The clinical picture of the painful diabetic shoulder--natural history, social consequences and analysis of concomitant hand syndrome

Continuous suprascapular nerve blockade to potentiate intensive rehabilitation for refractory adhesive shoulder capsulitis: a cohort study

PURPOSE

Evaluating the short- and long-term efficacy of a continuous ten day suprascapular nerve block combined with daily multidisciplinary rehabilitation on shoulder range of motion (ROM), pain, and function in patients with refractory adhesive capsulitis (AC).

METHODS

In this retrospective cohort study, patients admitted to a specialized pain clinic for refractory AC for more than 6 months underwent continuous suprascapular nerve blockade for ten days and received 2 hours of physiotherapy and occupational therapy daily. Standardized assessments were performed at baseline, at days three, six, ten, 30, 90, and 180, and included active and passive ROM measurements, the visual analog scale (VAS) for pain and the disabilities of the arm, shoulder and hand (DASH) questionnaire to assess pain, disability, and quality of life. Improvements over time were assessed using ANOVAs.

RESULTS

Thirty-two patients were followed (age: 52 ± 8 years, 25 females, mean symptoms duration of two years). There was a significant improvement in ROM for all amplitudes at day ten (short-term; range: 20-35°, p < 0.001) and at day 180 (long-term; range: 18-47°, p < 0.001). The pain and disability scores significantly reduced by day 180 (mean VAS reduction: 2.6 units, p < 0.001; mean DASH reduction: 9.5 points, p < 0.001).

CONCLUSION

Continuous SSNB combined with intensive multidisciplinary rehabilitation represents an efficient therapeutic option for patients with chronic AC who did not respond to conventional treatments.

Is the Anterior Injection Approach Without Ultrasound Guidance Superior to the Posterior Approach for Adhesive Capsulitis of the Shoulder? A Sequential, Prospective Trial

BACKGROUND

Shoulder injections for conditions such as adhesive capsulitis are commonly performed and can be administered through image-based or landmark-based injection approaches. Ultrasound-guided injections are widely used and accurate because ultrasound allows real-time visualization of the needle and injected contrast. Landmark-based injections would be advantageous, if they were accurate, because they would save the time and expense associated with ultrasound. However, few prospective studies have compared well-described landmark-based shoulder injection techniques without ultrasound.

QUESTION/PURPOSE

Using anatomic landmarks, and without using ultrasound, is the accuracy of glenohumeral injection for adhesive capsulitis greater via the posterior approach or via a new anterior approach?

METHODS

Between 2018 and 2020, we treated 108 patients potentially eligible for adhesive capsulitis treatment. These patients had clinical symptoms of aggravating shoulder pain with a duration of less than 4 months and passively impaired, painful glenohumeral ROM. Due to the exclusion of patients with other shoulder conditions (full-thickness rotator cuff ruptures and posttraumatic stiffness), 95 patients received an injection in this sequential, prospective, comparative study. Between 2018 and 2019, 41 patients (17 males and 24 females; mean age 52 ± 5 years; mean BMI 24 ± 3 kg/m2) were injected through the posterior approach, with the acromion as the anatomical landmark, during the first part of the study period. After that, between 2019 and 2020, 54 patients (20 males and 34 females; mean age 54 ± 4 years; mean BMI 23 ± 3 kg/m2) received an injection through a new anterior approach, with the acromioclavicular joint as the anatomic landmark, during the second part of the study period. Injections via both approaches were administered by two experienced shoulder specialists (both with more than 10 years of experience). Both specialists had experience with the posterior approach before this study, and neither had previous training with the new anterior approach. Injections contained a corticosteroid, local anaesthetic, and contrast medium. Radiographs were taken within 20 minutes after the injection, and a radiologist blinded to the technique determined accuracy. Accurate injections were defined as having contrast fluid limited to the glenohumeral joint, while inaccurate injections displayed leakage of contrast fluid into the soft tissue or subacromial space. All of the enrolled patients were analyzed.

RESULTS

In the group with the posterior approach, the accuracy was 78% (32 of 41) in contrast to 94% (51 of 54, odds ratio 0.21 [95% CI 0.05 to 0.83]; p = 0.03) in patients with the new anterior approach.

CONCLUSION

The new anterior approach without the use of ultrasound was more accurate than the posterior approach. In fact, it was nearly as accurate as previously published ultrasound-guided approaches. We recommend using the new anterior approach for intraarticular glenohumeral injections instead of ultrasound-guided injections because it will save time and costs associated with ultrasound. Still, the clinical effects (anxiety, pain, functional outcome, and adverse events) of the new anterior approach should be compared with ultrasound-guided injections in a randomized study.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Effect of Minimally Invasive Pain Intervention in Frozen Shoulder Patients: A Cross-Sectional Study

Background:

Adhesive capsulitis or frozen shoulder (FS) is the second most common disorder accounts for 15%–30% shoulder pain and functional disability. Suprascapular nerve (SSN) interventions with corticosteroid alone have shown limited duration efficacy, adding pulsed radiofrequency (PRF) provides long-term relief.

Aims and Objective:

We aimed to analyze the efficacy of SSN intervention on pain relief and range of mobility in patients with FS.

Settings and Design:

This is a cross-sectional study of 37 patients of FS who underwent SSN interventions in a dedicated pain medicine unit of the department of anesthesiology.

Materials and Methods:

Thirty-seven patients, who underwent SSN interventions for FS and followed for 6 months, were included in this study. Pain (Visual Analog Scale [VAS]), range of motion (ROM) (17), and Oxford 12 point Shoulder Score (OSS) for functional outcomes were recorded. In the final analysis, two subsets of patients who underwent SSN steroid injection or SSN PRF plus steroid were found and compared using Student's t-test paired and independent with P < 0.05 considered significant at 95% confidence interval.

Results:

The patient population was demographically comparable. Mean VAS score and ROM improved at 1, 3, and 6 months to statistically significant. On comparing the subgroups, the VAS score and OSS in both the SI and PRF groups were significantly improved, but the PRF group showed highly significant improvement, showing better and sustained improvement in the PRF group.

Conclusion:

PRF with steroid injection of the SSN provides better and long-lasting relief from pain and improved mobility in FS patients in comparison to steroid alone.

