A Novel/Sonographic Approach for Immediate Mobility Restoration in Adhesive Capsulitis

A 56-yr-old male patient presented with a 6-mo history of progressively worsening right shoulder pain and limited range of motion. Visual analog scale pain scores were 7 at night, 6 at rest, and 7 during movements. He declared that his complaints had not improved despite taking oral analgesics (Celecoxib, 1 tablet once daily) and receiving manual therapy (including joint mobilization and capsular stretching exercises). In our clinic, considering the need for repeated injections and the comparable efficacy of triamcinolone at doses between 10 and 40 mg,1 the patient initially received an ultrasound-guided posterior glenohumeral joint injection with 20 mg of triamcinolone and 3 ml of 1% lidocaine, followed by a rotator interval injection with the same dosage 1 month later.2 Although his pain scores improved to visual analog scale 4 at night, 2 at rest, and 4 during movements, significant range of motion limitations persisted (abduction: 80°, external rotation: 40°, internal rotation: 30°). Dynamic ultrasound examination2 demonstrated obstruction of the greater tubercle at the entrance of the subacromial space during passive abduction of the affected shoulder (Figs. 1A, B, and Video 1, https://links.lww.com/PHM/C787), indicating adhesive capsulitis based on the dynamic ultrasound protocol proposed by Bureau et al.3 Static ultrasound examination revealed no evidence of rotator cuff tendon tear but a markedly thickened anterior glenohumeral capsule on the affected side (Fig. 1C).FIGURE 1: Dynamic ultrasound examination of the affected shoulder—starting from neutral position (A) to passive abduction (B)—showed obstruction of the greater tubercle (asterisk) at the entrance of the subacromial space. Static ultrasound examination showed that the anterior glenohumeral capsule was markedly thickened (white double arrow) compared with the normal shoulder (green double arrow) (C). After ultrasound-guided anterior (D) and inferior (E) capsular hydrodilatations, dynamic ultrasound demonstrated that the greater tubercle could rotate smoothly beneath the lateral acromion during passive shoulder abduction (F). AC, acromion; Black arrowheads, needle trajectory; CP, coracoid process; DEL, deltoid; HH, humeral head; HS, humeral shaft; SS, supraspinatus tendon; SUB, subscapularis tendon; TMA, teres major.To address the persistent capsular restriction, the patient underwent ultrasound-guided anterior capsular hydrodilatation in sitting position. Using the direct in-plane technique, a 21-gauge needle was inserted from lateral to medial, between the middle glenohumeral ligament and the humeral head (Fig. 1D and Video 1, https://links.lww.com/PHM/C787). A mixture of 10-mg triamcinolone, 5 ml 2% lidocaine, and 9 ml normal saline was given.3 Subsequently, with the patient in the lateral decubitus position, a second in-plane hydrodilatation was performed via the axillary pouch, with the transducer placed in the short-axis view over the humerus (Fig. 1E and Video 1, https://links.lww.com/PHM/C787). The needle was directed between the inferior glenohumeral ligament and the humeral head, using the same injectate. The total volume used for hydrodilatation, including both anterior and inferior capsular injections, was 30 ml. Immediately after the procedure, the patient demonstrated substantial improvements in shoulder range of motion (abduction: 145°, external rotation: 70°, internal rotation: 70°). Repeat dynamic ultrasound examination confirmed successful gliding of the greater tubercle beneath the acromion (Fig. 1F and Video 1, https://links.lww.com/PHM/C787), with the proximal humerus forming approximately 140° with the lateral acromion. At 3-wk follow-up, full shoulder range of motion was restored without residual limitation. This technical report underscores two key findings. First, dynamic ultrasound serves as an objective tool to evaluate glenohumeral reciprocal motions during shoulder abduction, independent of the scapulothoracic compensation. Second, consistent with the cadaveric study by O’Brien et al.,4 the inferior glenohumeral ligament complex acts as the primary anterior-posterior restraint of the abducted shoulder, with the anterior band providing major stabilization at 30° of horizontal extension and the posterior band serving as the primary stabilizer at 30° of horizontal flexion. Our sequential hydrodilatation approach targets the middle glenohumeral ligament and the anterior band of the inferior glenohumeral ligament via the anterior injection, while the inferior injection specifically addresses the posterior band. This combined targeting of anterior and inferior structures appears to relieve capsular constraints, facilitate humeral head depression, and allow unobstructed passage of the greater tubercle through the subacromial space. Third, the effectiveness of hydrodilatation depends not only on injecting an adequate fluid volume but also on achieving abrupt capsular distension by forcefully pushing the plunger. Because fluid pressure is initially highest near the injection site before equilibrating, the force is not uniformly distributed. To target the inferior glenohumeral capsule effectively, the injectate must be specifically directed toward that region, as it may also extend to adjacent structures, such as the inferior glenohumeral ligament. Fourth, anterior glenohumeral joint hydrodilatation is generally safe when using an in-plane approach with clear visualization of the needle. Although the infraclavicular brachial plexus near the subclavian artery is a potential risk, proper technique minimizes this concern. In contrast, inferior hydrodilatation carries a higher risk due to the nearby axillary nerve and posterior humeral circumflex artery, which must be clearly identified under ultrasound before injection. Our approach shows promise as a therapeutic option for refractory adhesive capsulitis of the glenohumeral joint. Not to mention, further randomized controlled trials are warranted to compare its efficacy with other conventional ultrasound-guided interventions.