Shoulder pain is very common in patients who have diabetes. Not only can shoulder pain negatively impact a person’s overall quality of life, but it also may interfere with activities of daily living. One of the most common shoulder disorders that are associated with diabetes is adhesive capsulitis (commonly described as frozen shoulder).
Frozen shoulder is a condition that is characterized by painful, progressive, and loss of range of motion of the shoulder in multiple planes. The exact cause of frozen shoulder is still being investigated, but it is generally believed to be the result of decreased circulation and the byproducts of the break-down of excess sugars that penetrate the tendons and ligaments and cause these structures to become stiffer and weaker over time, leading to symptoms. That is why it is very important for diabetics to have good control of their sugars and normalized hemoglobin A1c values.
Frozen shoulder typically progresses through a series of stages. The first stage is usually the painful pre-frozen stage, which is usually characterized by symptoms of mild shoulder pain with decreased range of motion. Then comes the “freezing” stage, which is where there is a more profound loss of motion. The third stage is the frozen stage demonstrated by a marked loss of motion, and the pain tends to diminish somewhat. Finally, is the “thawing” stage during which there is painless stiffness, but range of motion will start improving. However, there may be residual loss of motion by the end of this stage.
The typical presentation of frozen shoulder can vary, as well as the physical findings and the severity of the symptoms, but usually patients will present with shoulder pain with any movement, which is alleviated by rest. Pain can often be more intense at night and disrupt sleep. Patients can have difficulties with activities of daily living, such as dressing, bathing, and household chores and, in particular, anything that requires reaching behind their back, overhead, or across their body can cause increasing discomfort as the process continues. Patients will also experience a progressive loss of motion, particularly in external rotation, because of the contracture of the structures in the front of the shoulder.
That is why it is important to see an orthopedic surgeon who specializes in shoulders, who can obtain a detailed history, perform a specialized physical examination, and order the correct imaging studies, such as x-rays, and more advanced imaging like an MRI to help confirm the diagnosis. Generally, the management for frozen shoulder consists of conservative measures, to include anti-inflammatory pain medication, physical therapy, corticosteroid injections to decrease the pain and discomfort and increase motion. However, in the management of a patient with frozen shoulder who also have diabetes, it is equally important to improve and maintain control of blood sugars.
Corticosteroid injections are typically effective in improving motion and decreasing pain during the first three to four weeks of the condition. However, steroids can increase blood sugar for days following an injection, so it is especially important to monitor sugars and adjust accordingly.
When conservative measures fail, surgical consideration can be undertaken. Surgical options include manipulation under anesthesia alone, as well as surgical capsular release before or after a manipulation, which usually have favorable results. Capsular release in patients with frozen shoulder is most commonly performed arthroscopically, allowing for a controlled and selective release of the capsule and adhesions.
In conclusion, shoulder pain from frozen shoulder is commonly seen in patients with diabetes.There appears to be an association between metabolic control of the blood sugar and frozen shoulder, but it has yet to be clearly shown in the literature. It is recommended that diabetic patients visit their primary care provider for help controlling the fluctuations of their blood sugars throughout the day using diet control and antidiabetic agents. With this, in combination with a visit to an orthopedic surgeon who specializes in arthroscopic shoulder surgery and the institution of conservative measures, most patients can get better, although a small number of those patients may need to undergo surgical release of their shoulder with removal of adhesions.