Frozen shoulder diabetic

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Frozen shoulder, also known as adhesive capsulitis, is a common disorder.

This condition affects 2 to 3 percent of the population. It tends to occur most commonly in patients in their 50s. Women develop the condition more often than men. Fifteen percent of patients develop bilateral disease.

The natural history of adhesive capsulitis is divided into three stages: the painful stage, the adhesive stage and the recovery stage. The painful stage is characterized by increasing pain and stiffness and lasts between three and eight months. Muscle spasms in the trapezius muscle also tend to occur during this phase.

The initial symptoms are described as a generalized shoulder ache with difficulty pinpointing the exact location of the discomfort. The pain is aggravated by movement and alleviated with rest. Sleep may be interrupted because of the pain.

The pain becomes associated with shoulder stiffness and decreased range of motion. The stiffening increases to the point where the patient tries to compensate by using other muscles. This places additional strain on the other muscle groups that support the shoulder.

Muscle spasm and diffuse tenderness of the shoulder is seen. With disease progression, disuse atrophy of the shoulder muscles results. Passive and active range of motion in all directions of shoulder movement are lost.

The second stage, the adhesive stage, involves increasing stiffness with diminishing pain. Pain decreases at night, and discomfort occurs only at the extremes of motion. Movement is dramatically decreased. This stage lasts roughly four to six months.

The final stage is called the recovery stage. It lasts from one to three months and is characterized by minimal pain but severe restriction of movement. In this stage, there is gradual and spontaneous increase in range of motion. External rotation improves first, followed by abduction and internal rotation.

Why diabetics are prone to the condition remains a mystery.It is felt that microvascular disease causes abnormal collagen repair, which predisposes diabetics to adhesive capsulitis.

X-ray can be useful for diagnosis of secondary adhesive capsulitis. Osteoarthritis, fracture, avascular necrosis, crystalline arthropathy, calcific tendinitis and cancer may be detected on plain x-rays. X-rays of patients with early adhesive capsulitis are normal. Later changes sometimes show osteopenia, cyst-like changes in the humeral head and joint-space narrowing. A chest radiograph may be useful in establishing the diagnosis of tuberculosis or malignancy-associated adhesive capsulitis.

Studies have shown changes seen on MRI are specific and sensitive for adhesive capsulitis. In most cases, the diagnosis of adhesive capsulitis is clinical.

Treatment requires early range of motion therapy to reduce muscle spasm while maintaining full range of motion. Heat, cold and other modalities that relax the muscles may help preserve range of motion. Adequate analgesia is necessary for successful treatment in this phase.

Non-steroidal anti-inflammatory drugs (NSAIDs) help to relieve pain and inflammation. Analgesics are indicated when NSAIDs are contraindicated. Muscle relaxants are helpful in the early stages of the disease when spasm is predominant. Low-dose antidepressant medications (e.g., 10 mg of amitriptyline [Elavil] taken at night) may be useful.

Intra-articular corticosteroid injections are used in affected patients to relieve pain and permit a more vigorous physical therapy routine. The corticosteroids will temporarily increase blood sugar levels.

Surgical intervention should be considered when physical therapy and injections fail (no improvement after three months of therapy). Manipulation under anesthesia to break up the adhesions is reserved for use in the adhesive stage. During this procedure, the joint capsule and subscapular muscles are ruptured, and aggressive rehabilitation is instituted to restore and maintain range of motion of the shoulder. Patients undergoing manipulation may receive an intra-articular corticosteroid injection after the procedure and begin physical therapy the day of the procedure. Icing is beneficial.

Risks associated with manipulation under anesthesia include humeral fracture, dislocation and rotator cuff rupture. Contraindications to manipulation include severe osteopenia, a history of fracture or dislocation, or recurrence following adequate manipulation. For some patients, arthroscopic capsular release has been shown to improve motion with minimal operative morbidity. In this study, most patients had a marked decrease in pain, and functional improvement. Some investigators showed that arthroscopic release was helpful in patients with diabetes-associated adhesive capsulitis who were refractory to conservative measures.

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