Ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of frozen shoulder

Abstract

BACKGROUND:

Frozen shoulder (FS), also known as shoulder adhesive capsulitis, is a musculoskeletal disorder associated with pain and functional disability. There is a lack of evidence on the optimal treatment strategy for FS.

OBJECTIVE:

The present study aimed to evaluate the effectiveness and safety of ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of FS.

METHODS:

In this prospective randomized, double-blind, controlled study, 63 FS patients were recruited, and equally allocated to treatment group and control group. The treatment group was treated with ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy, while the control group was only treated with ultrasound-guided hydrodilatation of glenohumeral joint. The pain and mobility of shoulder, overall efficacy and adverse reactions were evaluated 3 months after treatment.

RESULTS:

At baseline, no significant difference in all characteristic value was found between the treatment group ( $n=$ 33) and control group ( $n=$ 30). Three months after operation, the joint’s Active Range of Motion (AROM) and Constant-Murley Scale (CMS) scores in the experimental group were higher than those in the control group, and the coracohumeral ligament (CHL) thickness and the rate of hypoechoic thickening in rotator cuff space in the experimental group were lower than those in the control group (all $P<$ 0.05). The amount of injection volume at the third hydrodilatation was significantly higher in the experimental group than that in the control group (15.8 $\pm$ 4.7 vs 12.2 $\pm$ 5.2, $P=$ 0.03). After 2 times of treatment, the volume increment of glenohumeral joint $\Delta$ 2 in the experimental group was greater than that in the control group (3.5 $\pm$ 1.8 vs 1.2 $\pm$ 1.6, $P<$ 0.001). There were significant differences in the effective rate between the two groups (93.94% vs. 76.67%, $P=$ 0.04).

CONCLUSION:

The ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy may benefit FS patients.

Keywords

Ultrasound-guided hydrodilatation glenohumeral joint acupotomy frozen shoulder

1. Introduction

Frozen shoulder (FS), also known as adhesive capsulitis, is a common shoulder disease, involving the musculoskeletal system, which can lead to continuous pain and limited range of motion (ROM) [1]. In FS patients, chronic shoulder strain produces aseptic inflammation, stimulating thickening of fibro cells and secreting a large number of type I and III collagen fibers to deposit around the joint capsule, tendons, and ligaments, leading to capsular contracture and reduction of joint volume [2, 3]. Histopathology included inflammation of glenoid and acromion synovial membrane, coracohumeral ligament (CHL) hypertrophy and joint capsule fibrosis [4]. The prevalence of FS in the general population is 2.5%, it is very rare before the age of 40, usually occurs around the age of 60 population [5]. It is reported that 40% of FS patients without proper treatment suffer from persistent pain and limited ROM, while 11% of these patients suffer from permanent shoulder dysfunction [6].

The treatment methods of FS include nonsteroidal anti-inflammatory drugs, physical therapy and intraarticular corticosteroid injection [7], in which, due to the physiological benefits of the contracture of the shoulder, hydrodilatation has been used for a long time as a treatment for FS [8]. Hydrodilatation is typically performed using ultrasound guidance via the posterior glenohumeral joint. Hydrodilatation of glenohumeral joint is to inject normal saline and sodium hyaluronate into the glenohumeral joint capsule to release the adhesion of the joint capsule, lubricate the joint cavity, increase the volume of the joint capsule, improve symptoms and promote rehabilitation [9, 10]. In FS patients, the degree of adhesion and contracture of the joint capsule is different, the volume of the joint capsule is also different, and thus the fluid volume required for hydrodilatation treatment is different [11]. Whether the amount of fluid required during the hydrodilatation of glenohumeral joint can predict the difference in the efficacy of FS treatment is rarely reported in previous study. Further, in FS patients, not only the glenohumeral joint capsule was involved, but also the CHL and rotator cuff space were involved to varying degrees [12]. Thus, simple hydrodilatation of glenohumeral joint capsule may be usually ineffective in treatment of FS.

