Hydrodilation Therapy: An Effective Treatment for Severe Frozen Shoulder?

If you or one of your clients has ever dealt with frozen shoulder, or adhesive capsulitis as it’s known medically, you know just how painful and limiting it can be.

The intense shoulder stiffness, the restricted movement, and the constant ache can make even the simplest tasks, like reaching for a glass on a high shelf or putting on a jacket, feel like major challenges. In severe cases, frozen shoulder can disrupt daily life for months, if not years. While many treatments exist for frozen shoulder, one that has gained significant attention in recent years is hydrodilation therapy.

As a manual therapist and athletic trainer who has seen many clients with frozen shoulder, I understand the frustration that comes with treating this stubborn condition. Hydrodilation, also known as distension arthrography, is a relatively modern approach that’s especially useful in severe cases when other methods fall short. In this article, I’ll guide you through what hydrodilation therapy is, how it works, and why it can be such a powerful tool for treating frozen shoulder.

Understanding Frozen Shoulder: Why It’s So Challenging

Before we dive into hydrodilation, let’s take a moment to understand frozen shoulder itself. Frozen shoulder, or adhesive capsulitis, is a condition characterized by inflammation, thickening, and stiffness in the shoulder capsule. The shoulder capsule is a structure made up of ligaments and connective tissue that surrounds the shoulder joint, giving it stability. When it becomes inflamed and thickened, it restricts movement, leading to the pain and stiffness we see in frozen shoulder.

Frozen shoulder typically progresses through three stages, each with its own set of challenges. The freezing stage is the initial phase when the pain begins and the shoulder starts losing its range of motion. Next is the frozen stage, where the pain might lessen slightly, but stiffness remains extreme, severely limiting movement. Finally, the thawing stage gradually brings improvement, as the inflammation subsides and movement returns, but this phase can last several months or even years.

Frozen shoulder is commonly idiopathic, meaning the exact cause isn’t always known. However, it’s often associated with certain risk factors like diabetes, thyroid issues, or prolonged immobility (for instance, after a shoulder injury or surgery). It can affect people of all ages, but it’s most common in those aged 40 to 60.

What is Hydrodilation Therapy?

Hydrodilation is a minimally invasive procedure designed to help relieve the pain and stiffness associated with severe frozen shoulder. During the procedure, a healthcare professional injects a solution—usually saline mixed with a corticosteroid and sometimes a local anesthetic—directly into the shoulder joint. This injection is given under imaging guidance (usually ultrasound or fluoroscopy) to ensure precision.

The purpose of the injection is twofold. First, the saline solution physically stretches the shoulder capsule by filling it to capacity and applying pressure from within. This distension helps to separate the layers of the capsule, breaking up adhesions and increasing the available space within the joint. Second, the corticosteroid works to reduce inflammation, helping to manage pain and making movement less painful.

Hydrodilation has shown promising results for individuals whose frozen shoulder isn’t responding to other treatments like physical therapy, manual therapy, or corticosteroid injections alone. It’s an option worth considering for those dealing with severe shoulder immobility, particularly if other interventions have been unsuccessful.

How Does Hydrodilation Work?

Hydrodilation works by addressing two of the main issues that contribute to frozen shoulder: tightness in the capsule and inflammation within the joint. By filling the joint capsule with fluid under pressure, hydrodilation effectively “stretches” the capsule, breaking apart some of the adhesions that have formed. This stretching is somewhat similar to a balloon being inflated, where the fluid creates space and helps separate the restricted fibers.

Additionally, the corticosteroid in the injection targets inflammation directly. When the capsule becomes inflamed, it swells and thickens, which further limits movement. Corticosteroids are known for their strong anti-inflammatory effects, and in cases of frozen shoulder, they help reduce swelling, making movement smoother and less painful.

What’s particularly appealing about hydrodilation is that it combines these benefits in a single procedure. By physically expanding the capsule and calming inflammation simultaneously, hydrodilation offers a dual approach that can be highly effective, especially when other therapies have hit a wall.

Who Is a Good Candidate for Hydrodilation?

Hydrodilation is typically recommended for individuals with severe frozen shoulder, particularly those who have not found relief through other treatments. This can include those who have undergone months of physical therapy, have had corticosteroid injections, and still find themselves unable to move their shoulder freely.

