Diabetes e afecções do membro superior Folheto

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview

• Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications [1].
• In a cohort of 36 patients, both shoulders were involved in periarthritis, with a high incidence observed in insulin-dependent diabetics [2].
• Examination of the hands and shoulders should be included in the evaluation of patients with diabetes [3].
• The prevalence of musculoskeletal disorders in people with type 2 diabetes mellitus remains high despite advances in medical management over the last two decades [4].
• Shoulder pain and disability are common and persistent in adults with diabetes [5].
• Upper extremity impairments are prevalent and significant in patients with diabetes mellitus [6].
• Patients with insulin-dependent diabetes mellitus (IDDM) have a greater risk of complications following hand and upper extremity surgery, specifically surgical site infections [7].
• Limited joint mobility in diabetes shows continuing gradual deterioration with increasing duration of disease, though finger joint contractures are prevalent only in longstanding diabetics with a disease duration of nine years or more [8].
• Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by more proximal locations, deeper involved anatomy, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation [9].
• The systemic nature of musculoskeletal impairments in people with diabetes mellitus has traditionally been underappreciated but is recently gaining attention [11].
• More than one third of patients in a clinical series of hand infections were diabetic [12].
• The presence of diabetes mellitus, rather than its severity, was the most important factor for developing trigger digit after carpal tunnel release [13].
• Current evidence supports the efficacy of surgical interventions for managing upper limb conditions in diabetic individuals, though additional research is required to determine if outcomes are equivalent to nondiabetic patients and if diabetes increases complication risk [14].
• The prevalence of frozen shoulder is less than previously reported but still greater in diabetic patients [15].
• Diabetic patients showed a significantly higher prevalence of multiple digit involvement by stenosing flexor tenosynovitis than nondiabetic patients [19].
• Diabetes mellitus is associated with a variety of hand manifestations including stenosing tenosynovitis, Dupuytren's contracture, carpal tunnel syndrome, and limited joint mobility, which often present with multiple visits for hand conditions over time [21].
• Musculoskeletal hand disorders were prevalent in type 2 diabetes mellitus patients in a study conducted in Jordan [60].

Background & Causes

Epidemiology and Prevalence

• In a study of 36 patients, both shoulders were involved in 4.5 per cent of cases, with a high incidence observed in insulin-dependent diabetics [2].
• A patient presenting with a painful shoulder of insidious onset with restricted motion, where an intrinsic cause is ruled out radiographically, has a 38.6% chance of being diabetic and a 32.95% chance of being prediabetic [20].
• The frequencies of hand region abnormalities are significantly higher in diabetic subjects compared to controls [33].
• Diabetic patients show a significantly higher prevalence of multiple digit involvement by stenosing flexor tenosynovitis than nondiabetic patients [19].

Causal Associations and Risk Factors

• A genome-wide association study identifies diabetes as a likely causal risk factor for frozen shoulder, likely through a pathway involving long-term high blood glucose levels [27].
• A 2-sample Mendelian randomization analysis supports a genetic causal relationship between type 2 diabetes and fasting glucose and frozen shoulder [61].
• A cohort study in UK electronic health records suggests that type 2 diabetes may be a cause of frozen shoulder but does not support the hypothesis that the effect is mediated by metabolic health [38].
• People with diabetes are more likely to develop frozen shoulder [47].
• Strong evidence indicates that diabetes is associated with a higher risk of tendinopathy [35].
• Type 2 diabetes does not seem to be a risk factor for carpal tunnel syndrome [56].

Pathophysiology and Molecular Mechanisms

• Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic adhesive capsulitis with idiopathic adhesive capsulitis, suggesting these are distinct clinical entities [31].
• Matrix metalloproteinase-1 and matrix metalloproteinase-9 are highly expressed in the joint capsule of diabetic frozen shoulder, demonstrating their potential involvement in the pathophysiology [62].
• Higher RAGE expression is observed in the flexor tendon synovium of patients with diabetes who have more severe carpal tunnel syndrome, suggesting RAGE-mediated pathways may play a role in the pathophysiology [57].
• Molecular and pathological studies provide a potential basis for the predisposition of diabetic patients to the development of carpal tunnel syndrome [58].
• Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles [24].

