The Unexpected Correlation Between Metabolic Disease and Shoulder Pain
Frozen shoulder is a common and debilitating shoulder condition. Research has uncovered some of the metabolic disease associated with this conditions Treatment. Protocols currently focus on treatment of both the shoulder and underlying metabolic disease.
Featured Speaker:
Jai Iyengar, MD
Jaicharan Iyengar, MD is a nationally-recognized specialist in orthopaedic surgery with focus on treatment of the shoulder and elbow. He is the founder of the Stockton Shoulder Institute at Alpine Orthopaedics. He has served as the Head Team Physician to the Stockton Ports baseball team (Oakland A’s Class-A Affiliate) and the University of Pacific Tigers Division I collegiate athletics since 2013. He serves as an assistant professor in the Department of Orthopaedic Surgery at the Touro University College of Medicine. He was recognized as a “Top Doctor” in California by the International Association of Orthopaedic Surgeons. He also has earned a “Five-Star” honor rating by HealthGrades.com for his excellence in clinical care. Transcription:
The Unexpected Correlation Between Metabolic Disease and Shoulder Pain
Joey Wahler: Frozen shoulder is a debilitating condition common among those suffering from metabolic disorders like diabetes, so we're discussing the relationship between the two.
This is Hello Healthy, a Dignity Health Podcast. Thanks for listening. I'm Joey Wahler. Our guest, Dr. Jai Iyengar. He's founder of the Stockton Shoulder Institute at Alpine Orthopedics. Dr. Iyengar, thanks for joining us.
Dr. Jai Iyengar: Thank you for having me.
Joey Wahler: So first, in a nutshell, what causes frozen shoulder and what are the symptoms?
Dr. Jai Iyengar: Yeah. So in a lot of cases, it's not completely clear exactly what triggers a frozen shoulder, but we usually think that there's some sort of injury or insult or sprain to the shoulder that then turns into a cascade of inflammation, severe stiffness and, you know, a lot of functional loss as a result of that. So, it's not always clear as to what causes it, but we do know that certain metabolic disorders like diabetes or even thyroid disorders can put a patient significantly at risk for developing this.
Joey Wahler: And so what are some of the symptoms one would notice that could mean they have frozen shoulder?
Dr. Jai Iyengar: Yeah. Great question. Initially, it's mainly just pain, and the one thing that I hear a lot is a lot of nighttime pain that affects sleep and just inability to get in a comfortable position is one of the early symptoms. Initially, you won't see a lot of change and range of motion of the shoulder until you get to a later stage. But once you get to that second stage of the frozen shoulder, then you start to get a lot of limitation of range of motion and to the point where, you know, you can't really rotate your arm even into a functional position. And at that point, even simple activities like shampooing your hair or reaching into a cupboard becomes very difficult, so that's usually the second stage. And then, over time, this can turn into almost like a fixed position or we call it a contracture of the joint in time.
Joey Wahler: Now, you've done research on the relationship, the connection between frozen shoulder and metabolic diseases. I'm wondering what triggered that? And what have you learned that you can share with us?
Dr. Jai Iyengar: Yeah. Thats been a journey we've been on for several years now. But it's been known for a long time that there's been a relationship between diabetes and frozen shoulder or, you know, adhesive capsulitis being the medical term for that condition. what was not really well understood was something that I noticed in my first few years of practice was that, traditionally, we thought that the worse the diabetes was, the more at risk you were for developing the condition, and that wasn't exactly what I was seeing in my practice. I was actually seeing a lot of people who were either pre-diabetic or in the very early stages, or in some cases undiagnosed diabetics getting this condition. And that's what kind of prompted the interest in the research. And what we found out is that people can get problems with frozen shoulder in a very early stage of diabetes or even prediabetes.
And so the way we come to understand this is that as your overall metabolism starts to worsen in terms of insulin resistance, as your sugar level start to go up, it's when that body first starts to see that elevated blood sugar, that in and of itself can trigger some of the changes that results in a frozen shoulder.
So that was a little bit counter to the conventional wisdom that a well-controlled or an early diabetic is not going to get this, Actually, we found the opposite. And in the process of doing that, we started becoming more aggressive about screening people for this. And particularly in our county, in the Central Valley, we found high rates of undiagnosed diabetes associated with this in our research.
Joey Wahler: Wow. So in other words, to be clear, you've actually had patients that came in with what turned out to be frozen shoulder who had no idea they had diabetes, and you checked and found out they did, yeah?
Dr. Jai Iyengar: That's exactly right. So when we started screening more aggressively, we found up to 30% of the people that had a sugar level, what we call a hemoglobin A1c level consistent with diabetes, had no idea that they had it.
Joey Wahler: So what was your reaction when you found that out, again, especially since this was new or counterinformation to what had been out there?
