Hydrodilatation Injectate Selection for Adhesive Capsulitis
Use normal saline as the primary diluent for hydrodilatation in adhesive capsulitis, with hypertonic saline (3% NaCl) offering superior outcomes compared to normal saline, while dextrose solutions lack evidence for this specific indication and should be avoided in diabetic patients. 1, 2
Primary Recommendation: Saline-Based Solutions
The evidence strongly supports saline-based injectates for shoulder hydrodilatation:
Hypertonic saline (3% NaCl) demonstrates superior efficacy compared to normal saline (0.9% NaCl), with significantly better improvements in shoulder passive range of motion and Shoulder Pain and Disability Index scores at 2 weeks post-procedure. 2
Standard hydrodilatation protocols utilize normal saline (0.9% NaCl) mixed with corticosteroids and local anesthetic, with typical volumes of 12-35 mL achieving effective capsular distension. 3, 4, 5
The typical injection mixture consists of: 4 mL triamcinolone (40 mg), 4 mL lidocaine 2%, and 12 mL normal saline, though volumes up to 35 mL have been used successfully. 3, 4
Why Not Dextrose?
Dextrose solutions have no established role in adhesive capsulitis hydrodilatation:
Dextrose (D5W) is recommended for hydrodissection in thyroid radiofrequency ablation due to its hypotonic properties after metabolism, but this application is anatomically and physiologically distinct from glenohumeral joint distension. 1
No published studies evaluate dextrose-containing solutions for shoulder hydrodilatation in adhesive capsulitis. 6, 3, 2, 4, 5
Dextrose solutions require blood glucose monitoring in patients with impaired glucose regulation to prevent hyperglycemia and osmotic diuresis—an unnecessary complication risk when effective alternatives exist. 1
Special Considerations for Diabetes and Steroid Sensitivity
For diabetic patients:
Diabetic patients have worse outcomes with hydrodilatation, requiring more repeat procedures (16 capsular releases and 4 repeat hydrodilatations in one series) compared to non-diabetic patients. 3
Avoid dextrose-containing injectates as they impose additional glycemic burden without proven benefit, and monitor blood glucose if any dextrose is inadvertently used. 1
The corticosteroid component (triamcinolone 40 mg) is standard and necessary for therapeutic effect, though it will transiently elevate blood glucose regardless of diluent choice. 3, 4
For steroid-sensitive patients:
Hydrodilatation without corticosteroids lacks evidence for efficacy in adhesive capsulitis; the steroid component is integral to the therapeutic mechanism. 3, 4
Consider alternative treatments such as physiotherapy combined with oral NSAIDs if corticosteroid administration is contraindicated. 6
Practical Algorithm for Injectate Selection
First-line approach:
- Use hypertonic saline (3% NaCl) if available: 4 mL triamcinolone (40 mg) + 4 mL lidocaine 2% + sufficient 3% NaCl to achieve 20 mL total volume under ultrasound guidance. 2
Standard alternative:
- Use normal saline (0.9% NaCl): 4 mL triamcinolone (40 mg) + 4 mL lidocaine 2% + 12-27 mL normal saline, targeting capsular distension without rupture. 3, 4
Volume considerations:
- Inject to maximal capsular distension (typically 20-35 mL) while preserving capsular integrity under ultrasound visualization. 3, 2
- Smaller volumes may correlate with better outcomes, suggesting that adequate distension rather than maximal volume is the therapeutic goal. 5
Common Pitfalls to Avoid
Do not use dextrose solutions simply because they are available for other procedures—they lack evidence for shoulder hydrodilatation and add unnecessary glycemic risk. 1
Do not omit the corticosteroid component in an attempt to avoid steroid effects in diabetic patients; the transient hyperglycemia from triamcinolone is manageable and necessary for therapeutic benefit. 3, 4
Do not confuse hydrodissection techniques (used in thyroid or nerve procedures) with hydrodilatation for adhesive capsulitis—these are distinct procedures with different physiologic goals. 1