Original research| Volume 98, ISSUE 8, P1551-1559, August 2017

Very High Prevalence of Frozen Shoulder in Patients With Type 1 Diabetes of ≥45 Years' Duration: The Dialong Shoulder Study

Published:February 17, 2017DOI:


      • Of patients with type 1 diabetes for ≥45 years, 59% had frozen shoulder, with 73% affected bilaterally.
      • Patients with painful frozen shoulder had highest disability and least shoulder mobility.
      • High glycemic index was associated with severe disability and restricted shoulder mobility.



      To compare the prevalence of shoulder disorders and self-reported shoulder disability in patients with long-term type 1 diabetes mellitus and diabetes-free subjects; and to explore the association between the long-term glycemic burden and shoulder disability in the diabetes group.


      Cross-sectional study of shoulder diagnoses with 30 years' historical data on glycemic burden in patients with diabetes.


      Diabetics center and a university hospital.


      Subjects attending the Norwegian Diabetics Center in 2015 with type 1 diabetes since 1970 or earlier were eligible (N=136). One hundred and five patients were included, and 102 (50% women; mean age, 61.9y) completed the study together with 73 diabetes-free subjects (55% women; mean age, 62.5y).


      Not applicable.

      Main Outcome Measure

      Shoulder diagnoses decided through clinical examination according to scientific diagnostic criteria.


      Frozen shoulder was diagnosed in 60 (59%) patients with diabetes and 0 diabetes-free subjects, with a lifetime prevalence of 76% in the diabetes group versus 14% in the diabetes-free subjects. Patients with diabetes had higher disability and higher mean QuickDASH scores (23.0±19.9) than diabetes-free subjects (8.9±12.0), with a mean difference of −14.2 (95% confidence interval, −19.3 to −9.0) points (P<.001). We found an association between chronic hyperglycemia and QuickDASH scores, with a 6.16-point increase in QuickDASH scores per unit increase in glycated hemoglobin A1c (HbA1c) (P=.014).


      The point prevalence of frozen shoulder in patients with long-lasting type 1 diabetes was 59%, and the lifetime prevalence was 76%. The diabetes group had more shoulder disability than diabetes-free subjects. The historical HbA1c level was associated with increased shoulder disability.


      List of abbreviations:

