Sunday, November 06, 2005

Shoulder problems in Diabetics

Dr.A.K.Venkatachalam,consultant orthopaedic surgeon,Chennai Tel 00 91 9282165002, have an additional burden of joint problem in addition to their systemic problems of nerves, eyes, blood vessels, kidneys etc.
Diabetics are prone to develop a condition of the shoulders called primary frozen shoulder. It can affect both shoulders in a small percentage of people. It usually resolves over a period of time but can leave behind a lasting deficit of certain movements.
Middle aged diabetics also develop tears of the rotator cuff and this can lead to a secondary frozen shoulder. Rotator cuff is group of tendons on top of the shoulder which help to stabilize the joint.
They can develop calcium deposition in the rotator cuff tendons.
They are prone to develop Gouty arthritis in their shoulders like in any other joints since Gout has an association with diabetes. Gout is a condition due to consumption of uric acid which is a by product of the digestion of red meat.
In this article I shall discuss frozen shoulder.
Frozen shoulder (Adhesive capsulitis, periathritis) is a condition characterized by a loss all movements at the true shoulder joint. There is pain initially. Pain settles down and there remains stiffness which sets in over a short period of time. Clever people may recall a traumatic incident. In others it may come on slowly. Stiffness may be permanent. The movement that is maximally affected is external rotation (rotating the arm outwards away from the body). This results in inability to reach behind the head with the hand to tie the hair. When both shoulders are affected elderly women are in an embarrassing situation. Overhead activities are also affected as the degree of elevation of the arm is reduced.
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 to the mouth for eating and 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.
History of frozen shoulder-
Only in the last few years has the ideal treatment been suggested. It is a relatively rare disorder of the shoulder and in a population of 20 shoulder patients there may be one or two with this condition.
However many doctors and orthopaedic surgeons label any painful condition as a frozen shoulder and advice physiotherapy. This can make the condition worse.
Recent advances
It has been recently 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.
Standard treatment-
This is a combination of physiotherapy and steroid injections when the condition is initially painful. Physio can be done at home. The standard Orthopaedic treatment has been a manipulation under anaesthesia. This carries a theoretical risk of fracture but has not been validated in practice. Since I have pointed out that rotator cuff tears can coexist with a frozen shoulder, the ideal management would be an arthroscopic release of the contracted structures within the joint. An arthroscope is an instrument used to look into joints through tiny key hole incisions. The benefits are less pain after surgery and faster rehabilitation. Since scar tissue formation is minimized, lesser are the chances of recurrence and greater the chance of retaining the full range of movement. The range of movement achieved after the release has to be maintained with physiotherapy. In case there is some tear of the rotator cuff, repair can be done at a later stage.

1 comment:

Manuel Gomes Pereira said...


I am 60 y/o and I have been submmited in Lisbon to an arthroscopy to a frozen shoulder last June,2005. It all started in September,2004 when I first felt a little pain on my right shoulder when raising up my arm above trhe shoulder and when trying to put my arm around my lower back. Since the pain did not disapeared I went to an orthopaedic surgeon and after a Tac image and a physical exam, the doctor diagnosed a Sub acromial impingement tough physiotherapie treatments tooked place for more than one month twice a week. All of a sudden I started to feel pain in my left shoulder! The pain got more and more stronger on my left shoulder than on my right one. The doctor told me that sometimes that was normal but he did not had a reasonable explanation for that to happened. A steroid injection infiltration on my left shoulder tooked place on March 3,2005 but nothing got better. More and more physiotherapy and nothing better. Than finnaly it degenerated in a frozen shoulder and the arthroscopic surgery tooked place as stated on the biggining.
I have been submited twice a week to one hour physiotherapy seccion by a senior technicien but I hardly move my left shoulder special external rotation and arm raizing above the shoulder plan. Siffness is quite permanent and I normally feel a sensation of bad blud circulation at the shoulder and at the arm level.
Why did not the surgery solved the problem?
For how long should I must continue the physiotherapy before my soulder/arm pain stops?
Uptill know I have not have any Diabetics symptons yet average high glicemia values (105 mg/dl).
I did suffered a Linfoma, Non-Hodgkin, Grade 1 detected on Februart,2004 and I did Chimiotherapy treatments (6 Shop tratments followed by 4 Imunotherapy injections.
Your comments please.
Manuel Gomes Pereira-Lisbon/Portugal