Dr. Jai Iyengar: Yeah. I think it had a lot of downstream effects on how my practice changed over this. I mean, the first and foremost is that frozen shoulder traditionally has not been thought of as a surgical problem. It's something that is sort of a metabolic issue and you treat it with physical therapy. But what I found was this really lands in our lap, whether we like it or not, so we have to figure out ways to deal with this.
What I started doing is, number one, is I started aggressively screening people for diabetes. So I started ordering a lab called a hemoglobin A1c. And I would encourage everyone to go out there and get this checked if you're, you know, even above the age of 30, to have a sense of where you are, because that can give you a kind of a sense of where you stand on the spectrum. It's not the perfect test for diabetes, but it gives you a sense of where you are. So we started doing that. And then, as a second step, what I noticed is that a lot of these patients, like I said, were undiagnosed, and so I started treating them with antidiabetic medications in my practice. So one of the first line medications is called metformin. Traditionally, that's not something an orthopedic surgeon would ever prescribe. It's just not part of our practice. It's usually a primary care doctor or internal medicine doctor. But what I realize is that if I or someone who was involved in this process didn't take the initiative, it never got treated. And so, I started putting people on therapy for diabetes, which is not something that I was doing previously.
Joey Wahler: So in other words, as opposed to treating the shoulder specifically or directly, you were treating the diabetes and then that in turn treated the shoulder as well.
Dr. Jai Iyengar: Yeah, that's exactly right. I think of it as kind of treatment in parallel, meaning there are treatments for the shoulder that go along with this, and that can include cortisone injections done selectively, physical therapy. All that has to happen in terms of the shoulder. But what you said is, I think exactly right, is that if you don't treat some of the underlying metabolic disease, I don't think you get the result that you want.
Joey Wahler: Gotcha. So regardless of what stage the diabetes is at, from your experience, how common is it for someone with some level of diabetes to also have frozen shoulder?
Dr. Jai Iyengar: Yeah, that's a great question. And it kind of depends on which research study you point to. But the lifetime incidence of a diabetic getting a frozen shoulder of either shoulder can be upwards of 10% to 15%, which is quite high. I suspect that the actual number is probably a little bit higher than that, and some of this maybe just goes undiagnosed, or it's just mild, so it never really comes to fore, but it's at least probably 10% to 15%.
Joey Wahler: And I would imagine, doctor, that if someone has shoulder pain, shoulder stiffness, some of these frozen shoulder symptoms and they've not been diagnosed with diabetes, to find out that's the cause, if in fact it is, that's got to floor people to find out they not only have one, but they also have the other.
Dr. Jai Iyengar: Yeah. That's exactly right. And some of these conversations are quite shocking to patients that, one, they get a new diagnosis from their shoulder surgeon, which they never expected to get. And second of all, they have some notions of what this means in terms of their health and it can be quite shocking, like you said.
The flip side to that though is what I've noticed also is that in some cases, this has been a real catalyst to people making changes. And for whatever reason, it just strikes a chord that, "Hey, you know, I'm having this issue as a result of this sugar problem," and that can be a real driving force to make the changes. I've had a lot of patients really take the bull by the horns, you know, fix their diet, exercise, get on medication, and reverse the process entirely. So I think there is a silver lining there too as well.
Joey Wahler: Well, that's great news. And speaking of which, you just touched on some of the things that can happen to reverse these conditions, both of them. Frozen shoulder healing, from what I understand appropriately enough, is also called thawing, right? So tell people a little bit more, if you would, about what's happening when things start to heal and go in the right direction.
Dr. Jai Iyengar: Yeah, that's exactly right. So thawing is kind of the term we use to talk about the last or final resolution stage of this frozen shoulder process. Now, I want to be clear, non-diabetics can get frozen shoulders as well. And in fact, it can happen, like I said, for other reasons. There's other risk factors, one of them being thyroid disorders as well. So I don't want to make it sound like diabetes is the only issue here. But in this thawing phase is when the pain starts to reduce and, over time, you'll get things that approach normal range of motion and function. What I think is important is that if you don't address some of the underlying metabolic problems, that thawing phase may end up in a place that's still not perfect or still not very good. And so that's why I think it's important to get to both. We also know that this process can take up to two years if you just let it play out naturally. But if you are a little more aggressive about treatment and physical therapy, you can get that to speed up quite significantly within four to six months.
Joey Wahler: And so after treatment, whether it be after it entirely or during the latter stages when it started to take hold, what benefits do patients experience?
Dr. Jai Iyengar: Yeah. So I think the biggest one would be restoration of kind of a pain-free normal shoulder range of motion and functional activities that no longer hurt. So that's the main benefit that they experience. In some cases as well, there's also a significant return of strength as that progresses. They feel like their shoulder strength kind of gets back to normal.
