Shoulder Pain Management

Diabetes Management

Prevalence of Common Shoulder Ailments

The prevalence of shoulder pain in people with diabetes is at least twice as high compared with people who do not have diabetes.^1,2 More common shoulder conditions in people with diabetes include:

• Adhesive capsulitis (or frozen shoulder)
• Calcific periarthritis
• Arthritis
• Rotator cuff abnormalities
• Reflex sympathetic dystrophy^1,2

Of note, up to 78% of patients with diabetes may have rotator cuff conditions, and people with diabetes are about 3 times more likely to have calcific periarthritis than people without diabetes.³

Shoulder capsulitis affects about 10% of Type 1 diabetics and about 22% of Type 2 diabetics, but its prevalence is stratified by age. In Type 1 diabetes, shoulder capsulitis is more prevalent after age 40, and in Type 2 diabetes, prevalence increases after age 50.⁴

People with Type 1 diabetes are 5 times more likely to have rheumatoid arthritis than people with Type 2 diabetes.⁵

Shoulder Disability

People with diabetes are 5 times more likely to have shoulder pain than the general population, and the disability from shoulder pain and co-morbid diabetes is significantly worse than in people who do not have diabetes.¹ Shoulder pain and stiffness in people with diabetes may be exacerbated by:

• Age
• Gender
• Obesity
• Smoking¹

People with diabetes and shoulder pain or stiffness have significantly reduced mobility compared with shoulder patients who do not have diabetes.¹ Shoulder flexion and abduction can be significantly reduced in people with diabetes who report shoulder stiffness compared with people who did not have diabetes, even after adjustment for confounding factors.¹ A mean reduction of 4°-10° has been seen in shoulder flexion, abduction and external rotation after adjusting for age, gender, obesity and smoking.

Shoulder pain tends to be chronic and progressive in diabetics. About half of patients with these co-morbid conditions report increased pain and disability over the course of one year.²

Glycemic Control

Increased shoulder pain in patients with diabetes has been associated with duration of disease and may be due to glycosylation of connective tissue.⁶ High blood glucose levels have been shown to predict increased shoulder pain over one year, and diabetes complications, such as retinopathy requiring intervention, have been shown to predict increased shoulder disability over one year.⁶ These outcomes suggest that people with diabetes experience more rapid joint degradation than people who do not have diabetes.

A significant increase in pain scores over one year in patients with high HbA1c and current shoulder symptoms has been reported.² Older patients who had higher HbA1c and less initial shoulder pain were more likely to experience worsening shoulder pain after one year.⁶

Additionally, shoulder capsulitis tends to be more prevalent in Type 2 diabetics when glycemic control is poor compared with Type 2 diabetics who had good glycemic control.⁴

By contrast, in patients with tightly controlled blood glucose, lower levels of skin collagen glycosylation, glyco-oxidation and elevated advanced glycosylation endpoints have been observed, suggesting that better glycemic control may reduce the risk of musculoskeletal conditions.⁶

Obesity and Diabetes

People with diabetes are more likely to be obese or morbidly obese than people without diabetes. Up to 26% of people with diabetes are obese or morbidly obese compared with up to 11% of the general population.²

Obesity is a risk factor for pain that may be partly responsible for the association between diabetes and shoulder pain.^1,2 In one study, patients who were obese and who had diabetes were nearly twice as likely to report shoulder pain or stiffness compared with people of normal weight who did not have diabetes. People who were obese but did not have diabetes were nearly 1.54 times more likely to report shoulder pain or stiffness compared with people of normal weight who did not have diabetes.¹

Post-operative Diabetic Management

Hyperglycemia can prevent wound healing by hindering collagen production, impairing leukocyte chemotaxis and phagocytosis, and causing abnormal coagulation.⁷

These problems can be minimized by good glycemic control starting several weeks before scheduled surgery.⁷

It may be helpful to admit patients with diabetes one day before surgery to ensure metabolic control and electrolyte balance before surgery.⁷

Similarly, practical postoperative steps can help minimize complications. A sliding insulin scale and sick day insulin rules will help account for variable post-surgery eating. Prescribing anti-nausea medications in advance of surgery and instructing the caregiver on their appropriate use will help minimize variable eating due to upset stomach.⁷

Morbid obesity and diabetes have been associated with higher rates of deep infection after joint replacement.⁸ Patients with either diabetes or BMI above 40 are at more than 3 times the risk of postoperative infection compared with patients without these conditions. Therefore, patients with diabetes or who are morbidly obese should be monitored closely for signs of infection after surgery.

Summary

People with diabetes are twice as likely to have shoulder pain and stiffness compared with the general population, and the disability from shoulder pain and co-morbid diabetes is more severe and has a quicker onset than in people with shoulder pain alone. Therefore, patients with diabetes may benefit from early surgical intervention more than they would from prolonged conservative treatment that would allow continued rapid joint degradation. Obesity may compound the increased shoulder pain and disability seen in people with diabetes.

Shoulder pain and disability can lead to reduced quality of life. However, proactive treatment of shoulder pain and early referral to an orthopaedic shoulder specialist may provide earlier relief.

References