If a client is in the frozen stage of adhesive capsulitis and experiencing a great deal of stiffness without much improvement from more conservative treatments, they might be a good candidate for hydrodilation. It’s often suggested as an alternative to surgery, which can be more invasive and require a longer recovery period. However, it’s important to consult with a medical professional who can assess individual needs and determine whether hydrodilation is the right approach.

The Hydrodilation Procedure: What to Expect

For those considering hydrodilation, it can help to know what to expect from the procedure. While the exact process can vary slightly depending on the clinic or hospital, the core steps are generally the same.

1. Imaging Guidance
   Hydrodilation is usually performed under ultrasound or fluoroscopy guidance to ensure that the needle is accurately placed within the shoulder joint. This imaging helps the healthcare professional visualize the joint, allowing for precise placement of the fluid.

2. Injection of Local Anesthetic and Corticosteroid
   Before the hydrodilation begins, a local anesthetic and corticosteroid are often injected to help manage any discomfort during and after the procedure. This part of the injection helps reduce pain right away, making the procedure easier for the client to tolerate.

3. Saline Injection
   Once the needle is in place, saline solution is slowly injected into the shoulder joint. The solution fills the joint capsule, stretching it out and applying pressure to the capsule’s walls. This pressure breaks apart some of the adhesions and increases the available space within the joint.

4. Post-Procedure Recommendations
   After the procedure, clients are usually advised to perform specific exercises to maintain the gains in mobility. This may include gentle range-of-motion exercises, stretching, and in some cases, supervised physical therapy to help keep the shoulder moving and prevent the capsule from tightening up again.

How Effective is Hydrodilation for Frozen Shoulder?

The effectiveness of hydrodilation varies from person to person, but many individuals experience significant relief after the procedure. Studies have shown that hydrodilation can be highly effective in improving shoulder range of motion, reducing pain, and enhancing overall shoulder function, particularly for those in the frozen stage.

Some clients report feeling immediate relief in their range of motion, while others notice gradual improvement over a few weeks. This variation can depend on several factors, including the severity of the adhesive capsulitis, the duration of symptoms before the procedure, and adherence to post-procedure exercises. However, most people experience some degree of pain relief and improved mobility.

A 2014 study published in the Journal of Shoulder and Elbow Surgery found that hydrodilation was effective in reducing pain and improving function in patients with frozen shoulder, especially when combined with physical therapy. This combination of distension with targeted exercises seems to give clients the best outcomes, as the joint is less likely to revert to its restricted state if it’s kept moving and flexible.

Potential Risks and Considerations of Hydrodilation

As with any medical procedure, hydrodilation comes with some risks and considerations. While generally considered safe, there are a few potential side effects and complications to be aware of. These can include:

• Pain or discomfort during the procedure: Some clients may experience mild discomfort or pain as the saline stretches the joint capsule. However, this is usually manageable and can be minimized with a local anesthetic.
• Temporary soreness: It’s not uncommon for the shoulder to feel sore or tender for a few days following hydrodilation. This soreness usually resolves on its own and can often be managed with over-the-counter pain relief, if necessary.
• Risk of infection: As with any injection, there’s a small risk of infection at the injection site. Strict sterile techniques are used to minimize this risk, but it’s important for clients to monitor the area afterward.
• Allergic reactions: Rarely, clients may have an allergic reaction to the injected substances. This is uncommon, but it’s a consideration that medical professionals take into account.

For clients considering hydrodilation, it’s also important to discuss any other health conditions, especially if they have a history of shoulder instability, severe arthritis, or certain immune system disorders.

Hydrodilation vs. Other Frozen Shoulder Treatments

There are several treatments for frozen shoulder, and hydrodilation is just one option among them. When considering treatment options, it can be helpful to understand how hydrodilation compares to other approaches, such as:

• Physical Therapy: Physical therapy is usually the first line of treatment for frozen shoulder. Through specific exercises and manual therapy, physical therapists aim to restore shoulder mobility and reduce pain. However, in severe cases, the pain and stiffness may limit the effectiveness of physical therapy alone, making hydrodilation a useful complement.
• Corticosteroid Injections: Corticosteroid injections can help reduce inflammation and pain but may not address the underlying tightness in the capsule as effectively as hydrodilation.
• Manipulation Under Anesthesia (MUA): In this more invasive procedure, the shoulder is forcibly moved under anesthesia to break up adhesions. While MUA can be effective, it’s associated with more discomfort and recovery time than hydrodilation.
• Surgery: Surgery is generally considered a last resort for frozen shoulder. Arthroscopic capsular release, where the surgeon cuts through tight areas of the capsule, can be effective but is reserved for cases that don’t respond to other treatments. Hydrodilation is often considered before surgery due to its lower risk and recovery demands.

