Introduction

Frozen shoulder is a common and disabling condition. Although it is usually self-limiting, recovery times are often unacceptable for patients. While there are several minimally invasive therapeutic options, such as steroid-anesthetic subacromial injections, intra-articular injections, hydrodilation and under local anesthesia manipulation of the shoulder, none of them are considered the gold standard. On the other hand arthroscopic arthrolysis has not shown superior results compared to these less invasive options .

Objective

To report the results of our technique involving ultrasound-guided injections of cortisone and lidocaine in differents anatomicals points with capsular hydrodilation and a controlled mobilization under local anesthesia, followed by a rehabilitation protocol, in a group of patients with frozen shoulders.

Methods

& MATERIALS: The inclusion criteria were patients with a clinical diagnosis of frozen shoulder, who had failed conservative treatment for at least 2 months. The exclusion criteria were patients with previous infiltrations or other invasive treatments, those with medical contraindications for steroid use, associated rotator cuff injuries or glenohumeral osteoarthritis, and those who could not be adequately controlled. Shoulder X-rays and MRIs were performed in all the patients.
The procedure was carried out under sterile conditions, diluting 2 ml of betamethasone phosphate-dipropionate in 15cc of 2% lidocaine and 20cc of saline into 3 syringes of 10cc each. Ultrasound-guided injection was performed at various anatomical points of the shoulder. Initially, 4cc was injected into the bicipital groove, 4cc into the subacromial space, 10cc into the rotator cuff interval, and finally 10cc intra-articular from the posterior capsule.
After the injections, taking advantage of the anesthesia generated by infiltrations, a controlled manipulation of the shoulder in three steps-directions was performed: anterior elevation, external rotation, and internal rotation. At 96 hours, the rehabilitation protocol was resumed. Patients were assessed using the VAS scale and the SPADI score, and passive mobility, before the procedure and subsequently at 15 days, and at 1, 3, 6, and 12 months.

Results

A total of 82 patients were included, with an average follow-up time of 19 months (19-60). The average results of the VAS scale before the procedure, at 15 days, and at 1, 3, 6, and 12 months were (9.5-3.2-2.8-2.1-1.5-0.8). The average SPADI score before the procedure, and at day 15 and at 1, 3, 6, and 12 months were (84.6%, 50.7%, 21.53%, 6.10%, 3.07%, and 2.30%). In terms of passive mobility, the initial average evaluation was: anterior elevation (AE) 118.2°, lateral elevation (LE) 73.5°, external rotation (ER) 36.1°, internal rotation (IR) 20.8°. At 6 months, 87.6% of patients had fully recovered mobility, compared to the contralateral side, giving the following average values AE 172.2°, LE 93.8°, ER 95.2°, IR 66.9°.

Conclusion

To our knowledge, this is the first study to describe this technique for frozen shoulders treatment. Based on our experience, the combination of different ultrasound guide infiltration (Subacromial, Bicipital groove, rotator interval, posterior hydrodilatation) plus manipulation of the shoulder, has provided very good clinical results, and that's why it is our main approach in patients with frozen shoulder that fail to conservative treatment.