Joey Wahler: So if someone comes to you with frozen shoulder, do you now, as a matter of course, typically recommend that they have a blood work up and be checked for some underlying condition?
Dr. Jai Iyengar: Yeah, so that's exactly right. That's something that I do now routinely, which I was not doing before, is I will order them a basic diabetes screening test. I'll order them basic thyroid panel because those are the two kind of bigger risk factors. And then, I'll also screen them pretty carefully. I'll ask them about any other risk factors they might have that might be contributing to this as a causative factor. So, I'm much more aggressive about getting a history of anything abnormal in their metabolism. Again, that's something that I was not doing when I first started practice that I'm definitely doing now.
Joey Wahler: Interesting. And then, in summation here, doc, what's your message to those listening that may in fact have frozen shoulder?
Dr. Jai Iyengar: Yeah. I think the number one thing is, you know, if you have this condition or you've been diagnosed with this condition, make sure that you've been screened for these underlying problems. Get your sugar levels checked, get your thyroid function checked and then definitely get it treated. I think that with the current treatment protocols, you can achieve a resolution or symptom-free resolution, you know, in 80% of cases or more. It's very rare this require a surgery if this is treated thoroughly. So I think get it checked out, see your shoulder specialist and hopefully you can avoid a surgery.
Joey Wahler: Indeed. And folks, we trust you're now more familiar with that relationship between metabolic disorders and frozen shoulder. Dr. Jai Iyengar, thanks so much again and keep up the great work.
Dr. Jai Iyengar: I appreciate it. Thank you, Joey.
Joey Wahler: Same here. And for more information, please do visit dignityhealth.org/stockton/ortho. . Again, dignityhealth.org/S-T-O-C-K-T-O-N/O-R-T-H-O. If you found this podcast helpful, please do share it on your social media. And thanks again for listening to Hello Healthy, a Dignity Health podcast. Hoping your health is good health, I'm Joey Wahler.
The Unexpected Correlation Between Metabolic Disease and Shoulder Pain
Joey Wahler: Frozen shoulder is a debilitating condition common among those suffering from metabolic disorders like diabetes, so we're discussing the relationship between the two.
This is Hello Healthy, a Dignity Health Podcast. Thanks for listening. I'm Joey Wahler. Our guest, Dr. Jai Iyengar. He's founder of the Stockton Shoulder Institute at Alpine Orthopedics. Dr. Iyengar, thanks for joining us.
Dr. Jai Iyengar: Thank you for having me.
Joey Wahler: So first, in a nutshell, what causes frozen shoulder and what are the symptoms?
Dr. Jai Iyengar: Yeah. So in a lot of cases, it's not completely clear exactly what triggers a frozen shoulder, but we usually think that there's some sort of injury or insult or sprain to the shoulder that then turns into a cascade of inflammation, severe stiffness and, you know, a lot of functional loss as a result of that. So, it's not always clear as to what causes it, but we do know that certain metabolic disorders like diabetes or even thyroid disorders can put a patient significantly at risk for developing this.
Joey Wahler: And so what are some of the symptoms one would notice that could mean they have frozen shoulder?
Dr. Jai Iyengar: Yeah. Great question. Initially, it's mainly just pain, and the one thing that I hear a lot is a lot of nighttime pain that affects sleep and just inability to get in a comfortable position is one of the early symptoms. Initially, you won't see a lot of change and range of motion of the shoulder until you get to a later stage. But once you get to that second stage of the frozen shoulder, then you start to get a lot of limitation of range of motion and to the point where, you know, you can't really rotate your arm even into a functional position. And at that point, even simple activities like shampooing your hair or reaching into a cupboard becomes very difficult, so that's usually the second stage. And then, over time, this can turn into almost like a fixed position or we call it a contracture of the joint in time.
Joey Wahler: Now, you've done research on the relationship, the connection between frozen shoulder and metabolic diseases. I'm wondering what triggered that? And what have you learned that you can share with us?
Dr. Jai Iyengar: Yeah. Thats been a journey we've been on for several years now. But it's been known for a long time that there's been a relationship between diabetes and frozen shoulder or, you know, adhesive capsulitis being the medical term for that condition. what was not really well understood was something that I noticed in my first few years of practice was that, traditionally, we thought that the worse the diabetes was, the more at risk you were for developing the condition, and that wasn't exactly what I was seeing in my practice. I was actually seeing a lot of people who were either pre-diabetic or in the very early stages, or in some cases undiagnosed diabetics getting this condition. And that's what kind of prompted the interest in the research. And what we found out is that people can get problems with frozen shoulder in a very early stage of diabetes or even prediabetes.
