injectate outside the GH joint compared to the anterior approach. ⁴² Additionally, the posterior approach is safer in terms of avoiding important neurovascular structures, such as the axillary neurovascular bundle. ⁴¹ We have found that most patients are able to tolerate the posterior approach better than the anterior approach.

Technique

We describe a modified technique for performing an in-office ultrasound guided capsular hydrodilatation under local anesthesia, which we call ‘Sonographically-Navigated Frozen Shoulder Release (S-FSR)’ or ‘Dr Gonzalez's technique.’ Our technique combines both the anterior and the posterior approach. Under ultrasound guidance, the anterior approach is used for the intraarticular corticosteroid injection, which will initially help anesthetize the GH joint. The posterior approach is then utilized for the process of S-FSR.

Patient consent

Prior to starting the procedure, the steps of the procedure are reiterated to the patient one more time. Once the patient has expressed understanding of the procedure, the patient is asked to sign a consent form that outlines the standard risks and complications of any procedure that we perform in the office (i.e., neurovascular injury, bleeding, infection, etc.). The risks and complications associated with this procedure do not vary from any other procedure that is performed in-office, such as intraarticular injections.

Required materials

The supplies and equipment utilized in this technique are standard supplies that would be found in any orthopedic surgery and musculoskeletal office. The only equipment that may not be standard is an ultrasound machine, in which case this procedure should not be performed. We recommend the following supplies and equipment:

1. Ultrasound machine, with either a linear 8–17 MHz transducer or a convex 1–6 MHz transducer.

2. Sterile dressings and solution, physician preference (i.e., betadine vs. chlorhexidine).

3. One 10cc or 15cc syringe for CSI injection via anterior approach.

4. One 25-Gauge, 2-inch hypodermic needle for fenestration of the CHL/SGHL and CSI injection via anterior approach.

5. 10 cc of 1% lidocaine.

6. 2 cc of corticosteroid injection, physician preference.

7. One 22-Gauge, 2-inch hypodermic needle for hydrodilatation via posterior approach.

8. 50cc of normal saline for hydrodilatation via posterior approach. We prefer five 10cc NS flush syringes.

9. Two band-aids.

10. Prescription for diazepam 5 mg and Hydrocodone 5 mg-Acetaminophen 325 mg, one oral tablet each.

Patient preparation

Approximately 30 min prior to the scheduled procedure, the patient is instructed to take diazepam 5 mg one oral tablet and Hydrocodone 5 mg-Acetaminophen 325 mg one oral tablet.

Diazepam is prescribed as an anxiolytic, which has been shown to drastically decrease anxiety and fear in patients undergoing a surgical procedure. ⁴³ Diazepam activates GABA channels by facilitating the binding of GABA molecules, allowing for an influx of chloride ions to hyperpolarize the neurons within the CNS, ultimately depressing brain activity. ⁴⁴ With a half-life of 24–48 hours, diazepam has been shown to adequately mitigate pre-procedure and intra-procedure anxiety in most of our patients, while also providing the added benefit of reducing any other post-procedure sympathetic responses the patient may experience during their immediate post-procedure recovery period. ⁴⁵ It has been our experience that diazepam helps relax the patient to make the procedure more comfortable and reduce any anxiety or apprehension.

Hydrocodone 5 mg-Acetaminophen 325 mg is given to the patient as a pain control agent. Hydrocodone acts to inhibit nociceptive pain without affecting other sensory mechanisms, such as touch. ⁴⁶ With a half-life of 4–6 hours, hydrocodone allows for optimal pain control during the procedure, but also adequate pain control post-procedure as well. ⁴⁷ Although the analgesic effects of acetaminophen are not fully understood, studies have demonstrated that when combined with acetaminophen, hydrocodone is significantly more efficacious in the control of pain, without many significant side effects. ⁴⁸ This combination allows for an additional level of comfort for patients undergoing a procedure without sedation. It is the authors’ experience that this pre-procedural medication contributes to overall patient satisfaction, tolerance, and comfort during S-FSR.

Lastly, after the initial infiltration into the GHJ, the injection of lidocaine minimizes any residual discomfort the patient may experience that is not mitigated by Hydrocodone 5 mg-Acetaminophen 325 mg. This combination and method of simultaneous anxiolysis and pain control with diazepam and Hydrocodone 5 mg-Acetaminophen 325 mg, respectively, allows us to perform this procedure in an office setting without the need for anesthesia or other sedatives.

