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Frozen Shoulder

Source: American Diabetes Association

A body in motion tends to stay in motion, and a body at rest tends to stay at rest. Such is the case with your shoulder and a condition called adhesive capsulitis. Adhesive capsulitis is more commonly known as frozen shoulder, and with good reason: It can render your shoulder so stiff, it’s almost impossible to button your shirt — that is, if you aren’t in too much pain to get dressed in the first place.

Frozen shoulder usually begins innocently enough. Your shoulder is bothering you, so you don’t use it. Sure, there’s something to be said for resting an overused joint after a weekend softball tournament. But if you’ve injured your shoulder or are suffering from chronic shoulder pain and you don’t use your shoulder for a long time, your joint will stiffen up.

From there, it becomes a vicious cycle. If your joint begins to stiffen up, it’s more difficult and more painful to use your shoulder. So you use your shoulder even less. Your shoulder gets more and more stiff, and eventually, the lining of the joint gets stiff. Once that happens, you won’t be able to move your shoulder much, even if you want to. It simply won’t budge past a certain point because of pain and stiffness.

In general, frozen shoulder can come on after an injury to your shoulder or a bout with another musculo-skeletal condition such as tendonitis or bursitis. It can also develop after a stroke. Quite often its cause can’t be pinpointed. Nonetheless, any condition that causes you to refrain from moving your arm and using your shoulder joint can put you at risk for developing frozen shoulder.

Diabetes is also a risk factor for frozen shoulder, although precisely why that’s so is a subject the medical community is still researching. One theory involves collagen, one of the building blocks of ligaments and tendons. Collagen is a major part of the ligaments that hold the bones together in a joint. Glucose (sugar) molecules attach to collagen. In people with diabetes, the theory goes, this can contribute to abnormal deposits of collagen in the cartilage and tendons of the shoulder. The buildup then causes the affected shoulder to stiffen up.

Overall, frozen shoulder affects about 20 percent of people with diabetes, compared with 5 percent of people without diabetes.

Other risk factors are gender and age. Women are more likely to develop frozen shoulder than men, and frozen shoulder occurs most frequently in people between the ages of 40 and 60. It usually affects only one shoulder at a time, and for reasons unknown, the non-dominant shoulder is affected most often.

A Lengthy Condition

Frozen shoulder has several stages. First, there is the painful stage. There is a general ache in the shoulder, and your muscles might spasm. The pain may be worse at night. This stage can last anywhere from a few weeks to eight months.

The next stage usually isn’t as painful, but the shoulder does become more stiff. This is when the ligaments shorten and do not stretch, causing you to lose mobility in your shoulder. This “stiffening” stage can last from two to six months.

Third is the recovery stage. Like the stiffening stage, this stage generally is not as painful as the first stage. The ligaments start to stretch and, gradually, your shoulder and arm regain some or most of their natural movement. However, recovery may come in fits and starts, with a bout of pain before each step along the way as the lining of the joint stretches out. The recovery stage can last from one to nine months.

So, if left to run its course, frozen shoulder can last from eight months to 17 months or more. Some cases have lasted as long as two years.

The Importance Of Early Treatment

Some doctors concentrate on pain relief during the first stage, but others, like Lori B. Siegel, MD, chief of the division of rheumatology and associate professor of medicine at Finch University of Health Sciences/Chicago Medical School in North Chicago, Ill., opt for a more aggressive approach. Siegel says keeping the shoulder moving, to work the stiffness out of the ligaments and tendons so adhesions can’t form, is the way to go.

“If we catch it early, it might be possible to work through it with physical therapy, even if there’s some pain,” she says. “But once you enter the middle stage, there’s already been some stiffness and that makes it tougher to work through.”

She notes that in the middle stage, treatment can go beyond physical therapy and exercise and include shots of saline or cortisone to help you regain shoulder mobility and loosen up the stiff joint.

