Shoulder
Frozen Shoulder
Adhesive capsulitis treated with ultrasound-guided hydrodilatation and manipulation to restore range of motion and relieve pain — without surgery.
Understanding frozen shoulder
Frozen shoulder (adhesive capsulitis) is a condition in which the capsule surrounding the shoulder joint becomes thickened, inflamed, and contracted, leading to progressive pain and significant loss of range of motion. It most commonly affects adults between 40 and 60 years of age and is more prevalent in women, individuals with diabetes, and those with thyroid disorders.
The condition typically progresses through three overlapping stages: a painful "freezing" phase, a stiff "frozen" phase, and a gradual "thawing" phase. While frozen shoulder can eventually resolve on its own, the natural course often takes 18 to 30 months, and some patients are left with persistent stiffness. Targeted intervention can significantly accelerate recovery and improve outcomes.
Stages of frozen shoulder
- Freezing stage (2 to 9 months) — Gradual onset of diffuse shoulder pain, often worse at night. Range of motion begins to decrease as inflammation develops within the joint capsule.
- Frozen stage (4 to 12 months) — Pain may begin to diminish, but stiffness becomes the dominant problem. The shoulder capsule is significantly contracted, severely limiting movement in all directions.
- Thawing stage (5 to 24 months) — Range of motion gradually returns as the capsule begins to loosen. Without intervention, this phase can be prolonged and incomplete.
Diagnostic imaging
We use musculoskeletal ultrasound to evaluate the shoulder joint, assess capsular thickening, and rule out other causes of shoulder pain such as rotator cuff tears or calcific tendinopathy. Radiographs may be obtained to evaluate for osteoarthritis or other bony abnormalities. MRI is occasionally ordered for complex cases or when the diagnosis is uncertain, as it can demonstrate capsular thickening and inflammation characteristic of adhesive capsulitis.
Treatment options
Hydrodilatation (distension arthrography)
Hydrodilatation is a minimally invasive procedure that involves injecting a volume of fluid — typically a mixture of saline, local anesthetic, and corticosteroid — into the shoulder joint under ultrasound guidance. The goal is to stretch and distend the contracted joint capsule, breaking adhesions and restoring space within the joint.
The procedure is performed in-office using real-time ultrasound guidance to ensure the needle is accurately placed within the glenohumeral joint. As fluid is injected, the capsule progressively expands, and patients often experience an immediate improvement in range of motion.
Multiple randomized controlled trials and systematic reviews have demonstrated that hydrodilatation provides significant short-term improvements in pain and range of motion compared to corticosteroid injection alone or placebo. It is particularly effective during the freezing and frozen stages when capsular contracture is most pronounced.
Manipulation
Gentle manipulation of the shoulder may be performed immediately following hydrodilatation, while the capsule is distended and the local anesthetic is in effect. This involves carefully moving the shoulder through its available range of motion to further break adhesions and improve mobility.
Unlike manipulation under general anesthesia (which carries higher risks), in-office manipulation after hydrodilatation is a controlled, low-risk approach that takes advantage of the capsular distension and local anesthesia to maximize gains in range of motion during the same visit.
The combination of hydrodilatation followed by gentle manipulation has been shown to produce greater improvements in shoulder mobility than either technique alone.
What to expect
Your visit begins with a clinical evaluation, review of any prior imaging, and an in-office ultrasound assessment of the shoulder. We will discuss the stage of your condition, your current range of motion, and whether hydrodilatation is appropriate for you.
The hydrodilatation procedure takes approximately 30 to 45 minutes. Most patients notice an immediate improvement in range of motion following the procedure. Mild soreness at the injection site is common for 24 to 48 hours. We provide a structured home exercise and stretching protocol to maintain and build on the gains achieved during the procedure.
Some patients achieve significant improvement with a single session, while others may benefit from a second procedure several weeks later. Follow-up visits include repeat assessment of range of motion and ultrasound imaging to monitor progress.
References
- Buchbinder R, Green S, Youd JM, Johnston RV. Arthrographic distension for adhesive capsulitis (frozen shoulder). Cochrane Database Syst Rev. 2008;(1):CD007005. doi:10.1002/14651858.CD007005
- Catapano M, Mittal N, Engelbrecht B, et al. Hydrodilatation with corticosteroid for the treatment of adhesive capsulitis of the shoulder: a systematic review and meta-analysis. PM R. 2018;10(7):791-800. doi:10.1016/j.pmrj.2018.02.002
- Quraishi NA, Johnston P, Bayer J, Crowe M, Chakrabarti AJ. Thawing the frozen shoulder: a randomised trial comparing manipulation under anaesthesia with hydrodilatation. J Bone Joint Surg Br. 2007;89(10):1197-1200. doi:10.1302/0301-620X.89B10.18272
- Sharma SP, Baerheim A, Moe-Nilssen R, Kvale A. Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual: a randomised controlled trial in primary care. Br J Gen Pract. 2016;66(645):e268-e278. doi:10.3399/bjgp16X684325
- Lewis J. Frozen shoulder contracture syndrome — aetiology, diagnosis and management. Man Ther. 2015;20(1):2-9. doi:10.1016/j.math.2014.07.006
- Prestgaard T, Wormgoor MEA, Haugen S, et al. Ultrasound-guided intra-articular and rotator interval corticosteroid injections in adhesive capsulitis of the shoulder. BMC Musculoskelet Disord. 2015;16:207. doi:10.1186/s12891-015-0672-9