Disease Progression and Clinical Characteristics

• There is continuing gradual deterioration of limited joint mobility with increasing duration of disease, though finger joint contractures are prevalent only in longstanding diabetics with a disease duration of nine years or more [8].
• Although frozen shoulder might be associated with the duration of diabetes, the association between metabolic control and frozen shoulder or other shoulder disorders has yet to be clearly shown [18].
• In adults with hand syndromes associated with diabetes, disability was related to impaired muscle function and carpal tunnel syndrome [16].

Symptoms & Presentation

General Musculoskeletal Presentation

• Upper limb musculoskeletal abnormalities in diabetes are associated with poor metabolic control [1].
• The systemic nature of musculoskeletal impairments in people with diabetes has traditionally been underappreciated but is recently gaining attention [11].
• Diabetes mellitus is associated with a variety of hand manifestations including stenosing tenosynovitis, Dupuytren's contracture, carpal tunnel syndrome, and limited joint mobility [21].
• Hand manifestations of diabetes often present with multiple visits for hand conditions over time [21].

Shoulder Involvement

• In a series of 36 patients, both shoulders were involved in periarthritis of the shoulder associated with diabetes mellitus [2].
• There was a high incidence of bilateral shoulder involvement in insulin-dependent diabetics [2].
• The prevalence of frozen shoulder is greater in diabetic patients than previously reported [15].
• Frozen shoulder might be associated with the duration of diabetes [18].
• The association between metabolic control and shoulder disorders has yet to be clearly shown [18].
• Patients with and without diabetes experienced similar pain except during exertion [28].
• Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic adhesive capsulitis with idiopathic adhesive capsulitis [31].
• Diabetic patients are reported to have more residual pain, reduced motion, and inferior function compared to idiopathic cases following arthroscopic capsular release [52].
• A patient who presents with a painful shoulder of insidious onset with restricted motion for which an intrinsic cause can be ruled out radiographically has a 38.6% chance of being diabetic [20].
• A patient who presents with a painful shoulder of insidious onset with restricted motion for which an intrinsic cause can be ruled out radiographically has a 32.95% chance of being prediabetic [20].
• Patients diagnosed with idiopathic frozen shoulder who are 60 years or younger and are not known diabetics have a similar probability of having diabetes or prediabetes to an age-matched population [34].

Hand and Wrist Involvement

• Finger joint contractures are prevalent only in longstanding diabetics with a disease duration of nine years or more [8].
• There is continuing gradual deterioration of limited joint mobility with increasing duration of disease [8].

Infection and Surgical Complications

• Patients with insulin-dependent diabetes mellitus have a greater risk of complications following hand and upper extremity surgery, specifically surgical site infections [7].
• There was an increased severity of hand infections in diabetic patients treated during the COVID-19 pandemic, linked to poor glycaemic control [26].

Management

Assessment and Surveillance

• In 36 patients (4.5 per cent.), both shoulders were involved and there was a high incidence in insulin-dependent diabetics [2].
• Diabetes is associated with higher risk of tendinopathy [35].
• Limitation of joint mobility is not uncommon in the nondiabetic ageing population [53].

Non-Operative Management

• Local corticosteroid injection to the shoulder can create a significant, short-term increase in systemic glucose levels in patients with type 2 diabetes not treated with insulin [17].
• Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients [22].
• Patients with HbA1c levels of 7% or greater experience higher and longer-lasting blood glucose elevations after corticosteroid injections compared to those with lower levels [54].
• Radial extracorporeal shock-wave therapy (rESWT) might be considered a safe alternative to steroid injections in diabetic patients with shoulder adhesive capsulitis [51].
• Platelet-rich plasma injection is a safe and well-tolerated method for adhesive capsulitis management for diabetic patients [43].
• Long-term prospective randomised controlled trials on the effects of exercise in preventing musculoskeletal complications and disability in diabetics are needed [10].

Operative Management: General Considerations

• Insulin-dependent diabetes mellitus (IDDM) is associated with a greater risk of complications following hand and upper extremity surgery, specifically surgical site infections [7].
• The best current evidence supports the efficacy of surgical interventions for the management of upper limb conditions in diabetic individuals [14].
• Additional research is required to determine whether treatment outcomes in diabetic patients are equivalent to those of nondiabetic patients [14].
• Additional research is required to determine whether diabetes is associated with an increased risk of complications in upper limb surgery [14].
• More than one third of patients presenting with hand infections are diabetic [12].
• Increased severity of hand infections in diabetic patients treated during the pandemic was linked to poor glycaemic control [26].