A genome-wide association study identifies 5 loci associated with frozen shoulder and implicates diabetes as a causal risk factor

Frozen shoulder is a painful condition that often requires surgery and affects up to 5% of individuals aged 40-60 years. Little is known about the causes of the condition, but diabetes is a strong risk factor. To begin to understand the biological mechanisms involved, we aimed to identify genetic variants associated with frozen shoulder and to use Mendelian randomization to test the causal role of diabetes. We performed a genome-wide association study (GWAS) of frozen shoulder in the UK Biobank using data from 10,104 cases identified from inpatient, surgical and primary care codes. We used data from FinnGen for replication and meta-analysis. We used one-sample and two-sample Mendelian randomization approaches to test for a causal association of diabetes with frozen shoulder. We identified five genome-wide significant loci. The most significant locus (lead SNP rs28971325; OR = 1.20, [95% CI: 1.16-1.24], p = 5x10-29) contained WNT7B. This variant was also associated with Dupuytren's disease (OR = 2.31 [2.24, 2.39], p<1x10-300) as were a further two of the frozen shoulder associated variants. The Mendelian randomization results provided evidence that type 1 diabetes is a causal risk factor for frozen shoulder (OR = 1.03 [1.02-1.05], p = 3x10-6). There was no evidence that obesity was causally associated with frozen shoulder, suggesting that diabetes influences risk of the condition through glycemic rather than mechanical effects. We have identified genetic loci associated with frozen shoulder. There is a large overlap with Dupuytren's disease associated loci. Diabetes is a likely causal risk factor. Our results provide evidence of biological mechanisms involved in this common painful condition.

Effectiveness of surgical and non-surgical interventions for managing diabetic shoulder pain: a systematic review

PURPOSE

This systematic review evaluated and compared the effectiveness of non-surgical and surgical interventions for managing shoulder pain in patients with diabetes.

METHODS

PubMed, Scopus, CINAHL, EMBASE, Sport Discus, and Cochrane library were searched for studies published in the last 20 years. Randomized clinical trials (RCTs) and cohort studies that assessed shoulder pain in patients with diabetes and implemented one or a combination of non-surgical and surgical interventions were eligible for inclusion. The quality of the included studies was assessed using the Structured Effectiveness Quality Evaluation Scale (SEQES) tool. Data extracted from the eligible studies included study design, patient characteristics, duration of symptoms, type of interventions, outcome measures used to assess pain, follow-up intervals, and research findings.

RESULTS

A narrative synthesis with effect sizes (ES) or between-group differences was conducted. A total of 25 (14 non-surgical and 11 surgical) studies met the inclusion criteria. Six studies addressed physiotherapeutic interventions (three RCTs and three cohorts - ES = 0.07-1.3), three studies assessed the effect of steroid injections (two RCTs and one cohort - ES = 0.2-0.4), two cohorts addressed arthrographic capsular distension (between-group difference of 1.1 on Visual Analogue Scale), two cohorts addressed MUA, and one RCT addressed suprascapular nerve block (ES = 1-6). For the surgical studies, six cohorts addressed arthroscopic capsular release (ES = 0.2), three cohorts addressed arthroscopic rotator cuff repair (ES = 0.05-0.5), and one cohort addressed arthroplasty (ES = 0.3).

CONCLUSION

Moderate- to very-low-quality evidence suggests large effects of physiotherapy modalities plus exercise and suprascapular nerve block, and trivial to small effects for surgical interventions for improving shoulder pain in patients with diabetes. Future well-designed studies are needed to provide accurate estimates of the true effects of these interventions on improving shoulder pain in patients with diabetes.Implications For RehabilitationShoulder pain may lead to disability in patients with diabetes.We recommend the use of physiotherapy interventions to reduce shoulder pain.Corticosteroid injections are recommended for short-term shoulder pain relief.

Short term effect of yoga asana - An adjunct therapy to conventional treatment in frozen shoulder

BACKGROUND

The available treatments for frozen shoulder yield variable results. Physical therapy and analgesics are considered as the first-line treatment for this disorder, but the effects are not uniform. There is some evidence to support that alternative medicine may have a role in its management.

OBJECTIVE(S)

This study was designed to examine the short-term effects of yoga therapy in patients with frozen shoulder of mild to moderate severity.

MATERIALS AND METHODS

A prospective randomized controlled trial was conducted on patients with frozen shoulder between 30 and 60 years of age. They were divided into two groups: yoga (Y) and control (NY). A set of Asana exercises called "Standing Group of Asana" was practiced by the yoga group in addition to the conventional therapy as received by the control group. The patients were reviewed at 1, 2 and 4 weeks. The pain and functional assessment were done at baseline and at each review using the Shoulder Pain and Disability Index (SPADI).

RESULTS

There were 16 male and 20 female participants in the Y group, and 15 males and 21 females in the NY group. There was no statistically significant difference in age, sex, and pre-treatment SPADI score between the groups. At the end of the four weeks, the SPADI pain scores in the Y and NY group were 20.47 and 20.14, respectively (p = 0.666). The SPADI disability scores in the Y and NY group were 20.4 and 19.7, respectively (p = 0.599). Overall SPADI scores were 40.67 and 40.03 in the Y and NY group, respectively (p = 0.736). Both groups had a significant reduction in SPADI pain and disability scores. However, there was no significant difference between the groups in terms of SPADI scores.

CONCLUSION

The effect of the Standing Group of Asana has no added advantage relative to standard frozen shoulder treatment when practiced for one month.

Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review

INTRODUCTION

Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis.

HYPOTHESIS

Different aetiological groups yield variable outcomes following arthroscopic capsular release.

MATERIALS AND METHODS

A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines.

RESULTS

Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) DISCUSSION: Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases.

LEVEL OF EVIDENCE

IV, systematic review.

Do diabetic patients have different outcomes after arthroscopic capsular release for frozen shoulder?

INTRODUCTION

While the exact mechanism of primary adhesive capsulitis is unknown, we know that it has strong associations with diabetes mellitus (DM). Although self-limiting, a significant percentage of patients still have persistent pain and stiffness beyond 3 years. Arthroscopic capsular release (ACR) has been described as a successful intervention for recalcitrant adhesive capsulitis that provides early and long-term recovery. The aim of this study is to investigate the relationship between DM and ACR.

