Recently, DIABETES HEALTH received two letters regarding Frozen Shoulder (also called diabetic shoulder). Readers, Anna of Illinois and Joan of Michigan, wrote seeking additional information on the subject, stating that they could find very little.
Anna, who has been insulin dependent for nine years, has Frozen Shoulder, a condition where the shoulder gets stiff and painful to move. She reported that the pain sometimes runs from her fingers up to her neck. She has seen the doctor, received cortisone shots, and is currently seeing a physical therapist.
Joan wrote about her boyfriend who has had diabetes for 22 years. She said one day he started having pains in his shoulder and eventually he couldn’t lift his arm. He was diagnosed with Frozen Shoulder and after months of physical therapy, the doctor performed closed manipulation. During this procedure, an out-patient surgery, the patient is put to sleep and the arm is moved around to loosen it up. Joan said her boyfriend had the same thing done again four weeks later. She wrote to us to see if anything else could be done to alleviate the pain or to halt these monthly manipulations.
Here at DIABETES HEALTH, we seek to inform our readers of the wide range of therapy options. For information on the subject of Frozen Shoulder, we spoke to Richard K. Bernstein, MD, a board member and a diabetes specialist from Mamaroneck, NY.
DIABETES HEALTH: Can you explain exactly what Frozen Shoulder is?
Bernstein: Frozen Shoulder, also called shoulder capsulitis, is a common complication of poorly controlled diabetes. Sufferers first notice this when they try to put on a t-shirt or reach for something in the back seat of their cars while sitting in the front seat. Although this condition affects both shoulders, it is usually much more severe on the dominant side.
DIABETES HEALTH: You say that the condition can be found on both sides of the body. How do you determine the severity and exact location of the condition?
Bernstein: The following test, which I perform on all my new patients, will readily disclose this condition in its earliest stages-before the patient suffers any discomfort.
I ask patients to put their hands behind their backs and reach up from below as far as they can with their thumbs pointed upward. This way, I can see how far the thumb can extend up the back. I mark that point and then have patients do the same thing with the opposite hand. If Frozen Shoulder is present, the arm affected will not reach as high as the other arm. Initially, the distance between the two points may be less than an inch, but as the condition progresses, it can be as great as 12 inches.
DIABETES HEALTH: What are some of the other characteristics of Frozen Shoulder?
Bernstein: Another characteristic of capsulitis is the presence of tender trigger points. These are little spots that a physical therapist or physician can locate in the vicinity of the shoulder that are both tender and slightly hardened as if they were knots in the muscle. Commonly, we find one spot in the trapezius muscle that extends from the shoulder to the neck, another spot in the deltoid muscle which is on the outside of the shoulder, and another spot in the anterior joint capsule which is at the front of the shoulder joint.
DIABETES HEALTH: What kind of treatment do you recommend for this?
Bernstein: I use three approaches to treat Frozen Shoulder and find that using all three simultaneously has the most rapid effect.
- Trigger point massage. This can be done by a physical therapist, physician or family member and is quite painful if done properly. The trigger points should be massaged until they soften up.
- Variable frequency interferential electrical stimulation. This involves placement of special electrodes on the shoulder for the purpose of introducing low intensity electric currents. Most physical therapists, physiatrists, and rehabilitation departments of hospitals have the appropriate equipment.
- Physical therapists are familiar with a number of exercises that can loosen up the adhesions in the shoulder. The exercise I like best involves lying prone upon a bench while lifting dumbbells. The dumbbells are raised outwardly to the sides for one set, forward toward the head for another set, and toward the rear or legs for the third set. As flexibility improves, the weights of the dumbbells and the number of repetitions are increased. (Check with your doctor before beginning. Strenuous weight lifting can lead to blindness if you have proliferative diabetic retinopathy. The weights to be used should be determined by a physical therapist or physiatrist.)
DIABETES HEALTH: How often should the treatment be given?
Bernstein: Ideally, the above treatments should be rendered three times a week. Most people do not have this kind of time available, so I would suggest a minimum of one set of treatments per week. This combination of therapy is quite effective for Frozen Shoulder.
DIABETES HEALTH: One of our readers said that his shoulder was almost back to normal, but admitted that it would never be 100% well again. Is this correct?
Bernstein: I do not know of any therapy that will prevent the shoulder from freezing again if blood sugars continue to be elevated. Therefore, near normalization of blood sugar is essential if a permanent cure is to be achieved.
DIABETES HEALTH: One reader’s doctor said that as a last resort, surgery could be done on the nerves in the shoulder.
Bernstein: Frozen Shoulder is probably caused by glycosylation of protein in the fibers of the tendons that attach muscles to the shoulder. It is not a disease of the nerves. I do not recommend surgery for treatment.
Anna’s problem is clearly not ordinary capsulitis which spares the lower arm and hand. She may have radiculopathy of the spinal nerve, diabetic shoulder-hand syndrome, or one of many non-diabetes related problems.
DIABETES HEALTH: What is shoulder-hand syndrome?
Bernstein: Capsulitis (as described above) plus pain, swelling, and vasomotor instability (abnormal sweating) of the hand. Eventually the skin becomes shiny with loss of wrinkles. Later the skin and subcutaneous tissues atrophy (waste away) and tendon contractures of the fingers occur. The latter results in permanent closure of the fist. Again, both normalization of blood sugars and frequent intensive physical therapy, including night (and even day) splints are essential for proper treatment.
Richard Bernstein, MD, was recently recognized by the Joslin Diabetes Center for “living courageously with diabetes for more than half a century.” The award was signed by Joslin’s President, Kenneth Quickel Jr., MD.
Peter Lodewick MD, Medical Director, Diabetes Care Center, offers additional tips for sufferers of Frozen Shoulder:
Always warm up the shoubler before engaging in physical activity. It is better to exercise gently to strengthen the muscles. Finally, heat treatments or ultra-sound treatments have been found to be beneficial in helping to loosen the shoulder and providing some relief for pain.