What injectate composition is used for hydrodilatation of adhesive capsulitis, including adjustments for diabetic or steroid‑sensitive patients?

Hydrodilatation Injectate Composition for Adhesive Capsulitis

The standard injectate for adhesive capsulitis hydrodilatation consists of corticosteroid (typically triamcinolone acetonide 40 mg), local anesthetic (lidocaine 2% at 4 mL), and normal saline (12-20 mL), with a target total volume of approximately 20-35 mL. 1, 2

Standard Injectate Components

The typical hydrodilatation mixture includes three essential components:

• Corticosteroid: Triamcinolone acetonide 40 mg (4 mL) is the most commonly used preparation 2, 3
• Local anesthetic: Lidocaine 2% at 4 mL provides immediate pain relief during and after the procedure 2, 4
• Diluent: Normal saline (NaCl 0.9%) at 12-20 mL to achieve the target distension volume 1, 2
• Total volume: Target 20-35 mL, though studies show volumes up to 35 mL are effective 1, 5

Adjustments for Special Populations

Diabetic Patients

Diabetic patients require the same injectate composition but must be counseled about transient hyperglycemia risk and advised to monitor glucose levels closely from day 1-3 post-injection. 6, 7

• Blood glucose levels typically increase during the first 1-3 days following intra-articular glucocorticoid injection 6
• No severe adverse events (hyperosmolar hyperglycemic state or ketoacidosis) have been reported in studies 6
• Diabetic patients show higher rates of requiring repeat procedures or capsular release (16 capsular releases and 4 repeat procedures in one cohort) 1
• Do not reduce the corticosteroid dose - the standard 40 mg triamcinolone acetonide remains appropriate, but enhanced glucose monitoring is mandatory 6, 7

Steroid-Sensitive Patients

For patients with concerns about systemic corticosteroid effects or previous adverse reactions:

• Consider reducing corticosteroid concentration while maintaining adequate volume for capsular distension 3
• Alternative approach: Use hydrocortisone acetate 25 mg/mL instead of triamcinolone, though this is extrapolated from intralesional injection data 6
• The volume of injectate appears more important than corticosteroid concentration - one study demonstrated negative correlation between volume injected and outcome improvement, suggesting optimal volumes exist 5

Local Anesthetic Considerations

Lidocaine Dosing and Safety

• Maximum safe dose without epinephrine: 4.5 mg/kg in adults 7
• Maximum safe dose with epinephrine: 7.0 mg/kg 7
• Warming lidocaine to 37°C before injection reduces infiltration pain based on high-quality systematic reviews 6, 7
• Avoid using lidocaine within 4 hours of other local anesthetic interventions to prevent cumulative toxicity 7

Alternative Anesthetic Options

• Lidocaine can be infiltrated along the needle path, injected into the joint alone, or mixed with corticosteroid 6, 7
• Local anesthetics may be applied topically on skin (eutectic mixture of local anesthetic cream, lidocaine 2.5% and prilocaine 2.5%, or ethyl chloride spray) for additional comfort 6

Procedural Technique Considerations

Aseptic Technique Requirements

Strict aseptic technique is mandatory, including 6, 7:

• Surgical gloves
• Skin preparation with alcohol, iodine disinfectant, or chlorhexidine
• Changing needles between drawing the drug and injecting into the joint

Injection Approach

• Anterior rotator interval approach is superior to posterior glenohumeral recess approach for pain relief during shoulder movement 2, 4
• The rotator interval approach showed statistically significant better outcomes in VAS pain (p=0.003), SPADI scores, flexion, abduction, and external rotation compared to posterior approach 4
• Both approaches use identical injectate composition 2, 4

Volume Optimization

• Target volume around 35 mL has been used successfully in large cohorts 1
• Studies using 20 mL total volume (4 mL triamcinolone + 4 mL lidocaine + 12 mL saline) also demonstrate efficacy 2
• Interestingly, one study found negative correlation between volume injected and outcome improvement, suggesting excessive volume may not improve results 5
• The method of capsular distension (rupture versus preservation) may influence outcomes, though optimal technique remains debated 3

Post-Injection Management

• Patients should avoid overuse of the injected shoulder for 24 hours but complete immobilization is discouraged 6
• Greatest benefit is experienced within the first 3 months of intervention 3
• Mean improvement in range of motion: abduction from 59° to 110°, flexion from 50° to 120°, external rotation from 20° to 50° 1

Common Pitfalls

• Do not reduce corticosteroid dose in diabetic patients - instead, focus on glucose monitoring and patient education 6
• Avoid performing hydrodilatation within 3 months of planned joint replacement surgery if shoulder arthroplasty is being considered 8, 7
• Injection site soreness affects approximately 13% of patients and should be discussed during informed consent 8
• Diabetic patients account for disproportionately higher rates of treatment failure requiring capsular release 1