It should be noted that the use of pre-procedural or pre-surgical use of diazepam for anxiolysis and a narcotic, such as Hydrocodone 5 mg-Acetaminophen 325 mg, for pain control are common practices within anesthesiology and surgical specialties.^43,49 Since both diazepam and Hydrocodone 5 mg-Acetaminophen 325 mg are considered controlled substances, the patient is instructed to arrive to the office 30 min prior to their scheduled appointment and take the prescribed medication at that time under the supervision of our medical staff. Additionally, we strongly recommend a chaperone accompany the patient to ensure the patient can get home safely and does not have to operate a motor vehicle under the influence.

Patient positioning

We recommend the patient is placed in the lateral recumbent, with the contralateral shoulder on the examination table (i.e., left FS treated in right lateral recumbent). The patient's symptomatic shoulder is exposed superiorly and adequately prepared with 10% povidone iodine solution under sterile conditions (See Figure 2).

Figure 2.

Patient is positioned in lateral recumbent with the contralateral side facing down. In this image, the patient has adhesive capsulitis of the right shoulder. Therefore, the left shoulder is facing down on the table.

Glenohumeral joint/capsular infiltration

We use the Alpinion E-CUBE 8 Diamond Ultrasound machine, with either a linear 8–17 MHz transducer or a convex 1–6 MHz transducer, depending on patient anatomy and habitus. In most cases, the linear transducer is sufficient, with the convex transducer reserved for patients with larger body habitus and/or increased soft tissue surrounding the GH joint.

We begin the procedure by visualizing and inspecting different structures within the rotator interval. The rotator cuff interval is a triangular area in the anterosuperior aspect of the shoulder bordered by the supraspinatus and subscapularis muscles, and the coracoid process. ³⁶ It contains the long head of the biceps tendon, coracohumeral ligament, superior glenohumeral ligament, and anterosuperior portion of the glenohumeral capsule and the posterior joint (See Figure 3).

Figure 3.

Reprinted from Petchprapa CN, Beltran LS, Jazrawi LM, Kwon YW, Babb JS, Recht MP. The rotator interval: a review of anatomy, function, and normal and abnormal MRI appearance. American Journal of Roentgenology. 2010 Sep;195(3):567–76(39).

After we have identified and inspected the important structures and ruled out any pathologies, we start by injecting, under direct ultrasound-guidance in the long axis approach, approximately 10 mL of 1% lidocaine to establish adequate local and regional anesthesia. We then proceed with an 80 mg injection of Depo-Medrol (Methylprednisolone) into the glenohumeral joint through the anterior approach at the rotator interval with a 25 G needle. We then continue by fenestrating the superior glenohumeral ligament, the goal of which is to mildly disrupt the SGHL medial to the long head of the biceps tendon. It should be noted that as we approach the SGHL, we are also fenestrating the CHL to properly reach the SGHL. With the 25G needle, we aim to fenestrate the SGHL approximately five-to-ten times by driving the needle through the ligament, depending on the health of the ligaments seen on ultrasound. While there is no specific protocol we follow, this is purely up to the discretion of the physician performing the procedure and the integrity of the SGHL and CHL seen on ultrasound. Refer to the video linked in the abstract above. Fenestration of the SGHL and CHL occurs between time frames 3:30–5:33.

Once fenestration has been achieved, we begin the process of hydrodilatation by sequentially injecting 0.9% NaCl normal saline, under sterile technique, into the glenohumeral joint through the posterior approach using a 22 G needle until release of the glenohumeral capsule is visualized or until the procedure is no longer tolerated by the patient (See Figure 4). Typically, this can be achieved with approximately 30–50 cc of normal saline.

Figure 4.

Sonographically-guided hydrodilatation of the shoulder via posterior view. (a) Posterior view of the glenohumeral joint (b) Posterior view of the glenohumeral joint. White arrow highlights the expansion of the glenohumeral joint.

We recommend utilizing the posterior approach during the process of hydrodilatation. We have found the posterior approach provides easier visualization of the capsule distention and release through ultrasound, while also minimizing discomfort for the patient compared to the anterior approach.

