1. SAT0511
MANAGEMENT OF ADHESIVE CAPSULITIS WITH LANDMARK GUIDED HIGH VOLUME STEROID
INJECTIONS IN THE COMMUNITY BASED MUSCULOSKELETAL CLINIC
Stan Baltsezak, MD, MSc, FFSEM (UK)
Musculoskeletal and Pain Service, Anglian Community Enterprise, Colchester. Musculoskeletal Service, BUPA, London, UK. E-mail: stanislav@doctors.org.uk
References
1. Hand et al. The pathology of frozen shoulder. J Bone Joint Surg Jul
2007.
2. Tveita et al. Hydrodilatation, corticosteroids and adhesive capsulitis: A
randomised controlled trial. BMC Musculoskeletal disorders 2008.
3. Lee et al. Randomised controlled trial for efficacy of intra-articular
injection for adhesive capsulitis: ultrasonography-guided vs blind
technique. Arch Phys Med Rehabil. 2009.
Conclusion
Landmark guided high volume steroid injections
combined with stretching exercises are effective at
relieving symptoms of frozen shoulder. This treatment
can be recommended before considering further
secondary care orthopaedics interventions.
Introduction
Pathology of frozen shoulder (FS) includes inflammatory
response with fibroblastic proliferation [1]. It results in global
loss of motion due to rotator cuff interval and coraco-
humeral ligament contracture as well as capsular thickening.
Recently, image guided hydro-dilatation combined with
steroid injection became popular FS management. This
procedure is usually performed in outpatient radiology
department and requires referral to secondary care.
Sometimes, three injections with 2 week intervals are given
in the treatment of frozen shoulder [2].
It was shown that there was no significant difference in
symptomatic improvement between ultrasound guided and
‘blind’ injections after 3 weeks when treating adhesive
capsulitis [3].
I present an audit of community based treatment of the
frozen shoulder.
All patients were treated during their 1st appointment at
musculoskeletal clinic.
I observed that patients responded well to landmark guided
high volume steroid injection. It is quick to administer, does
not require assistance or additional imaging.
Method
All patients diagnosed with Frozen shoulder during
1st appointment between September 2013 and
August 2015 were included in the audit.
They were treated with high volume steroid injection:
1 ml 40 mg triamcinolone, 9 ml of 0.5% marcaine +/-
normal saline. Standard posterior approach was
used for glenohumeral joint injection.
Four shoulder stretches were advised to patients for
regular home unsupervised exercise.
They were followed up at 2-3 months when another
injection or surgical referral was offered to the
patient.
All patients had opportunity to access MSK service
within 6 months from the 1st appointment.
Their electronic record was reviewed again in
January 2016 to establish whether they represented
to our MSK service with the same problem.
Results
90 patients were treated within the study period.
35.6% (32) of patients were male and 64.4% (58)
were female.
The mean age of the patients was 56.6 years
(Table 1). Majority (54.4%) of patients had
duration of symptoms from 1-6 months (Table 2.).
53.3% of patients had only10 ml injected in
the GHJ (Table 3). Out of them 21 patients
(43.7%) required 2 or more repeat injections
compared with 14 patients (34%) when volume of
injected fluid was ≥15 ml.
During the study period, 35 (38.8%) patients
required more than 1 injection.
Overall, only three (3.3%) patients required
further orthopaedic management. One male
patient had Diabetes Mellitus (DM) type 2 with
symptoms of FS for 6 months. A female patient
had DM type 1 with duration of symptoms for at
least 24 months. Another male patient had
bilateral FS for 6 months before initial
presentation.
Aim
To assess whether landmark guided high volume steroid
injections combined with home based
unsupervised stretching exercises are effective in the
treatment of frozen shoulder.
The primary end point of the study was the need for
further secondary care orthopaedics referral.
Figure 1. Posterior approach for
glenohumeral joint injection
Table 2. Duration of shoulder symptoms.
Months Number of patients
1-6 49 (54.4%)
7-12 34 (37.8%)
13-18 6 (6.7%)
19-24 1 (1.1%)
Injected Volume Number of patients
≥ 30 ml 29 (32.2%)
≥ 20 ml 10 (11.1%)
15ml 3 (3.3%)
10ml 48 (53.3%)
Table 3. Volume of injected fluid.
Age (years) Number of patients
33-45 10 (11.1%)
46-56 41 (45.5%)
57-67 28 (31.1%)
≥ 68 11 (12.2%)
Table 1. Age groups.