METHODS

We reviewed prospectively collected data of 56 consecutive patients with idiopathic frozen shoulder who underwent ACR (360° arthroscopic capsulotomy) under a single surgeon. Range of motion, pain score and shoulder function (Constant Shoulder Score, Oxford Shoulder Score, University of California Los Angeles Shoulder Score) were documented preoperatively and one year postoperatively. Patients were dichotomized into diabetic (n = 32) and non-diabetic patients (n = 24) and compared using a mixed ANOVA design to investigate for differences in outcomes.

RESULTS

Both group of patients had significant improvement in range of motion, reduced pain scores and improved shoulder scores one year postoperatively (p = 0.000). Diabetic patients had poorer internal rotation (p = 0.000), forward flexion (p = 0.035) and poorer postoperative Constant Shoulder score (p < 0.05). Otherwise both groups improved equally in all other aspects.

CONCLUSION

ACR offered good outcomes in both diabetic and non-diabetic patients in terms of range of motion, pain relief and shoulder function. However diabetic patients had poorer improvement in internal rotation and forward flexion postoperatively. Preoperative counselling and postoperative rehabilitation can be better tailored to treat diabetic patients with idiopathic adhesive capsulitis.

Clinical Results and Complications of Shoulder Manipulation under Ultrasound-Guided Cervical Nerve Root Block for Frozen Shoulder: A Retrospective Observational Study

Introduction

Manipulation under ultrasound-guided fifth and sixth cervical nerve root block (MUC) is a recognized form of treatment for patients with persistent frozen shoulder (FS). This study aimed to investigate the confirmatory hypothesis testing that the MUC has a significant clinical effect on FS refractory to conservative treatments and to assess its adverse events.

Methods

This is a retrospective observational study on patients with FS treated in the past 8 years. Although 77 patients were eligible for this study, only 68 were enrolled. The patients were evaluated immediately before the MUC and at 1, 3, and 6 months after with the use of the Japanese Orthopaedic Association shoulder score. Simultaneously, ranges of motion of the affected shoulder were measured in two directions: forward flexion and external rotation. A paired t test or a Wilcoxon signed-rank test was used to compare differences in outcomes between before and 6 months after MUC. We also assessed any adverse events during and after the MUC.

Results

Regarding the primary outcome, confirmatory testing showed statistically significant improvements in every outcome value at 6 months after MUC (p < 0.001). In terms of adverse events, two patients (2.9%) had vasovagal reflex, one (1.5%) had a panic attack during the block procedure, and a 72-year-old female patient (1.2%) had an avulsion fracture of the inferior glenoid during the manipulation procedure, although all of them recovered spontaneously without any residual functional impairment.

Conclusion

The results showed that significant clinical effects of the MUC on FS were observed through a confirmatory analysis with a sufficient sample size. However, several complications that could occur during the block and manipulation procedures should be considered.

Is There a Genetic Predisposition to Frozen Shoulder?: A Systematic Review and Meta-Analysis

BACKGROUND

Frozen shoulder is a common disorder that leads to substantial functional loss for patients by impairing activities of daily living. It also adversely affects patients and society by impairing the ability to work. Its pathogenesis is not fully understood. The aim of the present study was to perform a systematic review and meta-analysis to assess the evidence suggesting a genetic link to frozen shoulder.

METHODS

A literature search of MEDLINE, EMBASE, and CINAHL databases using relevant keywords revealed 5506 studies. After appropriate screening of titles, abstracts, and full studies, seven studies were analyzed.

RESULTS

Three studies investigated rates of frozen shoulder among relatives. One study (n = 1828 twin pairs) showed an 11.6% prevalence in twin pairs and demonstrated a heritability of 42% for frozen shoulder after adjusting for age. A second study (n = 273) showed that 20% of patients with frozen shoulder had a positive family history involving a first-degree relative. The relative risk of frozen shoulder was 4:1 when all patients with frozen shoulder were compared with a control population. A third study (n = 87) showed that 29% of patients with frozen shoulder had a first-degree relative with frozen shoulder. Two studies evaluated racial predilection for frozen shoulder. One study (n = 50) reported a substantially higher number of white patients (76%) with frozen shoulder than black patients (24%). A second study (n = 87) showed that being born or having parents or grandparents born in the British Isles were risk factors for frozen shoulder. Four immunological studies investigated human leukocyte antigen (HLA)-B27 as a risk factor for frozen shoulder. Meta-analysis of two of these studies with clearly defined controls showed significantly higher rates of HLA-B27 positivity in patients with frozen shoulder as compared with controls (p < 0.001).

CONCLUSION

The limited evidence points toward a genetic link to frozen shoulder. We used family history and racial predilection as markers for genetic association, both of which indicated the presence of a genetic predisposition to frozen shoulder. However, as there is a lack of unbiased genetic approaches, there is an opportunity for genome-wide association studies to address definitively the molecular genetics of frozen shoulder. Such studies may eventually lead to a better understanding of the pathogenesis of frozen shoulder and the development of novel therapeutic interventions.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prevalence and Determinants of Frozen Shoulder in Patients with Diabetes: A Single Center Experience from Pakistan

Introduction

Frozen shoulder (FS) or adhesive capsulitis is a constellation of symptoms like pain, stiffness, and/or functional deficit at the glenohumeral joint. It is one of the musculoskeletal complications in patients with diabetes that can be particularly debilitating. The aim of this study is to estimate the prevalence of FS and to compare the determinants of this disease in a population with diabetes from Lahore, Pakistan.

Materials and Methods

We carried out this cross-sectional study on a systematically randomized sample of 80 patients with diabetes. It included 38 males and 42 females from 2,964 patients registered at the Diabetes Management Center, Services Hospital Lahore, Pakistan. The study was conducted in the months of April, May, and June 2017. A structured questionnaire was designed and the responses of patients were recorded at the clinic after informed verbal and written consent. The questionnaire outlined the key factors that can lead to a higher frequency of FS in patients with diabetes.

Results

Thirty-three of the total 80 respondents included in the study were diagnosed with FS. The estimated prevalence of FS in diabetics from this data was 41.3% in Lahore, which is an urban area of Pakistan with a population of more than seven million. Female sex, insulin dependence, uncontrolled blood glucose levels, and a positive family history were associated with a significantly higher prevalence of FS. In our study, most patients with FS were in Stage 1 of the disease and had unilateral involvement.