Operative Management: Carpal Tunnel Syndrome

• Patients with diabetes have the same beneficial outcome after carpal tunnel release as nondiabetic patients [30].
• Long-term improvement in patients with diabetes remained after carpal tunnel release to the same extent as for patients without diabetes [32].
• The duration of diabetes and its treatment can be related to the severity of the disease symptoms after carpal tunnel releasing surgeries [48].
• Preoperative semaglutide use was not associated with a reduction in 90-day complications or 2-year reoperation-free survival in patients with type II diabetes mellitus undergoing carpal tunnel release [55].

Operative Management: Frozen Shoulder

• Results in diabetics were significantly worse than those in non-diabetics six months post-operatively after arthroscopic release for frozen shoulder [29].
• There is a tendency towards persistent limitation of movement two years after arthroscopic release for frozen shoulder in diabetics [29].
• Arthroscopic capsular release (ACR) offered good outcomes in both diabetic and non-diabetic patients in terms of range of motion, pain relief and shoulder function [50].
• An initial failure rate of approximately one-third for manipulation under general anesthesia (MUA) may be considered unacceptably high in other general orthopedic procedures [36].
• With appropriate counseling and consent and combined with a repeat MUA for recurrence, the MUA protocol may represent a satisfactory treatment strategy in the diabetic population [36].
• When shoulder mobilization was achievable with gentle manipulation under anesthesia, the outcome was satisfactory in both patients with IDDM and those with NIDDM [49].
• Patients with and without diabetes experienced similar pain except during exertion regarding frozen shoulder range of motion recovery [28].

Operative Management: Trigger Finger

• Percutaneous release with or without simultaneous corticosteroid injection has shown promising results and is equally effective and safe in diabetics and nondiabetics [41].
• Excision of the ulnar slip of the flexor digitorum superficialis with or without A1 pulley release is a safe and effective treatment for stenosing flexor tenosynovitis in the diabetic patient [44].

Vascular Disease and Amputation

• Arterial occlusive disease in the distal upper extremity is primarily related to the combination of diabetes, renal disease, and often organ transplantation [40].
• The need for access for hemodialysis compounds vascular problems by potentially altering the circulation distal to the site of the arteriovenous fistula [40].
• An aggressive approach is warranted for patients with critical ischemia of the hand to try and avoid loss of the hand [40].
• Arteriography remains the gold standard for most patients with critical ischemia of the hand because proper evaluation requires good visualization of the forearm vessels, palmar arch, and digital vessels [39].
• Many patients with critical ischemia due to complications of diabetes and renal disease will have multiple levels of partial occlusion that can be seen in the forearm vessels on arteriography [39].
• In patients with factors or injury characteristics that contraindicate single-digit replantation, such as advanced age, diabetes mellitus, or smoking, revision amputation is indicated [37].

Key Considerations

Prevalence and Assessment

• In a clinical series of hand infections, more than one third of the patients were diabetic [12].
• A patient who presents with a painful shoulder of insidious onset with restricted motion for which an intrinsic cause can be ruled out radiographically has a 38.6% chance of being diabetic and a 32.95% chance of being prediabetic [20].

Pathophysiology and Risk Factors

• In 36 patients (4.5 per cent.), both shoulders were involved in periarthritis, and there was a high incidence in insulin-dependent diabetics [2].
• Diabetes is a likely causal risk factor for frozen shoulder, likely through a pathway involving long-term high blood glucose levels [27].

Surgical Outcomes and Complications

• The best current evidence supports the efficacy of surgical interventions for the management of these conditions in diabetic individuals; however, additional research is required to determine whether the treatment outcomes are equivalent to those of nondiabetic patients, and whether diabetes is associated with an increased risk of complications [14].
• Results in diabetics were significantly worse than those in non-diabetics six months post-operatively after arthroscopic release for frozen shoulder, with a tendency towards persistent limitation of movement two years after operation [29].
• An initial failure rate of approximately one-third may be considered unacceptably high in other general orthopedic procedures; however, with appropriate counseling and consent and combined with a repeat MUA for recurrence, this protocol may represent a satisfactory treatment strategy in the diabetic population for frozen shoulder [36].
• Patients with diabetes experience more symptoms both before and after open carpal tunnel release, but can expect the same relative improvement from surgery as patients without diabetes [63].
• There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus [64].