Acupotomy is the essence of traditional Chinese medicine in China. Its principle is mainly to remove and release inflammatory and adhesive tissues, activate the body’s immune system to fight inflammation, reduce swelling and repair damaged tissues [13]. Acupotomy can treat a variety of diseases, including various pain conditions, such as leg pain, knee pain, back pain and nerve root cervical spondylosis [14]. In addition, one study also has reported that acupotomy under ultrasound-guidance may achieve more satisfactory effect for the treatment of FS [15]. Whether acupotomy for FS treatment will contribute to increasing the volume of joint capsule and further increase the efficacy has not been reported in previous study. In this study, we investigated the possible effectiveness of ultrasound-guided hydrodilatation combined with acupotomy treatment for patients with FS, to explore its clinical application value.

2. Material and methods

2.1 Design

This study was designed as a prospective randomized, double-blind, controlled study with 2 parallel groups. The eligible patients with FS were recruited from our hospital From January 2018 to September 2020. After screening, all included subjects were randomly allocated to treatment group or control group in a ratio of 1:1. The present study was approved by the ethics committee of Huzhou Central Hospital (20210404-01). All included patients were asked to provide the written informed consent before the study.

2.2 Patients

All patients had confirmed diagnosis of primary FS according to the physicians specializing in Orthopedics or Physical Medicine. To be eligible for this study, patient should also meet the following inclusion criteria: (1) Chronic onset, persistent dull pain in shoulder, with or without aggravation of pain at night; (2) Active and passive flexion, abduction, external rotation or internal rotation of shoulder joint, at least two of them limited range of motion $>$ 30 ${}^{\circ}$ ; (3) Magnetic resonance imaging (MRI) examination showed thickening of rotator cuff space or CHL or the capsule of the inferior glenohumeral joint; (4) Musculoskeletal ultrasound examination of the shoulder joint indicated that the capsule thickness of the inferior recess of glenohumeral joint was $\geqslant$ 4 mm. Patients were excluded if they met the following criteria: (1) Fracture and dislocation of shoulder; (2) Rotator cuff tear; (3) Labral injury; (4) Calcified tendonitis; (5) Had history of trauma and surgery in shoulder joint; (6) Suffered from rheumatoid arthritis, tumor and tuberculosis; (7) Skin rupture and infection in the shoulder joint area; (8) Severe coagulation insufficiency.

2.3 Sample size, randomization and blinding

To detect the difference between the treatment group and control group of at least 30% in pain intensity, measured by the VAS scale, with $\alpha=$ 0.05, power of 80% and effect value of 0.75, the desired sample size for this study was 60 patients, with 30 subjects in each group. This was the minimum required sample size to evaluate the effectiveness of treatment for FS patients. A random number list was generated through SAS 9.1 package (SAS Institute Inc., Cary, NC, USA) by a specified research assistant who was masked to the study allocation. The stratified randomization was performed to randomize and allocate the patients equally to treatment group and control group in 1:1 ratio by using concealed in sequentially numbered, opaque, sealed envelopes. Attending investigators, subjects, outcome assessors, and data analysts were blinded in this study.

2.4 Musculoskeletal ultrasound

A Yum Mylab90 color Doppler ultrasonic diagnostic device with a LA523 probe set to a frequency of 12–18 MHz was used. The conditions were set as follows: low-pass filtering, pulse repetition frequency 800–1000 Hz, and maximum gain was appropriate when no Doppler signal occurred behind the bone cortex. An associate chief physician examined the patients by combining transverse and longitudinal scanning: pay attention to the continuity of tendon, smooth of the humeral head bone surface, avulsion fracture of bone cortex; focus on the hypoechoic thickening in rotator cuff space, the thickening of coracohumeral ligament and axillary recess bursa; and inflammatory blood flow signals in abnormal areas were evaluated by energy Doppler ultrasound.

2.5 Treatment

2.5.1 Hydrodilatation of the glenohumeral joint

The patient was placed in the lateral decubitus position, and the probe was placed diagonally below the scapula from the outer top to the inner bottom, clearly showing the posterior recess bursa and posterior axillary lip of the glenohumeral joint. The intra-plane injection method was adopted. After the needle tip was confirmed to be located in the glenohumeral joint cavity by ultrasound and there was no obvious resistance to syringe injection, 10 mg of triamcinolone acetonide, 2.0 ml of 2% lidocaine and 2.0 ml of sodium hyaluronate were injected, followed by the gradual injection of normal saline for hydrodilatation. During the process of hydrodilatation, the patient’s reaction should be observed, such as acid swelling, unbearable pain or large resistance to push injection. If ultrasound showed that the fluid in the joint capsule overflows to the muscular layer, the needle was withdrawn to stop the hydrodilatation (Fig. 1).