The high-pressure delivery mechanism offered through hydrodilatation allows for improved delivery and spread of the corticosteroids throughout the entire GH joint capsule. ⁵⁰ As the hydrodilatation technique works to release the capsule and liberate the fibrotic and restricted shoulder joint, the corticosteroids spread diffusely throughout the joint to provide potent anti-inflammatory effects throughout the shoulder.

Following the procedure, most of our patients experienced immediate significant improvement in range of motion with associated reduction in pain and discomfort, which continued to improve in the following days. Although there is variation in the amount of improvement and relief the patients experience, it is clear that all of our patients report a decrease in pain and discomfort and an increase in their ROM immediately after the procedure. It is unclear whether the reduction in pain is a direct result of the procedure, a consequence of the lidocaine that was injected at the beginning of the procedure which is allowing the patient to increase their range of motion without pain or discomfort, or both.

In Figure 5(a)-5(c), the preprocedural images display marked reduction in range of motion with lateral abduction, anterior flexion, and external rotation. The following images, figures 5(d)-5(f), demonstrate a significant improvement in overall range of motion immediately following the hydrodilatation procedure. From a subjective view, there is approximately 80 degrees, 90 degrees, and 40 degrees improvement in abduction, flexion, and external rotation, respectively.

Figure 5.

(5a) Pre-procedure abduction (5b) Pre-procedure flexion (5c) Pre-procedure external rotation, (5d) Post-procedure abduction, (5e) Post-procedure flexion, (5f) Post-procedure external rotation.

Discussion

Does S-FSR really work?

The modified technique we describe has shown to be more effective in those patients who have failed initial conservative treatments like NSAIDs, PT, and CSI, and is recommended for patients in the frozen or thawing phase. S-FSR has provided functional improvements in the range of motion in patients treated with this novel technique, accompanied by 100% patient satisfaction. Furthermore, in evaluating the 10 most recent patients that have been treated with S-FSR, there is an average improvement of 87.9 degrees, 94.5 degrees, and 40.5 degrees in forward flexion, abduction, and external rotation, respectively (see Figure 6).

Figure 6.

10 patients treated using novel S-FSR by Dr. Jorge Gonzalez. Average improvement: Forward Flexion (FF): 87.9 degrees; Abduction (ABD): 94.5 degrees; External Rotation (ER): 40 degrees.

In the UK FROST study, Rangan et al. evaluated the efficacy of early physiotherapy and two surgical procedures, MUA and arthroscopic capsular release. ²⁴ The UK FROST studies ultimately concluded that there was no clinically superior intervention between the three treatment modalities. ²⁴ Furthermore, although Rangan et al. considers MUA to be a surgical procedure, many clinicians consider MUA to be a non-invasive, conservative treatment modality for FS.^23,24 We consider early physiotherapy with corticosteroid injections and MUA to be conservative, non-invasive modalities and arthroscopic capsular release an invasive treatment method.

Although S-FSR requires the insertion of two needles into the GH joint, we consider S-FSR to be a semi-invasive procedure. There is no gross exposure of the GH joint and only involves the injection of various substances (i.e., corticosteroids, lidocaine, and normal saline). Since the UK FROST studies concluded there was no superior intervention in the management of FS, we are aiming to determine if a more semi-invasive modality may produce better results.

Patients are typically seen 7–10 days post procedure for follow up. At that appt, ROM is again documented, which are the values reported in Figure 6. Typically, patients are seen on an as-need basis (PRN) from that point on as their problem has been corrected and they can return to their normal activities.

Of the 10 patients presented in Figure 6, none of the patients have experienced a return in their symptoms, the oldest of which was performed in July 2022. Moreover, none of the patients treated with S-FSR over the past 2 years have experienced a return in their symptoms. While patients have mentioned they have not fully regained the same level of functionality or ROM prior to developing FS, all the patients treated with S-FSR have reported a significant improvement in functionality, successful return to work, and no return of pain, discomfort, or restricted ROM. Lastly, none of the patients we have treated with S-FSR have reported any complications, such as neurovascular deficits, infection at the site of procedure, adverse drug reactions, or return of symptoms.

