World's first medical networking and resource portal

Articles
Category : All
Medical Articles
Aug22
FROZEN SHOULDER IN DIABETICS
FROZEN SHOULDER IN DIABETICS
When we ponder upon diabetes mellitus and its complications, we might be imagining conditions like diabetic foot, renal failure, atherosclerosis, diabetic retinopathy and so on. Shoulder problems are not what come to mind when most people think of diabetes. But studies have found a link between both types of diabetes and a condition known as frozen shoulder.
The incidence of frozen shoulder has been estimated to be from 3% to 5% in the general population, with a significantly increased incidence amongst diabetics, on the order of
10% to 20%. It appears to be most common in adults between the ages of 40 to 70 years. Women appear to be at a slightly increased risk (4:1) and the non-dominant arm is most commonly affected. Idiopathic frozen shoulder is most strongly associated with insulin-dependent diabetes, in which the lifetime risk of developing adhesive capsulitis may be as high as 36%, with the first episode occurring at a significantly younger age than in the general population. Non-insulin-dependent diabetics also have an increased incidence of frozen shoulder, but not as high as in insulin users. Diabetics also have a tendency to develop bilateral shoulder involvement. Therefore, patients who present with a somewhat atypical set of findings should be screened for diabetes as part of their initial workup.
So, what is a frozen shoulder actually? A frozen shoulder is a shoulder joint with significant loss of its range of motion in all directions. The range of motion is limited not only when the patient attempts motion, but also when the doctor attempts to move the joint fully while the patient relaxes. A frozen shoulder is also referred to as adhesive capsulitis. The modern English words "adhesive capsulitis" are derived from the Latin words adhaerens meaning "sticking to" and capsula meaning "little container" and the Greek word itis meaning "inflammation". The shoulder is the most mobile joint in the body. Its function is to position the arm in space to reach out to objects and deliver them for other actions. The shoulder is a ball and socket joint formed by the upper end of the humerus (arm bone) and the socket formed by the glenoid of the shoulder blade. It is lined by a bag like capsule. The capacity of this joint is about 15- 20 cc. In frozen shoulder the capacity is reduced to 2- 3 cc. The movements at the shoulder joint occur synchronously with that at joint between the shoulder blade and the torso and are compensated to some extent by this.