Perioperative Management

• Data did not support the guidelines for enforcing HbA1c cutoff levels prior to elective hand surgery overall [45].
• A collaborative and comprehensive approach to the pre-operative medical evaluation of patients with diabetes mellitus is critical, as is future investigation into alternative methods associated with outcomes after shoulder arthroplasty in patients with diabetes mellitus [46].
• The incidence of poorly controlled blood glucose in the community was high, but the rate of diabetes follow-up was surprisingly high and timely in a hand and upper extremity surgery clinic [65].

Key Evidence

• [L3] Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications. [1] (10.1016/j.ejim.2009.08.001)
• [L4] In 36 patients (4.5 per cent.), both shoulders were involved and there was a high incidence in insulin-dependent diabetics. [2] (10.1136/ard.31.1.69)
• [L3] Examination of the hands and shoulders should be included in the evaluation of patients with diabetes. [3] (10.1016/s0002-9343(02)01045-8)
• [L3] The prevalence of musculoskeletal disorders in people with type 2 Diabetes mellitus remains high despite advances in medical management over the last two decades. [4] (10.1016/j.jht.2021.04.013)
• [L4] Shoulder pain and disability are common, and persistent in adults with diabetes. [5] (10.1093/rheumatology/ken333)
• [L3] These findings suggest that upper extremity impairments are prevalent and significant in this population. [6] (10.1016/j.physio.2014.07.003)
• [L2] Our data demonstrate a greater risk of complications following hand and upper extremity surgery for patients with IDDM, specifically surgical site infections. [7] (10.1016/j.jhsa.2018.06.006)
• [L3] There is continuing gradual deterioration with increasing duration of disease, though finger joint contractures are prevalent only in longstanding diabetics with a disease duration of nine years or more. [8] (10.1136/ard.44.2.93)
• [L2] Diabetes exacerbates the burden of surgical upper-extremity infections, characterized by more proximal locations, deeper involved anatomy, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation. [9] (10.1016/j.jhsa.2017.11.003)
• [L3] Long-term prospective randomised controlled trials on the effects of exercise in preventing musculoskeletal complications and disability in diabetics are needed. [10] (10.1007/s10067-003-0704-7)
• [L4] The systemic nature of musculoskeletal impairments in people with DM traditionally has been underappreciated but recently is gaining attention. [11] (10.1016/j.foot.2020.101680)
• [L4] Analysis of the authors' clinical series demonstrates that more than one third of the patients are diabetic. [12] (10.1016/s0749-0712(21)00424-8)
• [L4] The presence of diabetes mellitus rather than its severity was the most important factor for developing trigger digit. [13] (10.1016/j.jhsa.2013.10.023)
• [L4] The best current evidence supports the efficacy of surgical interventions for the management of these conditions in diabetic individuals; however, additional research is required to determine whether the treatment outcomes are equivalent to those of nondiabetic patients, and whether diabetes is associated with an increased risk of complications. [14] (10.1016/j.jhsa.2011.10.002)
• [L3] The prevalence of frozen shoulder is less than previously reported but still greater in diabetic patients. [15] (10.1016/j.jse.2007.02.133)
• [L4] In adults with hand syndromes associated with diabetes, disability was related to impaired muscle function and carpal tunnel syndrome. [16] (10.3899/jrheum.090239)
• [L2] Local corticosteroid injection to the shoulder can create a significant, short-term increase in systemic glucose levels in patients with type 2 diabetes not treated with insulin. [17] (10.1016/j.jseint.2022.05.016)
• [L2] Although frozen shoulder might be associated with the duration of diabetes, the association between metabolic control and the two aforementioned shoulder disorders has yet to be clearly shown. [18] (10.1111/jdi.12491)
• [L2] Diabetic patients showed a significantly higher prevalence of multiple digit involvement by stenosing flexor tenosynovitis than nondiabetic patients. [19] (10.3899/jrheum.081024)
• [L4] The study shows with statistical significance that a patient who presents with a painful shoulder of insidious onset with restricted motion for which an intrinsic cause can be ruled out radiographically has a 38.6% chance of being diabetic and a 32.95% chance of being prediabetic. [20] (10.1097/smj.0b013e3181705d39)
• [L4] Diabetes mellitus is associated with a variety of hand manifestations including stenosing tenosynovitis, Dupuytren's contracture, carpal tunnel syndrome, and limited joint mobility, which often present with multiple visits for hand conditions over time. [21] (10.1016/j.jhsa.2008.01.038)
• [L3] Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. [22] (10.1016/j.jhsa.2014.01.014)
• [L3] Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles. [24] (10.1186/s12891-022-05627-9)
• [L4] While fewer patients attended the service during the pandemic, there was an increased severity of hand infections in those treated, linked to poor glycaemic control. [26] (10.1177/17531934231196026)
• [L1] Diabetes is a likely causal risk factor for frozen shoulder, likely through a pathway involving long-term high blood glucose levels. [27] (10.1371/journal.pgen.1009577)
• [L3] Patients with and without diabetes experienced similar pain except during exertion. [28] (10.1177/0300060516675112)
• [L3] The results in diabetics were significantly worse than those in non-diabetics six months post-operatively with a tendency towards persistent limitation of movement two years after operation. [29] (10.1302/0301-620x.96b10.34476)