While the purpose of this publication is to describe a modified technique for treating frozen shoulder, future studies should focus on a more formal clinical trial-based study with an objective data collection and analysis process, utilizing common scoring systems for evaluating shoulder pain and FS symptomology, such as the Oxford Shoulder Score, to ultimately determine the efficacy of S-FSR compared to traditional interventions. Longitudinal studies would also benefit the utility of this technique and further reinforce the efficacy of S-FSR. Just like any novel technique, future studies are necessary along with long-term follow-up to determine the efficacy of our technique. Hopefully, by publishing our technique, we can encourage more clinicians interested in partnering with us to perform a more robust and longitudinal study.

Anterior vs. posterior approach

One study concluded that there were minimal differences between using the posterior approach vs. the anterior approach. The only significant difference between the two approaches was a reduction in pain during motion, as determined by the visual analog scale (VAS), when utilizing the anterior approach compared to the posterior approach. ⁴⁰ For this reason, we prefer to start the procedure with injection of 10 mL of 1% lidocaine and the 80 mg of triamcinolone acetonide, along with SGHL fenestration, through the anterior approach. This allows us to further anesthetize the GH joint with the lidocaine prior to starting hydrodilatation through the posterior approach.

There has been heterogeneity in the literature when it comes to the best approach for performing ultrasound-guided capsular hydrodilatation. Traditionally hydrodilatation has been performed through the posterior GHJ approach; however, novel anterior approaches through the rotator interval have since been described to be the superior approach.^40,51

Wang et al. concluded the only advantage of the anterior approach was a reduction in pain during motion following the procedure; however, a greater volume of injectate was also possible through the anterior approach, which may have contributed to this outcome. ⁵² Additionally, Elnady et al. concluded that hydrodilatation of FS through the anterior rotator interval, followed by guided exercise, was clinically and functionally superior to the posterior approach. ⁵³ Conversely, Elnady et al. also conducted a different study which concluded that hydrodilatation via posterior approach resulted in better recovery of shoulder function and range of motion compared to the anterior. ⁴⁰

Lastly, when determining the safety and risk of neurovascular injury between the two approaches, Kuratani et al. conducted a study analyzing the safety of ultrasound-guided glenohumeral joint injection, confirmed by magnetic resonance arthrography. ⁵⁴ Unfortunately, the study did not specifically evaluate the incidence of NV injury and was only able to conclude the accuracy and safety of using ultrasound-guidance for the posterior approach to the GH joint. ⁵⁴ Regardless, Kuratani et al. were still able to determine that when using ultrasound-guidance, injection into the GH joint is extremely accurate and the risk for NV injury is minimal, as confirmed by magnetic resonance arthrography. ⁵⁴ However, the accuracy and utility of ultrasound-guidance was still highly dependent on the experience of the clinician performing the procedure.

Due to the controversy and ambiguity between the two approaches, we recommend our technique due to the utilization of both approaches. When performing the initial corticosteroid injection, we utilize the anterior approach. This not only allows us to gain easier access to the SGHL and CHL for fenestration, but it also allows us to surround the subacromial bursa with CSI as well. Through the anterior approach, we can bathe the rotator cuff interval with anti-inflammatory steroids, while also providing adequate analgesia to the glenohumeral joint in preparation for hydrodilatation.

Following CSI, we utilize the posterior approach during the process of hydrodilatation. Since we know there is a lower chance of extravasation when using the posterior approach, we can ensure that all the injectate for hydrodilatation is being placed into the GH joint, subsequently maximizing the chances of reaching successful dilation and possible release of the GH capsule. Additionally, the posterior approach allows us to better visualize the distension of the GH capsule, along with subsequent release of the joint capsule, if achieved. Although the anterior approach allows for greater instillation of injectate into the GH capsule, we have seen capsular release achieved with as little as 30 mL of 0.9% saline. Therefore, we do not think it is necessary to specifically utilize the anterior approach solely for the sake of being able to inject a greater volume of injectate. ⁴⁰ Additionally, studies have demonstrated the posterior approach to be more comfortable and tolerable for the patient versus the anterior approach. ⁴⁰

Superior glenohumeral ligament fenestration

Although hydrodilatation for FS has been extensively researched and utilized, one unique aspect of this technique is the fenestration of the superior glenohumeral ligament. According to Mezian et al., FS is typically defined as fibrosis and inflammatory contracture of the rotator cuff interval. ⁸ Due to its contribution to the construct of the rotator interval and its role in the restricted ROM and loss of function in FS, we target the SGHL for fenestration due to ease of access relative to other ligaments within the GH joint for fenestration.

