To compare ultrasound-guided shoulder anterior capsular infiltration plus hydrodilatation with a steroid versus hyalase in patients with frozen shoulders

Frozen shoulder (FS) is a self-limiting pathology of the shoulder joint causing restriction in both the active and passive range of movements associated with pain (Konarski et al., 2020).

A frozen shoulder is a common condition causing severe pain and a reduced range of motion in the shoulder. It can result in detrimental effects on quality of life and the ability to perform activities of daily living (ADLs). It affects 2% to 5% of the global population and is more common in diabetic patients. There are a variety of treatment options available for patients with frozen shoulders as part of the management ladder of interventions. FS may persist for more than three years or may never resolve (Sam et al., 2023).

Conservative management includes physiotherapy, NSAIDs, Hydrodilatation (HD), intra-articular steroids, manipulation under anesthesia, and arthroscopic, or open capsular release. Distension of the shoulder capsule with normal saline and steroid infusion has been suggested to benefit by changing the biochemical properties of the capsule in FS (Cho et al., 2019).

Hydrodilatation of the shoulder joint capsule was a novel treatment to alleviate the pain of the affected shoulder. The procedure may be given with or without an adjuvant corticosteroid. Hydrodilatation, using saline and a corticosteroid, was superior in short-term pain reduction and range of motion improvement compared to management using only physiotherapy and corticosteroid injection in patients treated for frozen shoulder (Prasetia et al., 2022).

The proposed hypothesis regarding the mechanism of action in hydrodilatation and pain reduction in patients with frozen shoulder was associated with synovitis and fibrosis removal. Previous studies also noted better pain reduction in patients receiving hydrodilatation with adjuvant corticosteroid than only corticosteroid injection (Albana et al., 2022).

Several other adjuvants were studied in frozen shoulder treatment using hydrodilatation. The hydrodilatation method can cause pain in the shoulder during the intervention, so early manual exercise after the intervention is required to inhibit pain (Wang et al., 2021).

Hyaluronidases are a family of enzymes that catalyze the degradation of hyaluronic acid. By catalyzing the hydrolysis of hyaluronan, a constituent of the extracellular matrix, hyaluronidase lowers the viscosity of hyaluronan, thereby increasing the tissue permeability of injected solutes (Lee et al., 2021).

Accordingly, hyaluronidase is used in medicine in conjunction with other drugs, including steroids, to speed their dispersion and delivery. There is growing evidence that using a steroid in combination with hyaluronidase in shoulder joints or spinal epidural spaces both maximizes the anti-inflammatory properties of the steroid and minimizes the side effects of steroid therapy (Manna et al., 2020).

Inclusion Criteria:1- Patients diagnosed with unilateral frozen shoulder. 2- Diagnosis of frozen shoulder will be based on clinical examination (restriction of passive external rotation in the affected shoulder > 50% compared to the opposite side), in the presence of normal plain radiographs (anteroposterior and axillary projections other than calcific tendinopathy).

3- Patients with symptoms for more than three months but less than one year which has not improved with medications and physiotherapy.

4- aged 30 to 70 years old

Exclusion Criteria:

1. History of trauma to the shoulder.
2. History of fracture or dislocation around the shoulder.
3. Inflammatory arthritis
4. coagulation disorders
5. History of previous injections within three months.
6. Cervical radiculopathy.