Conclusion

The present study shows that the prevalence of FS is higher in patients with diabetes residing in Lahore than in comparable foreign populations with diabetes. It can be attributed to socioeconomic status, lack of awareness, a higher threshold for diagnosis, and/or poor glycemic control. Mass awareness campaigns, especially for female patients with diabetes, are required to be initiated to create awareness about the disease and to facilitate early diagnosis and appropriate management. In-depth and multicenter studies are needed to further explore the association between FS and diabetes.

Tendinopathy in diabetes mellitus patients-Epidemiology, pathogenesis, and management

Chronic tendinopathy is a frequent and disabling musculo-skeletal problem affecting the athletic and general populations. The affected tendon is presented with local tenderness, swelling, and pain which restrict the activity of the individual. Tendon degeneration reduces the mechanical strength and predisposes it to rupture. The pathogenic mechanisms of chronic tendinopathy are not fully understood and several major non-mutually exclusive hypotheses including activation of the hypoxia-apoptosis-pro-inflammatory cytokines cascade, neurovascular ingrowth, increased production of neuromediators, and erroneous stem cell differentiation have been proposed. Many intrinsic and extrinsic risk/causative factors can predispose to the development of tendinopathy. Among them, diabetes mellitus is an important risk/causative factor. This review aims to appraise the current literature on the epidemiology and pathology of tendinopathy in diabetic patients. Systematic reviews were done to summarize the literature on (a) the association between diabetes mellitus and tendinopathy/tendon tears, (b) the pathological changes in tendon under diabetic or hyperglycemic conditions, and (c) the effects of diabetes mellitus or hyperglycemia on the outcomes of tendon healing. The potential mechanisms of diabetes mellitus in causing and exacerbating tendinopathy with reference to the major non-mutually exclusive hypotheses of the pathogenic mechanisms of chronic tendinopathy as reported in the literature are also discussed. Potential strategies for the management of tendinopathy in diabetic patients are presented.

Steroid Injection Versus Physiotherapy for Patients With Adhesive Capsulitis of the Shoulder: A PRIMSA Systematic Review and Meta-Analysis of Randomized Controlled Trials

To compare the effect of steroid injection and physiotherapy for patients with adhesive capsulitis of the shoulder (ACS).An electronic search was performed on Pubmed, Embase, and Cochrane library, and reference lists were also reviewed for randomized controlled trials (RCTs) comparing steroid injection and physiotherapy for patients with ACS. The quality of included studies were assessed using PEDro scale. Standardized mean differences (SMDs) and 95% confidence interval (CI) were used for comparisons. The primary outcome was functional improvement.Nine RCTs including 453 patients were identified. From 6-7 weeks to 24-26 weeks postintervention, no superiority was noted in favor of either steroid injection or physiotherapy for functional improvement (SMD 0.28; 95% CI -0.01-0.58; P = 0.06) or pain relief (SMD -0.10; 95% CI -0.70-0.50; P = 0.75). Steroid injection provided more improvement in passive external rotation at 24 to 26 weeks (3 studies, SMD 0.42; 95% CI 0.11-0.72; P = 0.007) but not at 6 to 7 weeks (4 studies, SMD 0.63; 95% CI 0.36-0.89; P = 0.32) or 12 to 16 weeks (3 studies, SMD -0.07; 95% CI -0.79-0.65; P = 0.85). Steroid injection was as safe as physiotherapy for patients with ACS (risk ratio 0.94; 95% CI 0.67-1.31).Both steroid injection and physiotherapy are equally effective for patients with ACS. One steroid injection might be the 1st choice for ACS. Results should be interpreted with caution due to the heterogeneity among the studies.

In vivo kinetic evaluation of an adhesive capsulitis model in rats

BACKGROUND AND HYPOTHESIS

We hypothesized that extra-articular, internal fixation of the shoulder in rats would result in a subsequent decrease in rotational range of motion (ROM) and an increase in joint stiffness. We further hypothesized that residual kinematic changes would still be present at 8 weeks after immobilization. Extra-articular, internal fixation of the shoulder has been used to induce adhesive capsulitis in rats; however, the effects on in vivo kinematics have not been assessed.

METHODS

Baseline measurements of rotational torque and ROM were acquired (n = 10 rats), and the left forelimb of each animal was immobilized with sutures passed between the scapula and the humeral shaft. After 8 weeks, the sutures were removed, and changes in kinematics and kinetics were longitudinally quantified in the follow-up period. Changes in stiffness, defined as the area under the angle-torque curve, were also quantified.

RESULTS

Immediately after suture removal, there was a 63% decrease in total ROM compared with baseline (51° ± 10° vs. 136° ± 0°; P < .001). Similarly, total torque was found to increase 13.4 N.mm compared with baseline (22.6 ± 5.9 N.mm vs. 9.2 ± 2.6 N.mm; P = .002). Residual total ROM restrictions and an increased torque in internal rotation were still evident at 8 weeks of follow-up (113° ± 8° vs. 137° ± 0°, P < .001 and 3.5 ± 0.4 N.mm vs. 2.7 ± 0.7 N.mm, P = .036). Stiffness also increased after suture removal and at 8 weeks of follow-up compared with baseline.

CONCLUSION

This animal model of adhesive capsulitis rendered lasting effects on in vivo kinematics of the shoulder.

Case control study of risk factors for frozen shoulder in China

AIM

Frozen shoulder is a common self-limiting regional skeletal problem of unclear pathogenesis. It usually has an insidious onset and follows a protracted course. The aim of this study was to assess the prevalence and related risk factors for frozen shoulder in Shanghai, China.

METHODS

We performed a hospital-based case-control study involving 182 patients with pathologically diagnosed frozen shoulder and 196 patients hospitalized during the same time period with non-shoulder related complaints who were recruited as controls. Information on potential risk factors was collected on both case and control groups through questionnaires and face-to-face interview. Univariate and multivariate logistic regression analyses were performed.

RESULTS

Among the frozen shoulder patients, 24.2% had diabetes and 16.5% had history of shoulder trauma. Multivariate analysis suggested that diabetes and history of slight trauma were independent risk factors for the disease. The frozen shoulder patients also had a higher prevalence of thyroid disease, increased body mass index and cervical spondylosis than the controls. The incidence of frozen shoulder was higher in female compared to male patients. No significant difference was found in occupations, physical exercise, cholecystitis, history of surgical and ischemic heart disease between the frozen shoulder group and the control group.