Studies have identified the SGHL as one of the primary ligaments for stabilization of the GHJ, especially during abduction and external rotation. ⁵⁵ The SGHL has also been recognized as one of the primary restrictive ligaments in the pathophysiology of FS. ⁵⁶ Therefore, we hypothesize that by fenestrating the primarily restricting ligaments in FS, the SGHL and CHL, we can help release the frozen shoulder and improve the ROM.

We acknowledge that it is not easy to identify the rotator interval, CHL or SGHL on ultrasound for clinicians who are not familiar or competent with ultrasound. For this reason, we have included a detailed video linked in the abstract above, where we describe how to identify and fenestrate these structures.

Fortunately, because we encounter the CHL before the SGHL, we are able to fenestrate the CHL before reaching the SGHL. We know the CHL is the primary restrictor of external rotation in FS. Therefore, by fenestrating the CHL on the way to the SGHL, we are able to address and slacken both the CHL and SGHL during our procedure. After gentle fenestration through the CHL and SGHL, 10cc of 1% lidocaine is injected to create capsular anesthesia. By then performing high volume hydrodilatation through the posterior approach, direct visualization of capsular distension and subsequent release is documented.

In our technique, we have witnessed more consistency in achieving capsular release after fenestration, compared to hydrodilatation without fenestration. The idea of fenestrating the SGHL and CHL with a 25G needle was that it could potentially improve the laxity of those ligaments, which would ultimately facilitate the improvement in ROM. Since implementing the fenestration of the SGHL and CHL, we have noticed an overall improvement in patient outcomes.

Anecdotally, we have not noticed a significant difference in the overall volume of solution required to achieve capsular release. On the other hand, we have noticed significant improvement in symptoms and quicker recovery of functionality when fenestration is performed compared to previous procedures when fenestration was not performed. Future studies should aim to quantify or more objectively determine the efficacy and role of SGHL and CHL fenestration.

Lastly, we presume that by ensuring adequate capsular release through fenestration, the corticosteroid injectate used at the beginning of the procedure can leak out of the GH joint capsule and bathe other surrounding structures that may also be inflamed, which may also contribute to the patient's restricted ROM and clinical presentation.

When discussing more aggressive techniques beyond NSAIDs and physical therapy, it has been proven that CSI and hydrodilatation offer significant improvements in pain, shoulder function, and range of motion. For this reason, we believe combining hydrodilatation using normal saline, along with corticosteroids, is the best option for the patient. By combining two of the most effective techniques in treating FS, we hope to provide the patient with the greatest chance for improvement and resolution of FS without the need for more invasive surgical intervention. Previous studies that have utilized a regimen of 40–80 mg triamcinolone combined with 10 mL of 1% lidocaine and 40 mL normal saline have demonstrated up to 63% of patients regain near-normal function of the shoulder by the 1-month follow-up. ⁵⁷ Our hope is that by adding the fenestration of the SGHL, we can close the gap for the remaining 37% of patients who did not regain near-normal function through the regimen utilized by Clement et al. It is also important to note that patient selection and understanding the pathophysiology of the disease is crucial. For example, if the procedure is performed in patients still in the freezing or inflammatory phase, there is a high likelihood that the patient will not tolerate complete capsular distension and release.

Release of the glenohumeral joint

There has been much debate over whether rupture of the glenohumeral joint capsule is necessary; however, for our technique, we prefer and aim to visualize a gradual release of the glenohumeral joint capsule under ultrasound guidance. Studies have shown that corticosteroid hydrodilatation with arthroscopic capsular release significantly improves passive ROM and function, with no significant impact on pain relief compared to only corticosteroid hydrodilatation or arthroscopic capsular release. ⁵⁰ Therefore, we conclude that the ability to achieve capsular release with hydrodilatation under ultrasound guidance, instead of arthroscopic surgery, is a convenient and practical treatment modality for most patients with FS.