Figure 1.

The hydrodilatation of glenohumeral joint was performed, and a large number of fluid anechoic areas were observed in the posterior recess bursa of the glenohumeral joint.

2.5.2 Acupotomy

The patient was in a lateral decubitus position with forearm flat on the lateral edge of the shoulder joint. If preoperative musculoskeletal ultrasound showed hypoechoic thickening in rotator cuff space (Fig. 2) or thickening of paracoracoid process CHL (Fig. 3) $\geqslant$ 2.0 mm with reduced echo, ultrasonic-guided acupotomy was performed to release the tissue thickening between CHL and superior glenohumeral ligament. In detail, using the in-plane needle feeding method, ultrasonic-guided acupotomy was to cut the hypoechoic thickening in rotator cuff space or thickening of CHL for 3–5 times, and withdraw the acupotomy.

Figure 2.

Acupotomy was used to release the hypoechoic thickening in rotator cuff space and adhesion thickening area.

Figure 3.

Acupotomy was used to release the thickening of paracoracoid process coracohumeral ligament.

The treatment group was treated with ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy, while the control group was only treated with ultrasound-guided hydrodilatation of glenohumeral joint, all for once a week for 3 consecutive times. The musculoskeletal ultrasound interventional therapy was performed by an associate chief physician with more than 3 years of experience in musculoskeletal interventional surgery. After treatment, all patients underwent functional exercise within the maximum activity pain tolerance, such as climbing the wall, drawing circles, touching ears, once in the morning and evening, 30–60 mins.

2.6 Outcome measurements

After treatment, a 3-month follow-up was routinely performed to evaluate shoulder pain (Visual Analogue Scale, VAS [16]), mobility of shoulder joint (Active Range of Motion, AROM [17]), overall efficacy (Constant-Murley scale, CMS) and adverse reactions. CMS was classified into four subscales: pain, $\leqslant$ 15 points; activities of daily living, $\leqslant$ 20 points; range of motion, $\leqslant$ 40 points; and strength, $\leqslant$ 25 points [18]. Efficacy was evaluated by CMS: 1) Cured, symptom completely disappeared, range of motion of shoulder joint was normal, score $>$ 90; 2) Significantly effective, shoulder pain basically disappeared, only mild pain during movement, shoulder motion range was close to normal, score 70–89; 3) Effective, shoulder pain relief, improvement of motion range of shoulder joint, daily life and work are not affected or little affected, score 46–69; 4) Ineffective: no improvement in symptoms after treatment, score $\leqslant$ 45, effectiveness rate $=$ [(cure $+$ significantly effective $+$ effective)/N] $\times$ 100%.

2.7 Statistical analysis

SPSS 22.0 statistical software was used (IBM Corp., Armonk, NY, USA). The qualitative data were represented by rate, the quantitative data were represented by Mean $\pm$ SD, and the skewness distribution data were represented by median (M) and interquaternary interval (Q). Differences between groups were compared by $t$ -test or $F$ -test or chi-square test or Fisher’s exact probability method. A value of $P<$ 0.05 was considered statistically significant.

3. Results

A total of 63 FS patients (18 males and 45 females) were included in this study, divided into the treatment group ( $n=$ 33) and control group ( $n=$ 30). For all patients, the average duration of pain was 3.1 $\pm$ 2.3 months, the preoperative pain VAS was 7.3 $\pm$ 3.8, the joint’s AROM score was 17.6 $\pm$ 6.9, CMS score was 36.4 $\pm$ 9.3, the thickness of the affected axillary recess capsule (ARC) was 4.7 $\pm$ 2.3 mm, the CHL thickness was 3.5 $\pm$ 1.9 mm, and the rate of hypoechoic thickening in rotator cuff space was 36.51% (23/63). The characteristics and demographics of all included patients are showed in Table 1. At baseline, no significant difference in all characteristics values was found between the two groups.

