DIABETES INTERVIEW NEWS: 
a weekly e-newsletter for people with diabetes
Copyrighted 1996, Diabetes Interview
Newsletter 85#

This Week's Story:
Frozen Shoulder: 11% Of People With Diabetes Get It

Recently, Diabetes Interview 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 Interview, 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 Interview: 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 Interview: 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 Interview: 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 Interview: 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.

1. 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.

2. 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.

3. 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 Interview: 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 Interview: 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 Interview: 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 Interview: 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 shoulder 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.

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