Caroline Parlier Cuau Marc Wybier and Jean Denis Laredo

Department of Bone and Joint Radiology, Lariboisière Hôpital, Assistance Publique-Hopîtaux de Paris, Paris, France

INTRODUCTION

Frozen shoulder syndrome (FSS) is of uncertain etiology. It is characterized by the spontaneous onset of pain in the shoulder, with insidious progressive restriction of both active and passive motion in every direction, mainly external rotation and anterior elevation. Pain is often very severe and disturbs sleep. After several weeks and months, the painful phase gradually abates and is followed by a period of stiffness. This period of stiffness without improvement lasts between 4 and 12 months (1). Spontaneous gradual recovery of motion then follows over a period of several months. The total duration of FSS may be difficult to evaluate because the exact times of onset and resolution are frequently not clear: the initial pain may be confused with that of a shoulder tendonitis or trauma, which, not infrequently, often proceeds to FSS. Complete recovery from FSS is also difficult to define: some patients who consider their range of motion (ROM) still restricted are found to have no restriction on objective testing at long-term follow-up and conversely many other patients who regard their ROM as normal are found to have significant restriction at clinical examination (1-4). Distention arthrography (DA) involves the injection into the joint of contrast media, steroids, lidocaine, and a large volume of fluid in order to obtain joint distension.

TECHNIQUE

DA is usually performed on an outpatient basis. The patient is placed in the supine position, with the arm at the side and, as far as possible, the palm supported to hold the shoulder in external rotation in order to facilitate needle placement into the anterior aspect of the glenohu-meral joint. The X ray beam is vertically oriented over the joint. The skin is prepped with an iodine solution. The skin and superficial planes are anesthetized with 1% lidocaine. A 20-gauge 9-cm needle is vertically inserted under fluoroscopic control into the anterior aspect of the joint through the anesthetized skin. First, 2 to 3 mL of contrast material (meglumine loxaglate) is injected to outline the glenohumeral space, confirming correct intra-articular needle position. The joint capacity must be measured and is typically dramatically reduced (1,4-10). Most patients have not more than 2- to 3-mL joint space volume together with no more than 8 to 10 mL with loss of distensibility of the capsule. In most cases, the arthrogram is very suggestive of adhesive capsulitis (Fig. 1): there is a marked reduction in size of all joint recesses, the inferior (axillary) and internal (subcoracoid and subscapularis) recesses. The bicipital tendon sheath is inconstantly opacified. In addition, the synovial pouch around the humeral head is "tight looking" and has an irregular indented outline. Early lymphatic filling is not uncommon. However, arthrography may be surprisingly normal in some patients with full clinical criteria of FSS (4,5). A rotator cuff tear is present in 10% (1,3,5,7) to 3l.3% (9) of cases.

Next, 3 mL of 2% lidocaine and 1.5 mL of cortivazol are injected intra-articularly. This injection often causes a severe exacerbation of shoulder pain. Characteristically, releasing the finger from the plunger of the syringe leads to immediate return of fluid into the syringe and immediate decrease of shoulder pain. Third, distension of the capsule is then performed using 30 to 40 mL of chilled sterile saline solution according to Fareed and Gallwan's technique (8). The maximum volume injected depends on the distensibility of the joint capsule.

Joint distension, the "brisement procedure" (11), requires slow, gradual, intermittent injection of a larger and larger volume of chilled sterile saline solution. To avoid excessive fluid reflux from the needle while settling a new syringe of saline solution, a lockable three-way

FIGURE 1 Arthrogram of frozen shoulder syndrome; inferior and internal joint recesses are filling up insufficiently.

stopcock could be placed over the needle. The aim of the procedure is to distend the joint with the largest volume of fluid (usually up to 40-50 mL) (Fig. 2) without fluid extravasation. Fluid extravasation may occur at the subscapular recess or the bicipital tendon sheath, causing a sudden fall in the joint resistance to distension. Further injection would be then ineffective and the procedure should be stopped.

FIGURE 2 Arthrogram of distended shoulder after injection of a large amount of fluid.

Arthrographic distension is immediately followed by active assisted ROM exercises under the supervision of a physical therapist. The following days, the patient continues with regular home physical therapy exercises.

AUTHORS' EXPERIENCE

The authors' experience is a noncontrolled study including 30 glenohumeral joints in 29 patients with FSS (17 female and 12 male patients; age range 41-65 years; mean age 49 years) treated with DA. Patients were assessed for pain (Huskinsson scale) and shoulder ROM in internal and external rotation, anterior and posterior elevations, and abduction; first prior to DA and then at 15-day-and 45-day-follow-up after treatment. At 15-day follow-up, 80% of patients considered that they had very good (53%) or good (27%) results. At 45-day follow-up, 90% of patients considered that they had very good (80%) or good (10%) results; none of the patients considered that they had no benefit at all at 45-day follow-up.