Tveita et al. report that rupture of the glenohumeral capsule can be linked to the moment when there is a loss in resistance when injecting into the shoulder joint and a contrast leak is identified under fluoroscopic examination. ⁵⁸ Based on these findings, we believe capsular rupture can be identified by the moment there is a reduction or shrinkage of the GH joint on ultrasound. During the procedure, we notice a gradual increase in the size of the GH joint, which is proportional to the volume of solution we inject into the GH joint, which is easiest to visualize through the posterior approach. As we continue to instill the solution, at the moment where there is a loss of resistance, we visualize a sudden collapse of the GH joint on ultrasound (See Figure 7). We believe this to be the moment when capsular rupture is achieved and the remaining solution we inject starts to fill the extra-articular compartments.

Figure 7.

(a) Start of hydrodilatation process (b) GH joint expansion with instillation of injectate (c) decreased size of GH joint following capsular release.

Video evidence of GH joint expansion and capsular release can be seen in the video linked above in the abstract, starting at time marker 11:00. This belief is based on the theory that after capsular rupture is achieved, little additional distension of the joint can be visualized because the injected material begins to leak out of the intra-articular capsule and into the extra-articular space. ⁵⁸ It should be noted that visualization of capsular release is not always evident or present, but as long as the technique and protocol described above are followed, the patient's outcomes remain the same.

Hydrodilatation solution

Different clinicians have proposed varying solutions for hydrodilatation. From 30cc of 0.9% normal saline, to a 50cc mixture of 0.9% normal saline, corticosteroids, and lidocaine, there is a wide variety of different solutions that have been suggested; however, there are no studies that have definitively identified one specific solution to be superior. Since we already injected a 10 mL solution of corticosteroids and 1% lidocaine through the anterior approach, we prefer to use 30 mL-50 mL of 0.9% normal saline, only, through the posterior approach to achieve capsular release.

Utility of ultrasound

While many other protocols and techniques involving hydrodilatation involve imaging techniques such as fluoroscopy, our technique provides the flexibility of utilizing ultrasound to visualize the instillation of large volumes of fluid, along with the rupture or release of the glenohumeral joint capsule. Additionally, ultrasound allows the physician to directly visualize placement of the needle between the CHL and the biceps tendon sheath, ensuring the injectate is injected directly into the GH capsule. Ultimately, this method not only reduces radiation exposure to the patient and physician, but also eliminates the need for iodinated contrast media and ensures proper placement of the injectate into the GH joint and reduces the risk of damaging surrounding structures. ³⁸ It also allows for the procedure to be performed in an outpatient, in-office setting. From start to finish, the average time spent in the office is approximately 45–60 min.

Needless to say, when determining whether or not capsular rupture contributes to long-term resolution of FS, future studies would need to include patient survey and clinical evaluation to determine the long-term efficacy of capsular rupture and resolution of FS.

Physical therapy during the freezing phase

It is known and has been described that aggressive physical therapy can have a detrimental and negative affect in the disease progression. ⁵⁹ In our experience, once a patient starts on the path to a frozen shoulder (i.e., freezing phase), there is no stopping the progression to the frozen phase and thawing phase. There are, however, techniques we can utilize to shorten the duration of the freezing phase and quickly push the patients into the frozen phase, or even the thawing phase, where we can intervene and offer more definitive treatment.

During the freezing phase, we have noticed that when our patients undergo physical therapy, the pain and discomfort they experience is unbearable for them to continue. The inflammation that takes place during the freezing phase causes a pain that is far more debilitating for the patient, than if they were to simply immobilize their shoulder followed by aggressive physical therapy during the frozen and thawing phases. Therefore, we prefer to provide patients with NSAIDs, and when all else fails intraarticular injections, to speed up their progression through the freezing phase and into the frozen stage. From there, we can plan for S-FSR and aggressive physical therapy in hopes to shortening the overall duration of their FS.

Cost implication

The cost implication to perform this procedure is minimal as this can be easily done in a regular 30-min office visit in a procedure or examination room. There is no requirement for an ambulatory surgical center or hospital admission.