      AGE (advanced glycation end-product), CI (confidence interval), DASH (Disabilities of Arm, Shoulder and Hand), HbA1c (glycated hemoglobin A1c)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Agrawal R.P.
        • Gothwal S.
        • Tantia P.
        • et al.
        Prevalence of rheumatological manifestations in diabetic population from North-West India.
        J Assoc Physicians India. 2014; 62: 788-792
        • Banon S.
        • Isenberg D.A.
        Rheumatological manifestations occurring in patients with diabetes mellitus.
        Scand J Rheumatol. 2013; 42: 1-10
        • Bhat T.A.
        • Dhar S.A.
        • Dar T.A.
        • et al.
        The musculoskeletal manifestations of type 2 diabetes mellitus in a Kashmiri population.
        Int J Health Sci. 2016; 10: 57-68
        • Huang Y.P.
        • Fann C.Y.
        • Chiu Y.H.
        • et al.
        Association of diabetes mellitus with the risk of developing adhesive capsulitis of the shoulder: a longitudinal population-based followup study.
        Arthritis Care Res. 2013; 65: 1197-1202
        • Zhao J.
        • Randive R.
        • Stewart J.A.
        Molecular mechanisms of AGE/RAGE-mediated fibrosis in the diabetic heart.
        World J Diabetes. 2014; 5: 860-867
        • Brownlee M.
        Glycation products and the pathogenesis of diabetic complications.
        Diabetes Care. 1992; 15: 1835-1843
        • Arkkila P.E.
        • Kantola I.M.
        • Viikari J.S.
        • Ronnemaa T.
        Shoulder capsulitis in type I and II diabetic patients: association with diabetic complications and related diseases.
        Ann Rheum Dis. 1996; 55: 907-914
        • Larkin M.E.
        • Barnie A.
        • Braffett B.H.
        • et al.
        Musculoskeletal complications in type 1 diabetes.
        Diabetes Care. 2014; 37: 1863-1869
        • Palmer K.
        • Walker-Bone K.
        • Linaker C.
        • et al.
        The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb.
        Ann Rheum Dis. 2000; 59: 5-11
        • Walker-Bone K.E.
        • Palmer K.T.
        • Reading I.
        • Cooper C.
        Soft-tissue rheumatic disorders of the neck and upper limb: prevalence and risk factors.
        Semin Arthritis Rheum. 2003; 33: 185-203
        • Juel N.G.
        • Natvig B.
        Shoulder diagnoses in secondary care, a one year cohort.
        BMC Musculoskelet Disord. 2014; 15: 89
        • Muir S.W.
        • Corea C.L.
        • Beaupre L.
        Evaluating change in clinical status: reliability and measures of agreement for the assessment of glenohumeral range of motion.
        N Am J Sports Phys Ther. 2010; 5: 98-110
        • Tveita E.K.
        • Ekeberg O.M.
        • Juel N.G.
        • Bautz-Holter E.
        Range of shoulder motion in patients with adhesive capsulitis; intra-tester reproducibility is acceptable for group comparisons.
        BMC Musculoskelet Disord. 2008; 9: 49
        • Macedo L.G.
        • Magee D.J.
        Effects of age on passive range of motion of selected peripheral joints in healthy adult females.
        Physiother Theory Pract. 2009; 25: 145-164
        • Maund E.
        • Craig D.
        • Suekarran S.
        • et al.
        Management of frozen shoulder: a systematic review and cost-effectiveness analysis.
        Health Technol Assess. 2012; 16: 1-264
        • Hand C.
        • Clipsham K.
        • Rees J.L.
        • Carr A.J.
        Long-term outcome of frozen shoulder.
        J Shoulder Elbow Surg. 2008; 17: 231-236
        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG).
        Am J Ind Med. 1996; 29: 602-608
        • Roe Y.
        • Soberg H.L.
        • Bautz-Holter E.
        • Ostensjo S.
        A systematic review of measures of shoulder pain and functioning using the International classification of functioning, disability and health (ICF).
        BMC Musculoskelet Disord. 2013; 14: 73
        • Finsen V.
        [Norwegian version of the DASH questionnaire for examination of the arm shoulders and hand].
        Tidsskr Nor Laegeforen. 2008; 128 ([Norwegian]): 1070
        • Haldorsen B.
        • Svege I.
        • Roe Y.
        • Bergland A.
        Reliability and validity of the Norwegian version of the Disabilities of the Arm, Shoulder and Hand questionnaire in patients with shoulder impingement syndrome.
        BMC Musculoskelet Disord. 2014; 15: 78
        • Aasheim T.
        • Finsen V.
        The DASH and the QuickDASH instruments. Normative values in the general population in Norway.
        J Hand Surg Eur Vol. 2014; 39: 140-144
        • May S.
        • Chance-Larsen K.
        • Littlewood C.
        • Lomas D.
        • Saad M.
        Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review.
        Physiotherapy. 2010; 96: 179-190
        • Cooper J.
        • Sandberg S.
        • Løvaas K.F.
        • Thue G.
        • Norwegian Diabetes Register
        [Report 2015].
        ([Norwegian])2015 (Available at) (Accessed November 1, 2016)
        • Berg T.J.
        • Clausen J.T.
        • Torjesen P.A.
        • Dahl-Jorgensen K.
        • Bangstad H.J.
        • Hanssen K.F.
        The advanced glycation end product Nepsilon-(carboxymethyl)lysine is increased in serum from children and adolescents with type 1 diabetes.
        Diabetes Care. 1998; 21: 1997-2002
        • Kilhovd B.K.
        • Giardino I.
        • Torjesen P.A.
        • et al.
        Increased serum levels of the specific AGE-compound methylglyoxal-derived hydroimidazolone in patients with type 2 diabetes.
        Metabolism. 2003; 52: 163-167
        • Andersson D.A.
        • Gentry C.
        • Light E.
        • et al.
        Methylglyoxal evokes pain by stimulating TRPA1.
        PLoS One. 2013; 8: e77986
        • Buchbinder R.
        • Hoving J.L.
        • Green S.
        • Hall S.
        • Forbes A.
        • Nash P.
        Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial.
        Ann Rheum Dis. 2004; 63: 1460-1469
        • Page M.J.
        • Green S.
        • Kramer S.
        • et al.
        Manual therapy and exercise for adhesive capsulitis (frozen shoulder).
        Cochrane Database Syst Rev. 2014; 8: CD011275
        • Engebretsen K.
        • Grotle M.
        • Bautz-Holter E.
        • Ekeberg O.M.
        • Brox J.I.
        Determinants of the shoulder pain and disability index in patients with subacromial shoulder pain.
        J Rehabil Med. 2010; 42: 499-505
        • Ginn K.A.
        • Cohen M.L.
        • Herbert R.D.
        Does hand-behind-back range of motion accurately reflect shoulder internal rotation?.
        J Shoulder Elbow Surg. 2006; 15: 311-314