• [L2] Patients with diabetes have the same beneficial outcome after carpal tunnel release as nondiabetic patients. [30] (10.1016/j.jhsa.2009.04.006)
• [L5] Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC, suggesting that these conditions are distinct clinical entities. [31] (10.1016/j.jse.2021.06.016)
• [L2] Long-term improvement in patients with diabetes remained after carpal tunnel release to the same extent as for patients without diabetes. [32] (10.1016/j.jhsa.2014.01.012)
• [L3] The study found that the frequencies of hand region abnormalities were significantly higher in diabetic subjects as compared to the controls (p-value <0.001). [33] (10.1186/1756-0500-6-16)
• [L4] Patients diagnosed with idiopathic frozen shoulder who are 60 years or younger and are not known diabetics have a similar probability of having diabetes or prediabetes to an age-matched population. [34] (10.1177/2325967117716450)
• [L1] These findings provide strong evidence that diabetes is associated with higher risk of tendinopathy. [35] (10.1136/bjsports-2015-094735)
• [L3] An initial failure rate of approximately one-third may be considered unacceptably high in other general orthopedic procedures; however, with appropriate counseling and consent and combined with a repeat MUA for recurrence, this protocol may represent a satisfactory treatment strategy in the diabetic population. [36] (10.1016/j.jse.2011.11.006)
• [L2] This study suggests that type 2 diabetes may be a cause of frozen shoulder but does not support the hypothesis that the effect is mediated by metabolic health. [38] (10.1186/s12891-025-08672-2)
• [L4] Percutaneous release with or without simultaneous corticosteroid injection has shown promising results and is equally effective and safe in diabetics and nondiabetics. [41] (10.1016/j.jhsa.2018.03.045)
• [L3] Additionally, it is a safe and well-tolerated method for AC management for diabetic patients. [43] (10.5397/cise.2021.00381)
• [L4] This procedure is a safe and effective treatment for the often-difficult problem of stenosing flexor tenosynovitis in the diabetic patient. [44] (10.1007/s11552-007-9065-z)
• [L3] The data did not support the guidelines for enforcing HbA1c cutoff levels prior to elective hand surgery overall. [45] (10.1177/1558944720937363)
• [L4] A collaborative and comprehensive approach to the pre-operative medical evaluation of patients with DM is critical, as is future investigation into alternative methods associated with outcomes after shoulder arthroplasty in patients with DM. [46] (10.1007/s00264-018-3874-2)
• [L1] People with diabetes are more likely to develop frozen shoulder. [47] (10.1136/bmjopen-2022-062377)
• [Paper] However, the duration of diabetes and its treatment can be related to the severity of the disease symptoms after the carpal tunnel releasing surgeries. [48] (10.1055/s-0039-1697059)
• [L4] When shoulder mobilization was achievable with gentle manipulation under anesthesia, the outcome was satisfactory in both patients with IDDM and those with NIDDM. [49] (10.1067/mse.2002.127301)
• [L3] ACR offered good outcomes in both diabetic and non-diabetic patients in terms of range of motion, pain relief and shoulder function. [50] (10.1016/j.jor.2019.02.003)
• [L2] Therefore, rESWT might be considered a safe alternative to steroid injections in diabetic patients with shoulder AC. [51] (10.1016/j.jse.2020.03.005)
• [L4] However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. [52] (10.1016/j.otsr.2019.02.014)
• [L4] Limitation of joint mobility is not uncommon in the nondiabetic ageing population. [53] (10.1093/rheumatology/25.2.147)
• [L2] Patients with HbA1c levels of 7% or greater experience higher and longer-lasting blood glucose elevations after corticosteroid injections compared to those with lower levels, suggesting HbA1c can predict the degree of glucose elevation. [54] (10.1016/j.jhsa.2014.06.035)
• [L3] Preoperative semaglutide use was not associated with a reduction in 90-day complications or 2-year reoperation-free survival in patients with type II diabetes mellitus undergoing carpal tunnel release. [55] (10.1016/j.jhsa.2025.09.003)
• [L3] Type 2 diabetes does not seem to be a risk factor for carpal tunnel syndrome. [56] (10.1186/1471-2474-15-346)
• [L2] Among patients with diabetes who had CTS, higher RAGE expression was observed in those with more severe disease, suggesting that RAGE-mediated pathways may play a role in the pathophysiology of CTS in patients with diabetes. [57] (10.1097/corr.0000000000003800)
• [L4] It therefore provides a potential molecular and pathological basis for the predisposition of diabetic patients to the development of CTS. [58] (10.1007/s00125-014-3271-3)
• [L4] In the present study, musculoskeletal hand disorders were prevalent in T2DM patients in Jordan. [60] (10.1111/1756-185x.12617)
• [L1] This study supports a genetic causal relationship between type 2 diabetes and fasting glucose and frozen shoulder. [61] (10.1016/j.jse.2023.08.006)
• [L4] The findings of this study demonstrate the potential involvement of MMP-1 and 9 in the pathophysiology of diabetic FS. [62] (10.1016/j.jse.2024.03.062)
• [L3] Patients with diabetes experience more symptoms both before and after open carpal tunnel release, but can expect the same relative improvement from surgery as patients without diabetes. [63] (10.1136/bmjopen-2019-030179)
• [L3] There were no significant differences in outcomes between early and delayed arthroscopic release in patients with a history of diabetes mellitus. [64] (10.1016/j.jseint.2023.06.007)
• [L4] The incidence of poorly controlled blood glucose in the community was high, but the rate of diabetes follow-up was surprisingly high and timely. [65] (10.5435/jaaos-d-23-00593)