If we consider the ultrasound-guided anterior approach for hydrodilatation of FS as the standard of treatment, any clinician performing this procedure should have an ultrasound machine and materials for patient preparation and sterilization at their disposal (i.e., normal saline, betadine solution, sterile towels, etc.). One specific cost we cannot comment on is the cost of medication, which will widely depend on the clinician's preference. For example, when comparing CSI solutions outlined by Elnady at al. and Wang et al., an injectate utilizing 1cc of methylprednisolone, 1cc of 2% lidocaine, and 15cc of 0.9% normal saline, will not cost the same as an injectate consisting of 4cc triamcinolone acetonide, 4cc of 2% lidocaine, and 12cc of 0.9% normal saline.^52,53 Therefore, we are unable to comment on the specific cost implications of our CSI solutions described in our technique.

Regardless the supplies needed to perform the procedures are typical standard needles, syringes and antiseptic solution that would be standard in any orthopedic surgery/musculoskeletal practice. Although supply costs can vary in different states and countries depending on manufacturer, in our practice the cost of supplies was less than $50 USD for the entire procedure.

Time implications

In terms of any additional time that may be required with our modified technique, the most time-consuming aspect of the technique we describe is the time spent during the pre-procedural medication. We ask that patients arrive 30 min ahead of their scheduled appointment where they can take the prescribed diazepam 5 mg and hydrocodone 5 mg-acetaminophen 325 mg under the supervision of our medical team. During this time, we also prepare and position the patient, while also answering any last-minute questions they may have.

When examining the time implications for performing both an anterior and posterior approach, our technique only adds, on average, an additional seven minutes to the overall procedure. This procedure can be easily performed in a regular 30-min appointment. This is evidenced in the video link listed above in the abstract, where a 12-min video of the entire procedure is available, with additional time taken for commentary and instructional details. Therefore, this should be considered an in-office procedure and should be approached with similar time constraints and scheduling requirements as any other procedure.

It is important to note that the primary goal in treating patients with recalcitrant adhesive capsulitis is overall patient outcomes, specifically if we can help our patients with a safe, quick procedure that can be done without IV sedation.

Economical implication

One major benefit of our technique is the patient's ability to return to work the very next day. Although we typically advise our patients to rest for a few days, theoretically, the patient can return to work the very next day with a restriction of no lifting >5lbs and no overhead activities for 3–5 days. For this reason, we prefer to perform S-FSR on Friday, so the patient has the weekend to rest and recuperate from the procedure. Therefore, S-FSR allows patients to return to work faster, and because it can be performed in-office, there is no financial burden associated with hospital staff, equipment, or time. The only financial cost to the patient is that which is imposed by the physician performing the procedure.

Bouaicha et al. conducted a retrospective study involving 456,926 patients with FS. It was concluded that approximately 140,700 of those participants required, on average, 90 days of sick leave. Moreso, approximately 44,300 participants required, on average, 360 days of sick leave. ⁶⁰ Lastly, Bouaicha et al. also concluded that healthcare costs associated with FS totaled 78 million CHF each year, which is equivalent to approximately 85.6 million USD. ⁶⁰

While we are unable to provide the exact days of sick leave our patients have required, the simple fact that our patients can return to work the very next day reinforces the utility of S-FSR and the benefits our technique offers, such as faster return to work times and less sick days.

Lastly, many of the patients we have treated with S-FSR were referred by other providers after a prolonged course of shoulder limitation and failed conservative management. In fact, most of our patient struggled with FS for 6 months-1 year. All of these patients were able to recover the majority of the shoulder function within 10 days following S-FSR. One of the main reasons for publishing this technique is to teach other providers this technique, or at least improve recognition of the problem and refer the patient to someone who can perform the procedure as soon as possible.

Conclusion

Nonetheless, our modified sonographically navigated frozen shoulder release (S-FSR) technique is a relatively easy, safe and very tolerable in-office technique for those patients with recalcitrant FS. The modified technique also provides quick recovery to the patient's range of motion (See Figure 6) and should be considered an alternative treatment option.

We recommend the following modifications:

1. Pre-procedural medication with diazepam 5 mg, 1 tablet PO and Hydrocodone 5 mg-Acetaminophen 325 mg, 1 tablet PO.

2. Local anesthetic and corticosteroid injection via anterior approach/rotator interval under sonographic guidance.

3. Fenestration of the SGHL and CHL during intraarticular corticosteroid injection.

4. Hydrodilatation via posterior approach under sonographic guidance. We recommend 30–50cc of NaCl or until capsular release is observed.