DISCUSSION

A wide variety of treatments have been investigated in FSS. Physiotherapy is widely recommended in most of the published reports, including home exercises consisting of pendulum exercises and resisted exercises performed several times daily. Oral (2) and local (12) steroids are also frequently prescribed. Manipulations of the shoulder performed under general anesthesia (13) or under interscalenic brachial plexus block anesthesia (14,15) have also been proposed. More recently, arthroscopic release (14,16-19) or surgical excision (10,20) of the coracohumeral ligament has been reported to be highly effective in patients who did not improve under conservative therapy: the coracohumeral ligament normally restrains external rotation of the shoulder with the arm at the side, and its contracture due to the chronic fibrotic thickening present in FSS (10,20) acts as a check-rein against external rotation resulting in loss of both active and passive movement (20).

The therapeutic value of DA has been studied by many authors (6-9,13,21-25) since Andren and Lundberg first reported that joint distension occurring during diagnostic arthrography could be effective for shoulder restriction (11). Most studies evaluating DA were noncontrolled series (7-9,13,23,25). Satisfactory (good and excellent) results were obtained in 68% (13 cases) and 96% (22 cases). Data provided by controlled studies (6,22,24) is more limited with less convincing results. Corbeil et al. found no statistical difference in ROM at three-month follow-up between patients having a nondistensive arthrography with intra-articular injection of steroids and those having additional intra-articular injection of 20 mL of lidocaine (6). Also, Jacobs et al. reported no statistical difference in ROM at 16-week followup between patients treated with intra-articular injection of steroids alone and those treated with intra-articular steroids combined with joint distension (22). However, in the later group, distension consisted in intra-articular injection of only 6 mL of lidocaine plus 3 mL of room air (22). Gam et al. reported significant improvement in ROM at 12-week follow-up for the patients treated with intra-artic-ular steroids combined with distension (24). We believe that additional controlled studies are necessary to confirm the value of DA in FSS. DA should also be used in combination with other treatments (intra-articular glucocorticoids, gentle mobilization under local anesthesia, and sedation or general anesthesia) (25).

Considering the technique of DA, Rizk et al. found, in an open trial including 16 patients, that good results were achieved only when capsular rupture was obtained during the procedure (1); our own results do not confirm this statement as, in most of our patients, capsular rupture did not occur during joint filling.

As mentioned above, physiotherapy is widely recommended as an early therapy either alone or in association to other treatments including DA. The goal of physiotherapy is to relieve pain, improve motion, and restore function. Physiotherapy is widely used and generally held to be beneficial. However, no convincing evidence of efficacy has been found in well-designed studies (26). Also, to our knowledge, the advantage of physiotherapy in association with DA over DA alone has not been studied. In contrast, DA was found to be effective in patients unsuccessfully treated by previous physiotherapy in many reports (7,8,13) suggesting DA has advantages over physiotherapy alone in FSS. In our institution, patients treated with DA are instructed to self-perform home physical therapy exercises in the days following the procedure. Finally, mid-long-term assessment of treatment results in FSS is challenging because FSS is a self-limiting condition with spontaneous recovery after several months or years. Bulgen et al. reported that various treatment regimens, including intra-articular injection of steroids, ice therapy, and mobilizations, have little long-term advantage over no treatment in FSS (12). However, the aim of procedures such as DA in FSS is not to modify the overall course of the disease, but rather to shorten the most disabling phase of this condition.

CONCLUSION

In noncontrolled studies, DA, which includes intra-articular injection of steroids followed by hydraulic joint distension, provides good and excellent results in 90% of the cases. DA obtains rapid improvement in pain and joint stiffness and shortens the disabled period. However, the respective role of intra-articular injection of steroids and hydraulic distension in the achievement of good results remains to be studied in controlled studies.

REFERENCES

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2. Blockley NJ, Wricht J, Kellgren JH. Oral cortisone therapy in periarthritis of the shoulder. Br Med J 1954; 4:1455.

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25. Laroche M, Ighilahriz O, Moulinier L, Constantin A, Cantagrel A, Mazieres B. Adhesive capsulitis of the shoulder: an open study of 40 cases treated by joint distention during arthrography followed by an intraarticular corticosteroid injection and immediate physical therapy. Rev Rhum [Engl Ed] 1998; 65:313-319.

26. Noel E, Thomas T, Schaeverbeke T, Thomas P, Bonjean M, Revel M. Frozen shoulder. Joint Bone Spine 2000; 67:393-400.

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