Table 1
Baseline characteristics of the patients

Characteristics	Total ( $n=$ 63)	Treatment group ( $n=$ 33)	Control group ( $n=$ 30)	$P$
Age (years)	50.3 $\pm$ 10.6	49.6 $\pm$ 9.7	51.2 $\pm$ 11.3	0.63
Male/female ( $n$ )	18/45	10/23	9/21	0.86
BMI (kg/m ${}^{2}$ )	20.5 $\pm$ 6.3	19.6 $\pm$ 5.3	21.2 $\pm$ 6.1	0.59
Duration of pain (months)	3.1 $\pm$ 2.3	3.4 $\pm$ 2.5	2.9 $\pm$ 2.7	0.45
Shoulder pain side ( $n$ )				0.65
Right	20	13	12
Left	43	20	18
VAS score	7.3 $\pm$ 3.8	7.2 $\pm$ 3.3	7.5 $\pm$ 3.1	0.72
AROM score	17.6 $\pm$ 6.9	16.5 $\pm$ 6.2	18.6 $\pm$ 7.4	0.23
CMS score	36.4 $\pm$ 9.3	37.1 $\pm$ 8.6	35.8 $\pm$ 6.9	0.52
ARC thickness (mm)	4.7 $\pm$ 2.3	4.5 $\pm$ 1.7	4.9 $\pm$ 2.1	0.41
Hypoechoic rotator cuff space (%)	36.51% (23/63)	39.13% (13/33)	33.33% (10/30)	0.62
CHL thickness (mm)	3.5 $\pm$ 1.9	3.7 $\pm$ 1.5	3.3 $\pm$ 1.8	0.35

BMI, Body mass index; VAS, Visual Analogue Scale; AROM, Active Range of Motion; CMS, Constant-Murley Scale; ARC, Axillary recess capsule; CHL, Coracohumeral ligament.

Three months after treatment, there was no significant difference between the two groups in pain VAS score and the thickness of the affected ARC ( $P>$ 0.05), while the shoulder AROM and CMS score in the experimental group were higher than those in the control group, and the CHL thickness and the rate of hypoechoic thickening in rotator cuff space in the experimental group were lower than those in the control group ( $P<$ 0.05, Table 2).

Table 2

Comparison of postoperative clinical and ultrasonic characteristics between the two groups

	Treatment group ( $n=$ 33)	Control group ( $n=$ 30)	$t$ / $\chi^{2}$	$P$
Postoperative three months
VAS score	2.1 $\pm$ 1.0	2.3 $\pm$ 1.2	0.71	0.48
AROM score	34.8 $\pm$ 7.4	30.6 $\pm$ 8.3	2.09	0.04
CMS score	83.9 $\pm$ 10.6	78.1 $\pm$ 11.5	2.05	0.04
ARC thickness (mm)	1.8 $\pm$ 0.9	2.1 $\pm$ 0.8	1.37	0.18
Hypoechoic rotator cuff space (%)	3.03% (1/33)	20.00% (6/30)	–	0.03
CHL thickness (mm)	2.1 $\pm$ 1.2	2.7 $\pm$ 1.0	2.11	0.03
Injection volume
The first (ml)	8.1 $\pm$ 2.6	7.2 $\pm$ 2.5	1.38	0.17
The second (ml)	12.8 $\pm$ 3.1 ${}^{\ast}$	11.8 $\pm$ 2.9 ${}^{\ast}$	1.30	0.20
The third (ml)	15.8 $\pm$ 4.7 ${}^{\ast\&}$	12.2 $\pm$ 5.2 ${}^{\ast\#}$	2.13	0.03

${}^{\ast}$ Compared with the first time hydraulic release, $P<$ 0.05; ${}^{\&}$ Compared with the second time hydraulic release, $P<$ 0.05; ${}^{\#}$ Compared with the second time hydraulic release, $P>$ 0.05. VAS, Visual Analogue Scale; AROM, Active Range of Motion; CMS, Constant-Murley Scale; ARC, Axillary recess capsule, CHL, Coracohumeral ligament.