Alternative Therapies for Relieving Frozen Shoulder Symptoms

While hydrodilation can be an effective treatment for frozen shoulder, it’s far from the only approach. For those who prefer or need a less invasive option—or are looking for complementary therapies to aid their recovery—there are several alternative therapies that can provide symptom relief and support the shoulder’s range of motion. Let’s explore some of the most popular approaches, from acupuncture and trigger point therapy to self-help exercises and dietary considerations. These methods aim to reduce pain, improve flexibility, and support the body’s healing process, giving clients a well-rounded approach to managing frozen shoulder.

Acupuncture

Acupuncture, a practice rooted in Traditional Chinese Medicine (TCM), is increasingly used in Western settings to address musculoskeletal issues like frozen shoulder. By inserting fine needles into specific points on the body, acupuncture aims to stimulate circulation, reduce inflammation, and promote the release of endorphins—our body’s natural painkillers.

For frozen shoulder, acupuncture can help relieve pain and stiffness by targeting points around the shoulder joint and along meridians associated with the affected muscles and tendons. It’s believed that this therapy can help “unblock” energy channels, which can, in turn, restore balance and facilitate healing. In practical terms, acupuncture’s effects may involve reducing the body’s pain response, lowering inflammation, and promoting relaxation in the tissues around the shoulder. While studies are mixed on acupuncture’s efficacy specifically for frozen shoulder, many clients report reduced pain and an improved range of motion after a few sessions.

Trigger Point Therapy

Trigger point therapy is a technique focused on locating and releasing “knots” or hyperirritable spots within the muscles. In frozen shoulder cases, trigger points can develop in the muscles surrounding the shoulder, particularly in the rotator cuff, deltoid, upper back, and neck. These trigger points contribute to pain, restrict movement, and can even mimic the symptoms of frozen shoulder.

Trigger point therapy involves applying sustained pressure to these points, either manually or with tools like massage balls, to encourage the muscle fibers to relax. Releasing trigger points can improve circulation in the area, reduce local inflammation, and restore some of the shoulder’s natural range of motion. This approach can be used by therapists in a clinical setting, and there are also self-help techniques clients can use at home. A therapist can guide clients on finding and managing trigger points, helping them take a proactive role in their recovery.

Massage Therapy

Massage therapy is a versatile tool that can provide both immediate relief and long-term benefits for those with frozen shoulder. Through techniques like deep tissue massage, myofascial release, and even lymphatic drainage, massage therapists can target tight, overworked muscles around the shoulder and neck. By relaxing these muscles, massage can help reduce pain, relieve tension, and improve blood flow to the area, supporting the body’s natural healing processes.

Massage therapy can also help reduce stress, which is a valuable benefit for clients dealing with the chronic discomfort and restricted movement of frozen shoulder. As therapists work on the surrounding musculature, they also help restore balance to the shoulder girdle, addressing the secondary compensations that often develop as clients try to avoid pain. Regular massage therapy can be a valuable component of a recovery plan, either alongside or after hydrodilation or physical therapy.

Self-Help Exercises

Self-help exercises are essential for managing frozen shoulder, particularly for those in the thawing phase or post-treatment recovery. Gentle stretching, range-of-motion exercises, and progressive strengthening can help restore flexibility, prevent further stiffness, and support muscle balance around the shoulder.

Simple exercises, like the pendulum swing (where the arm swings gently in circles), wall walks, and passive stretches using a towel or exercise band, can provide relief and help clients maintain gains made through other treatments. Another valuable exercise is the shoulder external rotation stretch, where clients gently rotate the shoulder outward with the help of a doorway or wall for support. The key is to avoid pushing through pain—clients should aim for gentle, controlled movements that feel comfortable and promote gradual progress.

Self-help exercises are most effective when done consistently and with guidance from a therapist or rehabilitation professional. Building these exercises into a daily routine can help clients gain control over their recovery and feel more engaged in the healing process.