CONCLUSIONS

The findings in the present study indicate that diabetes, history of slight shoulder trauma, thyroid disease, increased body mass index and cervical spondylosis are factors significantly associated with increased frozen shoulder risk among individuals within the area of Shanghai, China.

Impact of diabetes mellitus on surgical outcomes in sports medicine

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.

The frozen shoulder: myths and realities

Frozen shoulder is a common, disabling but self-limiting condition, which typically presents in three stages and ends in resolution. Frozen shoulder is classified as primary (idiopathic) or secondary cases. The aetiology for primary frozen shoulder remains unknown. It is frequently associated with other systemic conditions, most commonly diabetes mellitus, or following periods of immobilisation e.g. stroke disease. Frozen shoulder is usually diagnosed clinically requiring little investigation. Management is controversial and depends on the phase of the condition. Non-operative treatment options for frozen shoulder include analgesia, physiotherapy, oral or intra-articular corticosteroids, and intra-articular distension injections. Operative options include manipulation under anaesthesia and arthroscopic release and are generally reserved for refractory cases.

The outcome of manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus

HYPOTHESIS

Frozen shoulder has a greater incidence, more severe course, and resistance to treatment in patients with diabetes mellitus compared with the general population. We hypothesized that diabetic patients with frozen shoulder undergoing treatment with manipulation under general anaesthesia (MUA) would have the same outcome as patients without diabetes.

MATERIALS AND METHODS

We retrospectively analyzed data collected during a 10-year period of referrals for frozen shoulder. In all cases, a standardized MUA protocol was followed once the diagnosis of frozen shoulder in the frozen phase was made; this included an early repeat MUA in individuals with recurrence. We compared outcomes for patients documented as having diabetes with a nondiabetic control group and assessed the effect of insulin dependence and frozen shoulder etiology within the diabetic group.

RESULTS

Of a consecutive series of 315 frozen shoulders, 36 patients (39 shoulders) were included in the diabetic group, with 256 patients (274 shoulders) as controls. There was a significant improvement in range of movement and Oxford Shoulder Score (P all <.001), with no difference between diabetic and control groups at early or late follow-up (mean, 41 months). A repeat procedure was required in 36% of diabetic patients compared with 15% of control patients. Recurrence in the diabetic group was influenced by etiology (47% of primary vs 0% of secondary frozen shoulders) and insulin requirement (39% insulin-dependent vs. 31% non-insulin-dependent).

CONCLUSION

We provide a strategy for the management of diabetic frozen shoulders using MUA and estimates of success and recurrence rates that may be useful when informing consent.

Chiropractic management of a 46-year-old type 1 diabetic patient with upper crossed syndrome and adhesive capsulitis

OBJECTIVE

To discuss the treatment of a patient with type 1 diabetes presenting with chronic neck and shoulder pain by using chiropractic manipulation and an active rehabilitation program with emphasis on correcting postural imbalances.

CLINICAL FEATURES

A 46-year-old insulin dependant (type1) diabetic female presented with neck and right shoulder pain of 6 to 8 months duration. Her history included similar left-sided complaints 2 years prior at which time she underwent 3 months of rehabilitation at a local medical center, which improved her condition. Over time her pain resolved but the residuals of restricted left shoulder range of motion remained. The patient had postural changes consisting of forward head posture, rounded shoulders and internally rotated arms.

INTERVENTION AND OUTCOME

Treatment included spinal manipulation, ultrasound and active rehabilitation consisting of at home exercises initially and followed with in office low-tech rehabilitation. Rehabilitation was primarily aimed at improving postural abnormalities, muscle imbalances and abnormal movement patterns. The patient improved with this course of treatment.

CONCLUSION

Chiropractic care including active rehabilitation may be helpful in treating diabetic patients suffering from chronic neck and shoulder problems.

Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes

INTRODUCTION

An increased prevalence of musculoskeletal disease is recognised in diabetes and is a common source of disability. It is known to predominantly affect the upper limbs especially the hand and shoulder. The relationship with other complications of diabetes and glycaemic control is uncertain. We designed this study to clarify these relationships, and to assess differences between types 1 and 2 diabetes.

METHODS

We identified a group of 96 people with established diabetes and examined them for the presence of locomotor disease focussing on the upper limbs. We recorded the mean HbA1c and the presence of diabetic complications, together with the health assessment questionnaire (HAQ) score. We explored correlations between locomotor disease and these variables using logistic regression. We compared data between type 1 and type 2 diabetics and contrasted the amalgamated data with that of a matched control population of medical out patients using Students t tests.

RESULTS

Locomotor disease was present in 75% of diabetics with the upper limb the commonest site for abnormalities. This prevalence was significantly higher than that seen in the controls (53%) [p=0.02]. Shoulder capsulitis (25%), carpal tunnel syndrome (20%), tenosynovitis (29%), limited joint mobility (28%) and Dupuytrens contracture (13%) were the most frequent findings and were much commoner than in controls. Capsulitis usually coexisted with other upper limb abnormalities and best predicted the presence of retinopathy and/or neuropathy. The mean HbA1c was significantly higher in patients with combined shoulder and hand problems (9.1%) than in those with no upper limb problems (8.0%) [p=0.018]. The pattern of results was similar in type 1 and type 2 diabetes, although the prevalence of abnormalities and mean HAQ were significantly greater in type 2 patients, which may be in part a function of their greater mean age.

CONCLUSION

Upper limb locomotor abnormalities are very common in diabetes and are associated with worse glycaemic control and more diabetic complications. Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications.

Advanced glycation end products increase transglutaminase activity in primary porcine tenocytes

OBJECTIVES

Tendon abnormalities, such as increased stiffness, thickness, and excess calcification, occur commonly in patients with diabetes mellitus and cause considerable disability. These changes are frequently attributed to increased cross-linking of extracellular matrix components by advanced glycation end-products (AGEs). However, cellular effects of AGEs, such as increased activity of the cross-linking transglutaminase (Tgase) enzymes, could also contribute to altered tissue biomechanics and calcification in diabetic tendons. We determined the effect of AGE-modified protein on tenocyte Tgase activity.

RESEARCH DESIGN AND METHODS

Primary porcine tenocytes were exposed to N- carboxymethyl-lysine (CML)-modified type I collagen in high or normal glucose media. Protein and mRNA levels of the Tgase enzymes and Tgase activity levels were measured, as were markers of apoptosis. We also determined the effect of antioxidants on CML-collagen mediated Tgase activity.

