Paper 89: Ultrasound-guided Glenohumeral Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder: The Role of Clinical Stage in Response to Treatment

Abstract

Objectives:The treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. The pathophysiology of adhesive capsulitis supports the rationale for intra-articular glenohumeral joint corticosteroid injection to treat the synovial inflammation in stages 1 and 2, that results in capsular fibrosis in the later stages of adhesive capsulitis. We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with stage 1 or stage 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness.Methods:This is a retrospective analysis of a cohort of patients with stage 1 or stage 2 idiopathic adhesive capsulitis, diagnosed using history and physical examination. A total of 61 patients met inclusion criteria. Range of motion (ROM) measurements documented in the patient charts were recorded in four planes: forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre-injection and at all subsequent post-injection visits by a single treating physician. All patients were treated with an ultrasound-guided intra-articular injection of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation to within 15 degrees of the contralateral side and internal rotation to within three spinous process levels of the contralateral side.Results:A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the study cohort. The mean age was 55 years (SD=8, range: 38 to 72) and 49 (80%) patients were female. Within the stage 1 cohort, all 11 patients met recovery criteria for forward flexion (100%), 10 patients met recovery criteria for abduction (91%), 11 patients met recovery criteria for internal rotation (100%), and 8 patients met recovery criteria for external rotation (73%). Within the stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 patients met recovery criteria for abduction (60%), 36 patients met recovery criteria for internal rotation (72%), and 24 patients met recovery criteria for external rotation (48%). Time to recovery in days for each ROM compared between the stage 1 and stage 2 cohorts was statistically significant in all ROM planes (forward flexion (p<0.0001), abduction (p<0.0001), internal rotation (p=0.0008), and external rotation (p=0.0096)), indicating a greater proportion of stage 1 patients had a shorter time to recovery after injection. Figures 1-4 depict cumulative survival functions between Stage 1 and Stage 2 patients for each individual ROM measurement.Conclusions:USGI for early adhesive capsulitis allows patients to recover ROM more rapidly. Importantly, Stage 1 patients recovered faster than Stage 2 patients in all ROM planes, with only forward flexion reaching statistical significance. This suggests that prompt recognition of early idiopathic adhesive capsulitis and subsequent USGI with corticosteroid and local anesthetic plays an important role in timely recovery of motion and symptom resolution thus shortening the natural history of this disease and preventing the development of significant fibrosis.Figure 1.Cumulative survival functions between Stage 1 and Stage 2 patients for Forward FlexionFigure 2.Cumulative survival functions between Stage 1 and Stage 2 patients for AbductionFigure 3.Cumulative survival functions between Stage 1 and Stage 2 patients for Internal RotationFigure 4.Cumulative survival functions between Stage 1 and Stage 2 patients for External Rotation