Dietary Considerations

While diet alone won’t cure frozen shoulder, a nutritious, anti-inflammatory diet can certainly play a supportive role in managing symptoms. Inflammation is a big contributor to the pain and stiffness associated with frozen shoulder, and certain foods are known to have anti-inflammatory properties that may help reduce this inflammation naturally.

A diet rich in whole foods—like leafy greens, berries, nuts, and omega-3-rich fish—can help the body fight inflammation, potentially alleviating some of the pain and promoting healing. Omega-3 fatty acids, in particular, are known for their anti-inflammatory effects, making foods like salmon, walnuts, and chia seeds valuable additions. Antioxidant-rich fruits and vegetables can also support the immune system and reduce oxidative stress, which is often linked to chronic inflammation.

On the other hand, processed foods, sugary snacks, and foods high in trans fats can increase inflammation, potentially exacerbating symptoms. Encouraging clients to adopt a balanced, anti-inflammatory diet not only helps with shoulder health but also supports overall well-being, energy levels, and recovery processes.

Finding the Right Combination for Frozen Shoulder Relief

Frozen shoulder is a complex condition, and each client’s experience with it can be unique. While hydrodilation can provide rapid relief for those with severe frozen shoulder, many find additional support and symptom relief through alternative therapies like acupuncture, trigger point therapy, massage, self-help exercises, and even dietary adjustments. The key is to find the right combination of treatments that work together to address the client’s pain, stiffness, and overall shoulder health.

As manual therapists and athletic trainers, we have the opportunity to guide clients in exploring these options and building a comprehensive approach to their recovery. When combined thoughtfully, these therapies can provide a powerful toolkit for managing frozen shoulder and empowering clients to take charge of their healing journey.

Post-Hydrodilation: The Importance of Continued Therapy and Exercise

Hydrodilation isn’t a standalone cure for frozen shoulder; rather, it’s a jumpstart to recovery. After the procedure, it’s essential for clients to maintain their gains in mobility through consistent movement, stretching, and physical therapy. The goal is to prevent the capsule from tightening up again, which can happen if the shoulder isn’t kept active.

Physical therapy can be invaluable during this phase, as it provides structure and guidance to help clients build strength and maintain mobility. Therapists can design a program that includes exercises targeting the rotator cuff, scapular stabilizers, and shoulder capsule to keep the joint stable and flexible. This approach not only helps clients retain their new range of motion but also reduces the risk of recurrent frozen shoulder.

Final Thoughts on Hydrodilation for Frozen Shoulder

Hydrodilation is a powerful option for individuals with severe frozen shoulder who haven’t found relief through other treatments. By physically expanding the shoulder capsule and reducing inflammation, this procedure provides a unique combination of benefits that can offer significant relief and restore function.

If you or a client is dealing with the pain and limitations of frozen shoulder, hydrodilation might be worth discussing with a healthcare provider. Like any medical intervention, it’s important to weigh the benefits and risks, but for those in the “frozen” stage who feel like they’ve exhausted other options, hydrodilation can provide a much-needed path to recovery.

Frozen shoulder can be a frustrating journey, but with effective interventions like hydrodilation and the right post-procedure care, regaining shoulder function and relieving pain is entirely possible. As therapists and trainers, we’re here to guide, support, and empower clients on this path, offering them relief and helping them move freely once again.

Disclaimer: This article is for informational purposes only and should not be considered medical advice. Always consult with a qualified healthcare provider for any questions regarding medical conditions or treatments.

References

• Eustace, J. A., Brophy, D. P., Gibney, R. G., Bresnihan, B., & FitzGerald, O. (1997). "Hydrodilatation of adhesive capsulitis (frozen shoulder) with corticosteroid and saline distension: An alternative to intra-articular steroids." British Journal of Rheumatology.
• Quraishi, N. A., Johnston, P., Bayer, J., Crowe, M., & Chakrabarti, A. J. (2007). "Thawing the frozen shoulder: A randomised trial comparing manipulation under anaesthesia with hydrodilatation." Journal of Bone and Joint Surgery, British Volume.
• Buchbinder, R., Green, S., & Youd, J. M. (2003). "Corticosteroid injections for shoulder pain." Cochrane Database of Systematic Reviews.