Table 3

The volume increment of the glenohumeral joint of the two groups

Group	$\Delta 1$ (ml)	$\Delta 2$ (ml)	$t$	$P$
Treatment group ( $n=$ 33)	4.9 $\pm$ 2.1	3.5 $\pm$ 1.8	2.86	0.006
Control group ( $n=$ 30)	4.3 $\pm$ 1.8	1.2 $\pm$ 1.6	93.48	$<$ 0.001
$t$	1.19	5.25	–	–
$P$	0.24	$<$ 0.001	–	–

There was no significant difference in injection volume at the first and second hydrodilatation between two groups ( $P>$ 0.05), and the injection volume at the third hydrodilatation was significantly higher in the experimental group than in the control group (15.8 $\pm$ 4.7 vs 12.2 $\pm$ 5.2, $t=$ 2.13, $P=$ 0.03). The intra-group comparison showed that the injection volume in the experimental group increased gradually with the increasing of treatment times (8.1 $\pm$ 2.6 mL vs 12.8 $\pm$ 3.1 mL vs 15.8 $\pm$ 4.7 mL), and there were statistically significant differences (all $P<$ 0.05). In the control group, the injection volume at the second hydrodilatation was higher than that in the first (7.2 $\pm$ 2.5 mL vs 11.8 $\pm$ 2.9 mL, $t=$ 6.47, $P<$ 0.001), and there was no significant difference in injection volume at the third hydrodilatation compared with the second time (11.8 $\pm$ 2.9 mL vs 12.2 $\pm$ 5.2 mL, $t=$ 0.36, $P=$ 0.71, Table 2).

After the first treatment, there was no significant difference in the volume increment of glenohumerus joint $\Delta$ 1 between the two groups (4.9 $\pm$ 2.1 vs 4.3 $\pm$ 1.8, $t=$ 1.19, $P=$ 0.24). After 2 times of treatment, the volume increment of glenohumeral joint $\Delta$ 2 in the experimental group was greater than that in the control group (3.5 $\pm$ 1.8 vs 1.2 $\pm$ 1.6, $t=$ 5.25, $P<$ 0.001). Intra-group comparison showed that the volume increment of glenohumeral joint $\Delta$ 1 in both groups was greater than $\Delta$ 2 (all $P<$ 0.05, Table 3).

The ultrasound-guided puncture of glenohumeral joint was successful in 63 patients, and the success rate was 100%. In the experimental group, there were 1 case of vagal reflex, 1 case of subcutaneous bruising, and 1 case of nausea and dizziness during treatment, with an adverse reaction rate of 9.09%. In the control group, there were 1 case of subcutaneous bruising, and 1 case of nausea and dizziness during treatment, with an adverse reaction rate of 6.67%. There was no significant difference in the incidence of adverse reactions between the two groups ( $P=$ 0.34). Three months after treatment, 15 cases were cured, 9 cases were significantly effective, 7 cases were effective, and the overall effective rate was 93.94% (31/33). In the control group, 8 cases were cured, 10 cases were significantly effective, and 5 cases were effective, with an overall effective rate of 76.67% (23/30). There were significant differences in the effective rate between the two groups ( $P=$ 0.04).

4. Discussion

The etiology of primary FS is numerous and the pathological mechanism is complex, which has not yet been clarified. The normal glenohumeral joint lumen volume is about 15–20 mL, and $<$ 10 mL is an important feature of FS [9]. This study showed that the initial injection volume by hydrodilatation was 8.1 $\pm$ 2.6 mL in the experimental group and 7.2 $\pm$ 2.5 mL in the control group, and the joint volume in both groups was less than 10 mL. Proliferation and fibrosis of ARC of glenohumeral joint resulted in the decrease of the flexibility of the bursa fold and the disappearance of the axillary pouch [19]. In this study, the ARC thickness of FS patients was thickened by 4.7 $\pm$ 2.3 mm, which was significantly thicker than normal. In addition to the glenohumeral capsule contracture, the limited ROM of shoulder joint is closely related to the fibrosis of the ligament of the shoulder joint, the proliferation of the anatomical structure fibers and the contracture [2, 20]. Inflammation, contracture and adhesion of the anterior joint capsule, such as CHL and rotator cuff space, mainly affect the external rotation, abduction and extension activities of the shoulder joint, especially the obvious limitation of external rotation [3, 20]. In this study, the CHL thickness was up to 3.5 $\pm$ 1.9 mm, and the rate of hypoechoic thickening in rotator cuff space reached 36.51% (23/63) in FS patients.

