By Paul Schickling, RPh, CDE, and John Walsh, PA, CDE
Long term complications of diabetes may include changes in connective tissue that occur as a result of high glucose levels. Adhesive capsulitis, often referred to as frozen shoulder refers to a pathological condition of the shoulder joint which causes a gradual loss of motion usually in just one shoulder.
Adhesive capsulitis (AC) has a prevalence of 2% in the general population, but is reported to occur in 10 to 29% of those with diabetes. Studies have shown it is caused by glycosylation of the collagen within the shoulder joint triggered by the presence of high blood sugars. Dupuytren's Contracture of the palms and fingers of the hand is another example of contracture syndrome related to diabetes. It is sometimes referred to as stiff-man syndrome although it occurs in both sexes.
Stages of Adhesive Capsulitis
Stage 1: The Initialization Stage has a duration of 0 to 3 months is associated with pain and reduced range of motion (ROM). It may be noticed when the person can no longer do things like comb their hair or reach a shelf above their shoulder.
Pain is described as achy at rest and at night. Arthroscopy and biopsy reveal joint changes and an influx of inflammatory cells. Evaluation is important to establish reference points for later assessment of the progression of the disease. Treatment goals are to lessen pain and inflammation by use of nonsteroidal anti-imflammatory drugs (NSAID) like aspirin and ROM exercises.
Stage 2: The Freezing Stage, which lasts from 3 to 9 months, presents itself with chronic pain and further reduced ROM. This stage moves from the inflammatory stage to the fibrotic process. X-rays reveal decreased joint space. Treatments may consist of NSAIDs and corticosteroid injections.
Stage 3: The Frozen Stage has a duration from 9 to 14 months with minimal pain, but a significantly limited range of motion in the shoulder. In stage 3, a person shows marked stiffening of the shoulder and substantial loss of ROM. In general, an extremely painful phase may resolve itself spontaneously, but with continued stiffness and loss of ROM. Treatment may be possible with surgical intervention, manipulation, aggressive stretching and a home exercise program.
Stage 4: The Thawing Stage is from 15 to 24 months and shows minimal pain and progressive improvement in ROM. At this stage the pain and active fibroplasia in the shoulder have completely subsided. An individual has to recover ROM by strength and conditioning exercises.
Early detection, proper staging, and appropriate treatment can allow the patient with diabetes to avoid the painful and disabling consequences of Adhesive Capsulitis.
Reference: For additional information, read "Clinical Appearance and Treatment of Adhesive Capsulitis in Diabetes" by J. MacGillvray, MD. and M. Drakos, BA in Practical Diabetology, June, 2001.
Paul Schickling, RPh, CDE, can be reached at Diabetes Wisdom, Inc. 1107 E. Chapman, Ste. 206, Orange, CA 9286