RESULTS

Carboxymethyl-lysine-collagen increased Tgase activity in tenocytes 2.3- to 5.6-fold over unmodified collagen controls in both normal and high glucose media, without altering enzyme protein levels. Anti-oxidant treatment reduced the effect of CML-collagen on Tgase activity. Deoxyribonucleic acid laddering and annexin V protein levels were not altered by CML-collagen exposure.

CONCLUSIONS

Carboxymethyl-lysine-collagen increased Tgase activity in tenocytes, likely posttranslationally. Increased levels of Tgase-mediated cross-links may contribute to the excess calcification and biomechanical pathology seen in diabetic tendons.

[Frozen shoulder. Diagnosis and therapy]

The condition of shoulder stiffness is often called adhesive capsulitis or frozen shoulder. It is regarded as a distinct clinical entity showing a benign and regular course. The major clinical feature is significant reduction in both active and passive range of motion (ROM) accompanied by stage-dependent pain, allowing for a clinical diagnosis. There are primary and secondary forms, the former having an unknown etiology and increased occurrence in patients with metabolic disorders and the latter being seen with prior injury or operation. Three stages, each lasting 4-6 months, mark the clinical course. The progression of the disease is self-limiting and may occasionally resolve in partial restitution. In the first stage ("freezing"), the shoulder continuously loses passive motion and causes worsening pain. Continuing stiffness and improvements in pain and inflammation are characteristic of the second stage ("frozen"). In the third stage ("thawing"), restriction of shoulder motion decreases, and ROM increases. Treatment should be adjusted to these stages. Recommendations include analgesics and joint injections in the first stage and physiotherapy in combination with manual therapy in the second and third stages. In cases of failure, passive exercise under interscalene block, manipulation under general anesthesia, or arthroscopic arthrolysis should be considered.

Functional outcome of arthroscopic repair with concomitant manipulation in rotator cuff tears with stiff shoulder

BACKGROUND

Little has been reported on treatment of rotator cuff tears with shoulder stiffness.

HYPOTHESIS

Rotator cuff tears with shoulder stiffness will show worse clinical results than will tears without stiffness. Those with stiffness are expected to take longer time in pain reduction and recovery of range of motion.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Among patients who underwent arthroscopic rotator cuff repairs, 15 cases with preoperative shoulder stiffness (group A) and 30 without shoulder stiffness (group B) were enrolled in this study. Preoperative mean forward flexion was 118.3 degrees in group A and 163.4 degrees in group B, whereas external rotation at the side was 34.6 degrees and 55.0 degrees , respectively. The mean follow-up period of group A was 29.8 months (range, 19.5-73.9 months) and 32.4 months (range, 16-70.6 months) in group B.

RESULTS

The mean visual analog scale during motion at the last follow-up was 0.75 in group A and 0.76 in group B (P = .942). The mean University of California at Los Angeles score was, respectively, 33.1 and 33.2 points (P = .561). Forward flexion was 166.7 degrees in group A and 170.2 degrees in group B, whereas external rotation at the side was 48.8 degrees and 53.4 degrees , respectively (P = .157 and .384, respectively). However, the 2 groups showed a significant difference in forward flexion until 1 year postoperatively as group A recovered more slowly (P = .021). Both groups showed significant differences in external rotation at the side, internal rotation to the back, and cross-body adduction until 6 weeks postoperatively (P = .009, P < .001, and P = .026, respectively).

CONCLUSION

Pain, range of motion, muscle strength, and function all significantly improved after arthroscopic rotator cuff repair, regardless of the presence of shoulder stiffness. Patients with full-thickness rotator cuff tears and stiffness of the shoulder can be treated with a single surgery and concomitant manipulation with overall good results. Although final outcomes were as good as those in patients without stiffness, the return of range of motion took longer in those patients undergoing manipulation for stiffness of the shoulder.

The prevalence of a diabetic condition and adhesive capsulitis of the shoulder

OBJECTIVES

Adhesive capsulitis is characterized by a progressive and painful loss of shoulder motion of unknown etiology. Previous studies have found the prevalence of adhesive capsulitis to be slightly greater than 2% in the general population. However, the relationship between adhesive capsulitis and diabetes mellitus (DM) is well documented, with the incidence of adhesive capsulitis being two to four times higher in diabetics than in the general population. It affects about 20% of people with diabetes and has been described as the most disabling of the common musculoskeletal manifestations of diabetes.

METHODS

Consented patients presenting with adhesive capsulitis reporting no history of DM had blood testing for diabetes and prediabetes. An anonymous database was analyzed for a diabetic condition.

RESULTS

The prevalence of diabetes in patients with adhesive capsulitis was 38.6% (34 of 88). The prevalence of prediabetes was 32.95% (29 of 88). The total prevalence of a diabetic condition in patients with adhesive capsulitis was 71.5% (63 of 88). Previous literature fails to reveal the incidence of newly diagnosed diabetes, 2 of 88 (2%), and prediabetes, 25 of 88 (28.4%) in patients presenting with adhesive capsulitis. Early diagnosis and effective management of DM reduces the risk of microvascular complications. DM is believed to play a role in the development of musculoskeletal complications.

CONCLUSIONS

Awareness of these findings alerts the practitioner to the risk of diabetes and prediabetes in patients presenting with adhesive capsulitis of the shoulder.

Frozen shoulder

Frozen shoulder is a painful, often prolonged, condition that requires careful clinical diagnosis and management. Patients usually recover, but they may never regain their full range of movement.

Musculoskeletal disorders in diabetes mellitus: an update

Diabetes mellitus (DM) is associated with several musculoskeletal disorders. The incidence of DM and the life expectancy of the diabetic patient have both increased, resulting in the increased prevalence and clinical importance of musculoskeletal alterations in diabetic subjects. The exact pathophysiology of most of these musculoskeletal disorders remains obscure. Connective tissue disorders, neuropathy, vasculopathy or combinations of these problems, may underlie the increased incidence of musculoskeletal disorders in DM. The development of musculoskeletal disorders is dependent on age and on the duration of DM; however, it has been difficult to show a direct correlation with the metabolic control of DM. Most of these disorders can be diagnosed clinically, but some radiological examination may help, especially in differential diagnosis. No specific treatment is available, and treatments used in the general population are also recommended for diabetic subjects. Infectious complications affecting the musculoskeletal system are common in DM subjects, and these, possibly life-threatening, complications should be systematically discussed.