A few theories had been put forth by a number of physicians and researchers to explain the link between frozen shoulder and diabetes mellitus. Dr. Aaron Vinik, MD, PhD who is the Director of Diabetes Research Institute in Eastern Virginia Medical School, Norfolk, Virginia said that certain compounds accumulate in the linings of joints in the collagen. The collagen fibers then stick together and limit the capacity for the joint and ligaments to stretch with movement. Ultimately this ends up as a frozen shoulder. Agreeing with the fact, Dr. Richard Bernstein of the Diabetes Center Mamaroneck, New York offers his perspective on frozen shoulder:
Muscular and skeletal problems are virtually universal among people with long-standing, poorly controlled diabetes. Sometimes the problems are very painful and even disabling. They probably stem from glycosylation of collagen (a protein in tendons).
Collagen fibers normally slide along one another during muscular movement. In glycosylation, they become glued together by glucose. This process can also occur in the skin, which becomes hard and tough (diabetic scleredema).
In another studies, Neviaser and Neviaser in 1945 coined the name "adhesive capsulitis" to suggest an adhesive process of the capsule to the humeral head and was first termed by. However, this name appears to be somewhat of a misnomer, as later shown by later arthroscopic evaluations. What has been found is a contracture that consists of thickening and fibrosis within the joint capsule itself. This process results in decreased intra-articular volume and diminished capsular compliance, so that glenohumeral motion is limited in all planes. Normal intra-articular volume is about 15 to 30 cc; in patients with adhesive capsulitis, the joint capacity is typically less than 10 cc.
Histologically there has been some controversy regarding the etiology of the fibrosis and contracture of the capsule. In original studies done by Neviaser there was evidence of synovial inflammation. In separate studies, however, Bunker suggested that the active pathologic process is that of fibroblastic proliferation. Interestingly, it appears that the histologic changes are very similar to Dupuytren's contracture, which is also associated with diabetes.
Meanwhile, recent advances discovered that the answer to frozen shoulder lies in the genes. These genes may also be associated with Diabetes mellitus. The alterations in these genes and chromosomes lead to a distorted response to wound healing and scar tissue formation. Exuberant scar tissue forms in response to trauma. The remodeling of scar tissue collagen is less. When more scar tissue forms in the capsule of the shoulder joint, the normally possible movements are grossly reduced. Diabetics also develop nodules in their palms and feet, another evidence of the exaggerated healing process.
Whatever it is, the pathophysiology of frozen shoulder in diabetics remains elusive. What can be said is that, there is a positive evidence to link the excessive level of glucose in the blood and the process of glycosylation of the collagen fibers to be responsible in the development of frozen shoulder.
Classically, the frozen shoulder has been described as occurring in 3 stages:
(1) painful, (2) stiff, and (3) resolving. The natural course of these phases
typically takes from 1 to 3 years to resolve. The first phase often begins
with pain in the shoulder. Patients will complain of pain while sleeping on
their side and will self-restrict the movement of their shoulder to their side
in order to avoid pain. They often complain of generalized pain in the deltoid
region. Often, patients will not seek medical attention during this phase,
expecting that the pain will resolve on its own. They may self-medicate with
analgesics, and will only present when the restriction of motion becomes problematic.
There is usually no inciting trauma or other event, although patients may remember
the specific moment when they were unable to do a particular activity due to
restricted motion. The painful phase may last from 2 to 9 months.
In the stiff or frozen phase, the shoulder is significantly
restricted, and patients note the inability to perform daily functions, especially
those that require significant internal or external rotation or elevation (e.g.
hair washing, reaching overhead). Patients often present at this point with
very specific complaints, such as an inability to scratch their back, fasten
their bra, or get an item from an overhead shelf. When moving within the limits
of their motion, the patient has little or no pain. It is only when the patient
attempts an activity that requires motion beyond their capability that they
develop "end-range pain." The frozen stage can last for 3 months
to 1 year.
In the resolution phase, the "thawing" begins and the patient gradually regains some range of motion. The ability to perform functional activities improves over 1 to 3 years; however, full range of motion is rarely recovered. On long-term follow-up (even up to 11 years later), up to 60% of patients appear to have persistent restriction. What is notable is that loss of less than 20% of the normal range of motion does not appear to affect activities of daily living, nor cause significant functional disability.
How a frozen shoulder is usually diagnosed? A frozen shoulder is suggested during examination when the shoulder range of motion is significantly limited, with either the patient or the examiner attempting the movement. Underlying diseases involving the shoulder can be diagnosed with the history, examination, blood testing to exclude any endocrine disorders e.g. hyperthyroidism, and x-ray examination of the shoulder.
If necessary, the diagnosis can be confirmed when an x-ray contrast dye is injected into the shoulder joint to demonstrate the characteristic shrunken shoulder capsule of a frozen shoulder. This x-ray test is called arthrography. Arthrogram contrasts are special x-rays that show details of the shoulder capsule, such as a decrease in size (in a normal shoulder the capsule is rounded, but in a frozen shoulder the capsule is squat, square and contracted).

The tissues of the shoulder can also be evaluated with an MRI scan. The MRI findings that suggest adhesive capsulitis include soft tissue thickening in the rotator interval, which may encase the coracohumeral and superior glenohumeral ligaments, and soft tissue thickening adjacent to the biceps anchor. Other findings that can be demonstrated on MRI include thickening of the inferior glenohumeral ligament greater than 4 mm and loss of definition of the inferior capsule secondary to edema and synovitis.