Ultrasound-guided hydrodilatation of glenohumeral joint is one of the effective methods in FS treatment [21]. We should make full use of the advantages of musculoskeletal ultrasound to comprehensively evaluate the involvement of FS structures. In this study, the effective rate of patients in the control group was 76.67% (23/30). Some patients had poor functional improvement, and ultrasound reexamination still showed thickening of CHL and rotator cuff space. In the experimental group, preoperative ultrasound examination was performed, and acupotomy treatment was performed on the areas with abnormal CHL thickness and rotator cuff space. The results showed that injection volume by hydrodilatation gradually increased with treatment times, and the joint volume continued to increase. Especially, after the second treatment, the increase value of glenohumeral joint volume $\Delta$ 2 in the experimental group was significantly greater than that in the control group, and the effective rate was 93.94%. Therefore, if there are abnormal areas detected by musculoskeletal ultrasound, hydrodilatation of glenohumeral joint combined with acupotomy can achieve better effect in the treatment of FS patients.

Ultrasound-guided acupotomy therapy can avoid tendon, ligament, nerve, blood vessel and other injuries caused by anatomical positioning and blind ligation of traditional small acupotomology [22, 23]. Ultrasonographic guidance greatly increased the safety of acupotomy treatment. Except the inflammation and contracture of the glenohumeral joint capsule, CHL, rotator cuff space and other anterior joint capsule involvement are also one of the important features of FS [2]. In this study, after acupotomy treatment was added in the experimental group, the CHL thickness and hypoechoic thickening in rotator cuff space were significantly lower than those in the control group 3 months after operation. The experimental group was performed acupotomy therapy on the abnormal areas that found under ultrasound examination, which could avoid the unnecessary damage to normal tissues caused by traditional needle knife and multi-point needle insertion.

Although there are several treatments for chronic pain in musculoskeletal disorders, such as continuous radiofrequency [24], extracorporeal shockwave therapy [25] and percutaneous electrical nerve stimulation [26], a certain number of patients may experience persistent or refractory pain. This study found that 3–5 days after the first treatment, the patient’s shoulder pain symptoms such as resting pain and nocturnal pain could be well controlled, which indicated ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy might be benefit to multidimensional rehabilitation projects of FS patients. Triamcinolone acetonide 10 mg was injected into the two groups for anti-inflammatory treatment, which was about half of the dose of conventional local sealing treatment. With the help of ultrasound guidance, drugs can be accurately injected into the glenohumeral joint cavity, thus the dosage of steroid hormones is greatly reduced compared with the traditional palpation blind therapy. Further, after 3 months treatment, there was no significant difference in the pain VAS between two groups. The reason may be that the pain of FS patients was mainly related to inflammatory factors, and steroid hormones had a strong anti-inflammatory effect, which could quickly inhibit inflammation and improve symptoms [27].

Although the present study achieved satisfied results, it still suffered from several limitations. First, the sample size of this study was pretty small. Second, due to individual differences in pain sensitivity, there might be bias. Third, patients with different degree of fibrosis of joint capsule also have different elasticity of joint capsule, which might affect the elastic capacity of hydraulic fluid. In the future, we will include more cases who have the indication for acupotomy with both arms with and without acupotomy to further validate this study.

5. Conclusion

The ultrasound-guided hydrodilatation of glenohumeral joint combined acupotomy therapy is safe and effective, and can effectively improve the adhesion of the shoulder joint, increase the volume of the joint capsule and improve the efficacy of FS patients.

Footnotes

Conflict of interest

The authors declare that they have no competing interests.

Funding

This study was supported by the Public Welfare Application Research Project of Huzhou City, Zhejiang Province, China (No. 2017GYB25, No. 2018GYB68); and Medical and Health Science and Technology Project of Zhejiang Province, China (No. 2022RC263).

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Ultrasound-guided hydrodilatation of glenohumeral joint combined with acupotomy for treatment of frozen shoulder

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Introduction

2. Material and methods

2.1 Design

2.2 Patients

2.3 Sample size, randomization and blinding

2.4 Musculoskeletal ultrasound

2.5 Treatment

2.5.1 Hydrodilatation of the glenohumeral joint

2.7 Statistical analysis

3. Results

Table 1 Baseline characteristics of the patients

5. Conclusion

Footnotes

Conflict of interest

Funding

References

Table 1
Baseline characteristics of the patients