Rotator cuff repair in patients with type I diabetes mellitus

Insulin-dependent diabetes mellitus is associated with shoulder stiffness and a propensity toward postoperative wound complications and infection. We compared our results of open repair of full-thickness rotator cuff tears in 30 diabetic patients with those of a matched, nondiabetic population. No differences were observed in preoperative range of motion, although at a mean of 34 months, significant differences in shoulder active range of motion and passive range of motion were found postoperatively at 6 weeks, 6 months, and final follow-up (P <.05). On the basis of American Shoulder and Elbow Surgeons shoulder scoring, there were 27 (90%) and 28 (93%) good or excellent results in the diabetic and comparison groups, respectively. Complications occurred in 5 diabetic patients (17%), with 2 failures (7%) and 3 infections (10%), as compared with 1 failure (3%) and no infections in the comparison group. Repair of the diabetic rotator cuff may be performed with the expectation of improved motion and function, although less than nondiabetic counterparts. The surgeon should remain cognizant that a higher rate of complications, infection in particular, may occur after rotator cuff repair in the diabetic population.

Rheumatologic manifestations of diabetes mellitus

Diabetes mellitus has been linked to disorders of bones and joints, including neuroarthropathy, limited joint mobility, and hyperostosis. Some of the relations have known pathogenic mechanisms, but most are based on epidemiologic findings. This article reviews the associations between diabetes mellitus and its putative rheumatologic manifestations, and proposes a classification composed of four categories: consequences of diabetic complications, consequences of metabolic derangements inherent to diabetes, syndromes that may share etiologic mechanisms with microvascular disease, and probable associations. This approach may facilitate a clearer understanding of the musculoskeletal conditions that are prevalent in patients with diabetes mellitus.

Operative management of the frozen shoulder in patients with diabetes

Forty-three patients with diabetes (47 shoulders) who had a manipulation under anesthesia only (24 shoulders), a manipulation under anesthesia followed by an arthroscopy (12 shoulders), or an arthroscopic release (11 shoulders) for a frozen shoulder were followed-up for a mean period of 35 months. The mean Constant score improved from 20.3 to 63.7 points (P <.001). The mean improvement in forward flexion was 71.7 degrees, in abduction 78.5 degrees, in external rotation with the arm at the side 36.3 degrees, and in internal rotation from the buttock to the first lumbar vertebra (P <.001 for all). When gentle manipulation with the patient under anesthesia was possible, the outcome was satisfactory in 13 of 15 shoulders (86.7%) in patients with non-insulin-dependent diabetes and in 17 of 21 shoulders (81%) in patients with insulin-dependent diabetes (P >.5). Insulin-dependent patients with diabetes were more likely to require an arthroscopic release than patients with non-insulin-dependent diabetes (P <.05). Most of our patients obtained their maximum relief of pain and functional recovery within 3 months of surgery. We recommend manipulation under anesthesia for the resistant frozen shoulder in patients with diabetes. Arthroscopic release is required when mobilization under anesthesia is not possible.

Arthroscopic management of refractory shoulder stiffness

Glenohumeral stiffness is a major cause of shoulder disability and pain. Conventional management strategies often fail to yield consistent or prompt return of comfort and function. Over the past 5 years, we have employed a prospective approach to the evaluation and management of glenohumeral stiffness using arthroscopic release of capsular contractures for the most refractory. This report concerns the first 30 patients who failed at least 6 months (28 month mean) of nonoperative management for unilateral refractory shoulder stiffness and who were managed by arthroscopic capsular release. Fourteen patients were diabetic. Follow-up averaged 33 months (range 12 to 56 months). Each patients' motion and strength was documented according to the American Shoulder and Elbow Surgeons standard examination. Functional outcome measures were patient-assessed using the Simple Shoulder test before and after surgery. Before surgery, active range-of-motion of the affected shoulder average 41% of the opposite asymptomatic side. The day after surgery, motion had improved dramatically to a mean of 78%. An additional 15% of motion was gained after discharge from the hospital. The final motion averaged 93% of the opposite side. All Simple Shoulder Test (SST) parameters and six of nine SF-36 health status scores were improved significantly. Only 6% of patients were able to sleep comfortably on their side and 35% could place 1 lb. on a shelf at shoulder height before surgery. After surgery, 73% were able to sleep comfortably on the affected side and 83% were able to place 1 lb. on a shelf at shoulder height. There were no differences among all outcome measures between diabetic or nondiabetic patients. Three patients developed recurrent refractory stiffness. The only complication was a single axillary neuropraxia which resolved spontaneously. No patient developed instability. Arthroscopic capsular release can be a safe and effective tool in the management of refractory shoulder stiffness.

Shoulder capsulitis in type I and II diabetic patients: association with diabetic complications and related diseases

OBJECTIVE

To examine the association between shoulder capsulitis and chronic diabetic complications and diseases closely related to diabetes.

METHODS

A cross sectional study in 291 type I [mean (SD) age 33.2 (9.9) years] and 134 type II [61.1 (12.4) years] diabetic patients. The presence of shoulder capsulitis, Dupuytren disease, and limited joint mobility was sought. The patients were assessed for background and proliferative retinopathy, nephropathy, autonomic neuropathy, and peripheral symmetrical somatic polyneuropathy. Diseases closely related to diabetes (hypertension, history of myocardial infarction, coronary heart disease, and peripheral vascular disease) were also recorded.

RESULTS

Prevalence of shoulder capsulitis was 10.3% in type I and 22.4% in type II diabetic subjects. Shoulder capsulitis was associated with the age in types I (P < 0.01) and II (P < 0.05) diabetic patients, and with the duration of diabetes in type I patients (P < 0.01). Odds ratios for autonomic neuropathy in type I and type II diabetic subjects with shoulder capsulitis were 4.1 (95% confidence interval, 1.6 to 10.9) and 2.7 (95% CI, 1.1 to 7.0), respectively, after controlling for age and duration of diabetes. Odds ratio for history of myocardial infarction in type I diabetic subjects with shoulder capsulitis was 13.7 (95% CI, 1.3 to 139.5) after controlling for age, duration of diabetes, hypertension, and smoking habits. Other associations between shoulder capsulitis and diabetic complications, related diseases, and other hand abnormalities were fully explained by age and the duration of diabetes.