References

[1] Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes. European Journal of Internal Medicine. 2009. DOI: 10.1016/j.ejim.2009.08.001

[2] Periarthritis of the shoulder and diabetes mellitus.. Annals of the Rheumatic Diseases. 1972. DOI: 10.1136/ard.31.1.69

[3] Musculoskeletal disorders of the hand and shoulder in patients with diabetes mellitus. The American Journal of Medicine. 2002. DOI: 10.1016/s0002-9343(02)01045-8

[4] Proportion and distribution of upper extremity musculoskeletal disorders and its association with disability in type 2 diabetes mellitus. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2021.04.013

[5] Predictors of shoulder pain and shoulder disability after one year in diabetic outpatients. Rheumatology. 2008. DOI: 10.1093/rheumatology/ken333

[6] Upper extremity impairments, pain and disability in patients with diabetes mellitus. Physiotherapy. 2015. DOI: 10.1016/j.physio.2014.07.003

[7] Insulin Dependence Is Associated With Increased Risk of Complications After Upper Extremity Surgery in Diabetic Patients. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.06.006

[8] Limited joint mobility in diabetes mellitus.. Annals of the Rheumatic Diseases. 1985. DOI: 10.1136/ard.44.2.93

[9] Quantifying the Effect of Diabetes on Surgical Hand and Forearm Infections. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2017.11.003

