Corticosteroid injections has been shown to offer short-term benefit in recent systematic reviews (6,7), and the rationale is to attempt to reduce inflammation. Hydrodilatation (learn more here) mechanically enlarges the joint space, and has also been shown to be beneficial in a number of studies (Sun et al.; Lin et al.; Wu et al.; Saltychev et al.). The combination of hydrodilatation and corticosteroid injections is routinely used to address inflammation and disrupt scar tissue (capsular fibrosis).

Although these 2 procedures are often performed together, the dose of the corticosteroid used during the procedure had not been well studied. Only a few studies have compared different doses of steroids in frozen shoulder, although the following studies did not combine the cortisone injection with a hydrodilatation procedure. De Jong et al. enrolled 57 patients in a study and injected the shoulder joint with 40mg vs 10mg of triamcinolone acetonide (Kenalog steroid), and patients reported greater relief with the higher dose of steroids. Yoon et al. and Kim et al. both conducted a trial with 53 patients comparing 40mg to 20mg of triamcinolone in patients with a frozen shoulder, and found no difference in outcomes between the different doses of steroids.

In the study by Wang et al. (2023), the authors examined whether different dosages of triamcinolone combined with a hydrodilatation procedure impacted the outcome of the dilation. Patients with adhesive capsulitis of the shoulder (frozen shoulder) were randomized into 2 groups: 1) 40 mg triamcinolone; 2) 10 mg triamcinolone. A total of 20 mL of fluid was used to dilate the joint capsule in both groups. A total of 84 patients underwent the procedure using a posterior approach, and in both groups there was a significant decrease in pain and increased range of motion at 6 and 12-weeks after the injection. There was no difference in outcomes between the high and low-dose cortisone groups.

Take Home

Hydrodilatation resulted in a significant improvement in pain and function, and in this study the dose of the steroid used did not seem to impact outcomes. Corticosteroid injections carry potential risk, including chondrotoxic effects on cartilage, soft tissue fat atrophy, skin hypopigmentation and tendon weakening or rupture (Nichols; Wernecke et al.). However, corticosteroids do seem to improve outcomes when combined with hydrodilatation compared to dilatation alone (Lee et al.).

Given the potential risks of corticosteroids, this study is helpful in determining the ideal dose of corticosteroids to improve outcomes of the hydrodilatation procedure and low-dose corticosteroids seems to be preferable to high-dose steroids.

References

de Jong BA, Dahmen R, Hogeweg JA, Marti RK. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Clin Rehabil. 1998 Jun;12(3):211-5.

Kim KH, Park JW, Kim SJ. High- vs Low-Dose Corticosteroid Injection in the Treatment of Adhesive Capsulitis with Severe Pain: A Randomized Controlled Double-Blind Study. Pain Med. 2018 Apr 1;19(4):735-741.

Lee JH, Kim SB, Lee KW, Lee SJ, Lee JU. Effect of Hypertonic Saline in Intra-Articular Hydraulic Distension for Adhesive Capsulitis. PM R. 2015 Jul;7(7):721-726.

Lin MT, Hsiao MY, Tu YK, Wang TG. Comparative Efficacy of Intra-Articular Steroid Injection and Distension in Patients With Frozen Shoulder: A Systematic Review and Network Meta-Analysis. Arch Phys Med Rehabil. 2018 Jul;99(7):1383-1394.e6.

Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med. 2005 Sep;15(5):370-5.

Saltychev M, Laimi K, Virolainen P, Fredericson M. Effectiveness of Hydrodilatation in Adhesive Capsulitis of Shoulder: A Systematic Review and Meta-Analysis. Scand J Surg. 2018 Dec;107(4):285-293.

Sun Y, Zhang P, Liu S, Li H, Jiang J, Chen S, Chen J. Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis. Am J Sports Med. 2017 Jul;45(9):2171-2179.

Wang JC, Hsu PC, Wang KA, Wu WT, Chang KV. Comparative Effectiveness of Corticosteroid Dosages for Ultrasound-Guided Glenohumeral Joint Hydrodilatation in Adhesive Capsulitis: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2023 May;104(5):745-752.

Wernecke C, Braun HJ, Dragoo JL. The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review. Orthop J Sports Med. 2015 Apr 27;3(5):2325967115581163.

Wu WT, Chang KV, Han DS, Chang CH, Yang FS, Lin CP. Effectiveness of Glenohumeral Joint Dilatation for Treatment of Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sci Rep. 2017 Sep 5;7(1):10507. doi: 10.1038/s41598-017-10895-w.

Yoon SH, Lee HY, Lee HJ, Kwack KS. Optimal dose of intra-articular corticosteroids for adhesive capsulitis: a randomized, triple-blind, placebo-controlled trial. Am J Sports Med. 2013 May;41(5):1133-9.