The aim of treatment for frozen shoulder is to alleviate pain and preserve mobility and flexibility in the shoulder. However, recovery may be slow, as symptoms tend to persist for several years. Treatment options for frozen shoulder include painkillers to relieve symptoms of pain. Nonsteroidal anti - inflammatory drugs (NSAIDs), such as ibuprofen, are over - the - counter (OTC, no prescription required) painkillers and may reduce inflammation of the shoulder in addition to alleviating mild pain. Acetaminophen (paracetamol, Tylenol) is recommended for extended use. Prescription painkillers, such as codeine (an opiate - based painkiller) may also reduce pain. Not all painkillers are suitable for every patient; be sure to review options with doctor.
Exercise which is frequent and gentle can prevent and even reverse stiffness in the shoulder. Vigorous activity involving shoulder joint should be hindered to prevent more injury from occurring at the site and thus slowed down the healing. Hot or cold compression packs may help to reduce pain and swelling. It is often helpful to alternate between the two.
Corticosteroid injection is a type of steroid hormone that reduces pain and swelling. Corticosteroids may be injected into the shoulder joint to alleviate pain, especially in the 'painful stage' of symptoms. However, repeated corticosteroid injections are discouraged as they could cause damage to the shoulder. It is also a diabetogenic hormone which is not so preferably good choice of treatment for frozen shoulder in diabetics.
Transcutaneous electrical nerve stimulation (TENS) numbs the nerve endings in the spinal cord that control pain and sends small pulses of electricity from the TENS machine to electrodes (small electric pads) that are applied to the skin on the affected shoulder.
Physical therapy or physiotherapy session can teach exercises to maintain as much mobility and flexibility as possible without straining the shoulder or causing too much pain. Physiotherapy in the form of gentle, firm stretching exercises in various planes of motion has been proven to be effective in the relief of pain and in recovery of range of motion in up to 90% of patients with idiopathic frozen shoulder.
Ultrasound can speed the recovery of a frozen shoulder injury significantly by breaking down the scar tissue around the shoulder joint. Using ultrasound on a regular basis or throughout the day will help relax the shoulder muscles, tendons and tissues, diminish pain and inflammation, soften scar tissue and contribute greatly to the healing of injury.
For a resistant frozen shoulder or if patient has poor compliance to the aforementioned regiments, shoulder manipulation can be used as an alternative. The shoulder joint is gently moved while patient is under a general anesthetic. Another way is shoulder arthroscopy - a minimally invasive type of surgery used in a small percentage of cases. A small endoscope (tube) is inserted through a small incision into the shoulder joint to remove any scar tissue or adhesions.
As a conclusion, most patients who present with a restriction of shoulder motion with history of diabetes mellitus and no significant history of trauma to the shoulder may fall under the category of frozen shoulder. This fact can help the clinician to choose an appropriate treatment regimen. Patients diagnosed with the idiopathic form of adhesive capsulitis should be put on a gentle stretching regimen, and counseled about the natural history of the disease, which can take many months to resolve. All of the above treatments absolutely work if properly performed with the right equipment. But, if blood sugar remains elevated, such problems will in all likelihood recur.

REFERENCES:
1. http://www.medicinenet.com/frozen_shoulder/article.htm
2. http://www.diabeteshealth.com/read/1999/11/01/1702/how-is-frozen-shoulder-associated-with-diabetes/
3. http://www.med.ucla.edu/modules/wfsection/article.php?articleid=233
4. http://EzineArticles.com/?expert=Alampallam_Venkatachalam
5. http://www.nlm.nih.gov/medlineplus/ency/article/000455.htm
6. http://www.deccanchronicle.com/health/diabetes-can-lead-frozen-shoulder-571
7. http://www.cnn.com/HEALTH/library/frozen-shoulder/DS00416.html
8. http://www.diabeteshealth.com/read/1999/11/01/1702/how-is-frozen-shoulder-associated-with-diabetes/
9. http://www.medicalnewstoday.com/articles/166186.php


This article is excerrpted from
: Orthopedic and Rheumatological afflictions in Diabetes Mellitus A review - Paperback (July 30, 2010) by Gourishankar Patnaikhttp://www.amazon.com/Musculoskeletal-Manifestations-Diabetes-Mellitus-Rheumatological/dp/363928089X/ref=sr_1_1?ie=UTF8&s=books&qid=1282478501&sr=8-1


Category (Muscles, Bones & Joints)  |   Views (15132)  |  User Rating
Rate It


Browse Archive