[10] The musculoskeletal complications seen in type II diabetics: predominance of hand involvement. Clinical Rheumatology. 2003. DOI: 10.1007/s10067-003-0704-7

[11] Relationships within and between lower and upper extremity dysfunction in people with diabetes. The Foot. 2020. DOI: 10.1016/j.foot.2020.101680

[12] DIABETIC HAND INFECTIONS. Hand Clinics. 1998. DOI: 10.1016/s0749-0712(21)00424-8

[13] The Incidence of Trigger Digit After Carpal Tunnel Release in Diabetic and Nondiabetic Patients. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2013.10.023

[14] Impact of Diabetes on Outcomes in Hand Surgery. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2011.10.002

[15] Prevalence of symptoms and signs of shoulder problems in people with diabetes mellitus. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.133

[16] Hand Syndromes Associated with Diabetes: Impairments and Obesity Predict Disability. The Journal of Rheumatology. 2009. DOI: 10.3899/jrheum.090239

[17] The effect of steroid injection into the shoulder on glycemia in patients with type 2 diabetes. JSES International. 2022. DOI: 10.1016/j.jseint.2022.05.016

[18] Diabetes and shoulder disorders. Journal of Diabetes Investigation. 2016. DOI: 10.1111/jdi.12491

[19] The Presence of Limited Joint Mobility Is Significantly Associated with Multiple Digit Involvement by Stenosing Flexor Tenosynovitis in Diabetics. The Journal of Rheumatology. 2009. DOI: 10.3899/jrheum.081024

[20] The Prevalence of a Diabetic Condition and Adhesive Capsulitis of the Shoulder. Southern Medical Journal. 2008. DOI: 10.1097/smj.0b013e3181705d39

[21] Hand Manifestations of Diabetes Mellitus. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.01.038

[22] Blood Glucose Levels in Diabetic Patients Following Corticosteroid Injections Into the Hand and Wrist. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.014

[24] Shoulder muscle changes in patients with type 2 diabetes mellitus who have a painful shoulder: a quantitative muscle ultrasound study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05627-9

[26] The incidence and severity of diabetic hand infection presentations during the COVID-19 pandemic. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934231196026

[27] A genome-wide association study identifies 5 loci associated with frozen shoulder and implicates diabetes as a causal risk factor. PLOS Genetics. 2021. DOI: 10.1371/journal.pgen.1009577

[28] Range of motion of diabetic frozen shoulder recovers to the contralateral level. Journal of International Medical Research. 2016. DOI: 10.1177/0300060516675112

[29] Comparative outcome of arthroscopic release for frozen shoulder in patients with and without diabetes. The Bone & Joint Journal. 2014. DOI: 10.1302/0301-620x.96b10.34476

[30] Clinical Outcomes of Surgical Release Among Diabetic Patients With Carpal Tunnel Syndrome: Prospective Follow-Up With Matched Controls. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2009.04.006

[31] Evaluating whole-genome expression differences in idiopathic and diabetic adhesive capsulitis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.06.016

[32] Carpal Tunnel Release in Patients With Diabetes: A 5-Year Follow-Up With Matched Controls. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.01.012

[33] Upper limb musculoskeletal abnormalities in type 2 diabetic patients in low socioeconomic strata in Pakistan. BMC Research Notes. 2013. DOI: 10.1186/1756-0500-6-16

[34] Should Patients With Frozen Shoulder Be Screened for Diabetes Mellitus?. Orthopaedic Journal of Sports Medicine. 2017. DOI: 10.1177/2325967117716450

[35] Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. British Journal of Sports Medicine. 2015. DOI: 10.1136/bjsports-2015-094735

[36] The outcome of manipulation under general anesthesia for the management of frozen shoulder in patients with diabetes mellitus. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.11.006

[37] Aaos Comprehensive Orthopaedic Review 3. Orthoses, Amputations, and Prostheses > V. Upper Limb Amputations.

[38] Type 2 diabetes, metabolic health, and the development of frozen shoulder: a cohort study in UK electronic health records. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08672-2

[39] Green S Operative Hand Surgery. Vascular Disease > Preoperative Evaluation.

[40] Green S Operative Hand Surgery. Vascular Disease.