Most experts agree that physical therapy should be the first treatment attempted for frozen shoulder. But such therapy, during which a therapist stretches and moves your shoulder, along with daily home exercise, may not appear to make much sense, especially if your shoulder hurts. After all, pain is an indication that something is wrong, and it could be a sign of inflammation. Why move your shoulder if there is pain and inflammation? Because lack of use and motion is what leads to stiffness.

“Inflammation should be taken into consideration by your physical therapist, but unless the shoulder is severely inflamed, you would want physical therapy” says Michael Mueller, PT, PhD, associate professor at the Washington University School of Medicine in St. Louis, MO. Anti-inflammatory drugs like ibuprofen can help bring mild to moderate inflammation down to the point where you are able to start therapy. After that, it’s a matter of how much you hurt.

“The gauge is how much pain you are in,” he says. “Your physical therapist should work with you to see what you can tolerate.” But if you cannot do physical therapy because of pain, you should see your doctor for medication or shots.

How Early Is Early Enough?

How long should you wait before coming to the conclusion that this isn’t “weekend warrior” pain and it’s time to go to the doctor?

That depends on what your symptoms are, says Rachel Peterson Kim, MD, staff rheumatologist at the Scripps Clinic in La Jolla, CA. “If it’s a mild nagging pain, you can try rest, ice, and anti-inflammatory drugs such as ibuprofen for a week or two,” she says. “But if you suddenly can’t move it at all, or there’s a lot of pain, see a doctor.”

If you’ve lost any mobility in your shoulder, it’s time to see a doctor as well, says Mueller. He suggests a simple test.

Lie on the floor or on your bed. Bring your arm up and over like you are doing a backstroke. You should almost be able to touch the floor or bed with the back of your hand. Of course, if you can actually touch it, that’s great, but as long as you can come within a few inches, that’s fine. If not, you’ve lost some range of motion in your shoulder and you should talk to your doctor about it.

When you go to your doctor, provide as much information as you can, and don’t be afraid to ask questions or repeat yourself. The shoulder is vulnerable to many different conditions and injuries, and your doctor will need as much information as possible to give you a correct diagnosis. It’s not unheard of for a doctor to mistake frozen shoulder for other conditions, particularly a torn rotator cuff.

“There are lots of different reasons for shoulder pain, and some doctors will think of torn rotator cuffs because that is another important condition and part of so many other problems,” says Mueller. So don’t be afraid to ask your doctor why he or she has come to a diagnosis — any diagnosis.

If your doctor confirms frozen shoulder, take his or her advice about exercise seriously and act immediately, says Kim. “Patients should definitely be doing physical therapy or exercises at home, in addition to their physical therapy, and they should follow up with their doctors if there is no improvement,” Kim says.

She adds that this is especially important for people with diabetes because they are less likely than others to have a complete recovery, even with therapy. According to Kim, permanent loss of as much as 50 percent of shoulder mobility can occur among people with diabetes. (In the general population, any permanent decrease of range of motion is usually negligible.) That’s why it’s so important to stack the odds in our favor.

“We don’t know why people with diabetes have a greater risk of incomplete recovery,” she says. “No one has really looked at it yet. Is it their blood sugars? Are they less active? I don’t think there’s a good answer for it yet.”

Siegel adds that it’s important not to ignore any signs that the condition is getting worse. “It’s easy to ‘cheat’ with the shoulder,” she says. “A lot of people compensate for it by bending in other ways or relying on other muscles, but that can lead to other chronic pain syndromes. It’s really a quality-of-life issue.”

And if there’s no improvement? If it’s not getting worse, but it’s not getting better either, then it’s time to consider more aggressive treatments, including surgery.

Your doctor may give you general anesthesia and then, while you are completely out and unable to feel pain, manipulate your arm to loosen the joint. Surgery is the last resort and should be approached with great caution because the condition usually improves on its own over time.

The bottom line is, if you’ve had a traumatic injury to one of your shoulders, like a fall or a blow, or you suddenly experience intense shoulder pain or a loss of mobility, even for no apparent reason, get to a doctor. Then learn everything you can about all of the treatment options available.

Taken from the August 2002 issue of Diabetes Forecast