CONCLUSIONS

Shoulder capsulitis is common in type I and type II diabetic patients. It is associated with age in type I and II diabetic patients and with the duration of diabetes in type I patients. It is associated with autonomic neuropathy in type I and II diabetic patients and with history of myocardial infarction in type I diabetic patients, independently of time related variables.

Connective tissue and joint disease in diabetes mellitus

Connective tissue is ubiquitous and subject to alterations that result in changes in the extracellular matrix of vessels and tissues leading to the long-term complications of diabetes. This article reviews only those abnormalities of interstitial connective tissue involving skeleton, joints, skin, and periarticular tissues. Abnormalities in the skin and periarticular tissues result in syndromes limiting joint movement, including limited joint mobility, Dupuytren disease, flexor tenosynovitis, carpal tunnel syndrome, stiff-hand syndrome, and shoulder-hand reflex dystrophy. Of these, only limited joint mobility and stiff-hand syndrome occur exclusively in patients with diabetes. In all of these conditions, advanced glycation end products are thought to form as a result of nonenzymatic reaction of glucose with proteins, causing stiffening.

Long-term follow up to patients with frozen shoulder after mobilization under anesthesia, with special reference to the rotator cuff

In order to evaluate the efficacy of mobilization under anesthesia as a therapy for frozen shoulder, 43 patients with a mean age of 52.8 years were examined after an average time of 4.7 years. Since some authors have been concerned about rotator cuff tears, special attention--using sonography--was paid to rotator cuff lesions.

RESULTS

Clinical and sonographic examinations were very similar and showed a perfect recovery in 27 of 37 patients (73.0%). The average time off work after mobilization was 6.2 weeks compared with expected spontaneous recovery of about 30 months. Outcome was worse in patients with previous trauma to their shoulder. In 2 patients (5.4%) the sonography revealed a slight rotator cuff tear, which is not uncommon in 60-year-old persons. Two additional patients (5.4%) underwent shoulder surgery two years after mobilization due to a persistent impingement syndrome and to a supraspinatus-tear. We conclude, that mobilization under anesthesia for frozen shoulder is an effective treatment modality causing little harm.

A quantitative assessment of limited joint mobility in patients with diabetes. Goniometric analysis of upper extremity passive range of motion

OBJECTIVE

The syndrome of limited joint mobility is a common but not widely recognized musculoskeletal complication of diabetes. The purpose of this study was to further characterize this syndrome using quantitative goniometric measures.

METHODS

Cross-sectional analysis of a sample population was performed to establish the prevalence, location, and severity of limited joint mobility and to determine its relationship to extraarticular manifestations and complications of diabetes. Passive range of motion of both upper extremities was measured by goniometry in 70 adult patients with insulin-dependent diabetes mellitus and 70 nondiabetic controls who were group-matched for age, sex, and general activity level. Joint mobility was assessed by both individual joint motions and a composite scoring technique.

RESULTS

Analysis of individual joints and composite scores revealed significant differences between dominant and nondominant extremities in both the control and the diabetic groups. Diabetic patients were generally less flexible than nondiabetic subjects throughout the arm, especially in shoulder and finger joints. In the full study population, multivariate analysis revealed that advanced age, male sex, and the presence of diabetes were associated with decreased passive range of motion for a majority of joints (P < 0.05). In the diabetes group, passive range of motion was significantly correlated (P < 0.05) with age, sex, duration of diabetes, and to a variable extent, glucose control, but was not correlated with the presence of clinically significant neuropathy, retinopathy, nephropathy, or peripheral vascular disease, with activity level, or with hand dominance. Stepwise regression analysis failed to identify single key joint motion(s) to serve as possible screening tests in predicting generalized limited joint mobility of the upper extremity. Finally, the effect of limb usage on range of motion in flexion may differ in diabetic and nondiabetic subjects.

CONCLUSION

Limited joint mobility is a generalized phenomenon occurring throughout the upper extremities of many diabetic patients. It is significantly related to age, sex, and to a variable extent duration of diabetes and glucose control. It is not related to the standard complications of diabetes as defined in this study.

Limited joint mobility in insulin dependent childhood diabetes

Limited joint mobility (LJM), beginning typically in the fifth finger and moving radially, affecting interphalangeal, metacarpal-phalangeal, and large joints, is the earliest clinically apparent complication of diabetes in childhood and adolescence. It is painless and not disabling. Approximately 50% of post-adolescent patients with more than 5 years duration of diabetes are affected, with age being more important than duration of diabetes, as is the case with other complications. Growth failure is more frequent in the presence of LJM, although correlations with diabetic control have not been found. Variations in frequency in various reports, including high prevalence in controls or relatives, appear to be related to the quality of the examination; simple inspection with hands pressed flat on the table top or together in the prayer position is inadequate; passive extension must be performed. Although differential diagnosis from other conditions causing limitation of the fingers in diabetes would appear simple, LJM has been confused with other conditions which can be distinguished by the presence of pain or paresthesias, neurologic findings, disability, finger-locking, swelling, muscle atrophy, palmar skin or fascial thickening, absence of typical distribution, calcification of the vessels and, particularly, the age group affected. That the periarticular thickening found on examination and demonstrated on roentgenograms reflects generalized abnormalities is suggested by association with thick tight waxy skin, decreased pulmonary function, and association with retinopathy, nephropathy, and neuropathy, independently of duration of diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

Frozen shoulder: current concepts

The literature on frozen shoulder (FS) is reviewed. The etiology of FS is still not known and our understanding of the pathogenesis is limited. Studies on treatment programs under controlled conditions are few and incomplete. Further research is urgently needed.

Limitation of finger joint mobility in diabetes mellitus

Diabetes mellitus, both insulin dependent and non-insulin dependent, is associated with limitation of joint mobility of the fingers, which can be due to connective tissue changes, neuropathy, vasculopathy, or combinations of these problems. Distinct clinical problems include Dupuytren disease, flexor tenosynovitis, carpal tunnel syndrome (diabetic hand), stiff hand syndrome, shoulder-hand syndrome (reflex dystrophy) and limited joint mobility (LJM). Stiff hand and LJM syndromes are only seen with diabetes; the others have distinct clinical characteristics in those with diabetes compared to the nondiabetic presentation. LJM is of particular interest because it is common in young patients and associated with an increased risk for the serious complications of nephropathy and retinopathy.