[41] Management of Diabetic Trigger Finger. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.03.045

[43] The benefit of platelet-rich plasma injection over institution-based physical therapy program in adhesive capsulitis patients with diabetes mellitus: prospective observational cohort study. Clinics in Shoulder and Elbow. 2021. DOI: 10.5397/cise.2021.00381

[44] Treating Trigger Finger in Diabetics Using Excision of the Ulnar Slip of the Flexor Digitorum Superficialis with or without A1 Pulley Release. HAND. 2007. DOI: 10.1007/s11552-007-9065-z

[45] HbA1c and Infection in Diabetic Elective Hand Surgery: A Veterans Affair Medical Center Experience 2012-2018. HAND. 2022. DOI: 10.1177/1558944720937363

[46] Outcomes of shoulder arthroplasty in diabetic patients as assessed by peri-operative A1C. International Orthopaedics. 2018. DOI: 10.1007/s00264-018-3874-2

[47] Diabetes as a risk factor for the onset of frozen shoulder: a systematic review and meta-analysis. BMJ Open. 2023. DOI: 10.1136/bmjopen-2022-062377

[48] Subjective Outcomes of Carpal Tunnel Release in Patients with Diabetes and Patients without Diabetes. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0039-1697059

[49] Operative management of the frozen shoulder in patients with diabetes. Journal of Shoulder and Elbow Surgery. 2002. DOI: 10.1067/mse.2002.127301

[50] Do diabetic patients have different outcomes after arthroscopic capsular release for frozen shoulder?. Journal of Orthopaedics. 2019. DOI: 10.1016/j.jor.2019.02.003

[51] Effectiveness of radial extracorporeal shock-wave therapy versus ultrasound-guided low-dose intra-articular steroid injection in improving shoulder pain, function, and range of motion in diabetic patients with shoulder adhesive capsulitis. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.03.005

[52] Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary shoulder adhesive capsulitis: A Systematic Review. Orthopaedics & Traumatology: Surgery & Research. 2019. DOI: 10.1016/j.otsr.2019.02.014

[53] LIMITATION OF JOINT MOBILITY AND SHOULDER CAPSULITIS IN INSULIN- AND NON-INSULIN-DEPENDENT DIABETES MELLITUS. Rheumatology. 1986. DOI: 10.1093/rheumatology/25.2.147

[54] Elevated Hemoglobin A1C Levels Correlate With Blood Glucose Elevation in Diabetic Patients Following Local Corticosteroid Injection in the Hand: A Prospective Study. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.035

[55] Endoscopic and Open Carpal Tunnel Release in Patients With Type II Diabetes Mellitus: Influence of Preoperative Semaglutide Use on Postoperative Outcomes. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2025.09.003

[56] Type 2 diabetes seems not to be a risk factor for the carpal tunnel syndrome: a case control study. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-346

[57] Is RAGE Expression in Flexor Tendon Synovium Associated With Carpal Tunnel Syndrome in Patients With Diabetes?. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003800

[58] Molecular and pathological studies in the posterior interosseous nerve of diabetic and non-diabetic patients with carpal tunnel syndrome. Diabetologia. 2014. DOI: 10.1007/s00125-014-3271-3

[60] Musculoskeletal disorders of the hand in type 2 diabetes mellitus: prevalence and its associated factors. International Journal of Rheumatic Diseases. 2015. DOI: 10.1111/1756-185x.12617

[61] Type 2 diabetes and fasting glycemic traits are causal factors of frozen shoulder: a 2-sample Mendelian randomization analysis. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.006

[62] Matrix metalloproteinase-1 and matrix metalloproteinase-9 are highly expressed in the joint capsule of diabetic frozen shoulder. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.03.062

[63] Open carpal tunnel release and diabetes: a retrospective study using PROMs and national quality registries. BMJ Open. 2019. DOI: 10.1136/bmjopen-2019-030179

[64] Effect of surgical timing in outcomes in Hispanic patients after arthroscopic capsular release in diabetic and idiopathic adhesive capsulitis. JSES International. 2023. DOI: 10.1016/j.jseint.2023.06.007

[65] Is There a Role for Diabetes Stewardship in Orthopaedics? Observations From a Hand and Upper Extremity Surgery Clinic. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-23-00593