And so the way we come to understand this is that as your overall metabolism starts to worsen in terms of insulin resistance, as your sugar level start to go up, it's when that body first starts to see that elevated blood sugar, that in and of itself can trigger some of the changes that results in a frozen shoulder.
So that was a little bit counter to the conventional wisdom that a well-controlled or an early diabetic is not going to get this, Actually, we found the opposite. And in the process of doing that, we started becoming more aggressive about screening people for this. And particularly in our county, in the Central Valley, we found high rates of undiagnosed diabetes associated with this in our research.
Joey Wahler: Wow. So in other words, to be clear, you've actually had patients that came in with what turned out to be frozen shoulder who had no idea they had diabetes, and you checked and found out they did, yeah?
Dr. Jai Iyengar: That's exactly right. So when we started screening more aggressively, we found up to 30% of the people that had a sugar level, what we call a hemoglobin A1c level consistent with diabetes, had no idea that they had it.
Joey Wahler: So what was your reaction when you found that out, again, especially since this was new or counterinformation to what had been out there?
Dr. Jai Iyengar: Yeah. I think it had a lot of downstream effects on how my practice changed over this. I mean, the first and foremost is that frozen shoulder traditionally has not been thought of as a surgical problem. It's something that is sort of a metabolic issue and you treat it with physical therapy. But what I found was this really lands in our lap, whether we like it or not, so we have to figure out ways to deal with this.
What I started doing is, number one, is I started aggressively screening people for diabetes. So I started ordering a lab called a hemoglobin A1c. And I would encourage everyone to go out there and get this checked if you're, you know, even above the age of 30, to have a sense of where you are, because that can give you a kind of a sense of where you stand on the spectrum. It's not the perfect test for diabetes, but it gives you a sense of where you are. So we started doing that. And then, as a second step, what I noticed is that a lot of these patients, like I said, were undiagnosed, and so I started treating them with antidiabetic medications in my practice. So one of the first line medications is called metformin. Traditionally, that's not something an orthopedic surgeon would ever prescribe. It's just not part of our practice. It's usually a primary care doctor or internal medicine doctor. But what I realize is that if I or someone who was involved in this process didn't take the initiative, it never got treated. And so, I started putting people on therapy for diabetes, which is not something that I was doing previously.
Joey Wahler: So in other words, as opposed to treating the shoulder specifically or directly, you were treating the diabetes and then that in turn treated the shoulder as well.
Dr. Jai Iyengar: Yeah, that's exactly right. I think of it as kind of treatment in parallel, meaning there are treatments for the shoulder that go along with this, and that can include cortisone injections done selectively, physical therapy. All that has to happen in terms of the shoulder. But what you said is, I think exactly right, is that if you don't treat some of the underlying metabolic disease, I don't think you get the result that you want.
Joey Wahler: Gotcha. So regardless of what stage the diabetes is at, from your experience, how common is it for someone with some level of diabetes to also have frozen shoulder?
Dr. Jai Iyengar: Yeah, that's a great question. And it kind of depends on which research study you point to. But the lifetime incidence of a diabetic getting a frozen shoulder of either shoulder can be upwards of 10% to 15%, which is quite high. I suspect that the actual number is probably a little bit higher than that, and some of this maybe just goes undiagnosed, or it's just mild, so it never really comes to fore, but it's at least probably 10% to 15%.
Joey Wahler: And I would imagine, doctor, that if someone has shoulder pain, shoulder stiffness, some of these frozen shoulder symptoms and they've not been diagnosed with diabetes, to find out that's the cause, if in fact it is, that's got to floor people to find out they not only have one, but they also have the other.
Dr. Jai Iyengar: Yeah. That's exactly right. And some of these conversations are quite shocking to patients that, one, they get a new diagnosis from their shoulder surgeon, which they never expected to get. And second of all, they have some notions of what this means in terms of their health and it can be quite shocking, like you said.
The flip side to that though is what I've noticed also is that in some cases, this has been a real catalyst to people making changes. And for whatever reason, it just strikes a chord that, "Hey, you know, I'm having this issue as a result of this sugar problem," and that can be a real driving force to make the changes. I've had a lot of patients really take the bull by the horns, you know, fix their diet, exercise, get on medication, and reverse the process entirely. So I think there is a silver lining there too as well.
Joey Wahler: Well, that's great news. And speaking of which, you just touched on some of the things that can happen to reverse these conditions, both of them. Frozen shoulder healing, from what I understand appropriately enough, is also called thawing, right? So tell people a little bit more, if you would, about what's happening when things start to heal and go in the right direction.
Dr. Jai Iyengar: Yeah, that's exactly right. So thawing is kind of the term we use to talk about the last or final resolution stage of this frozen shoulder process. Now, I want to be clear, non-diabetics can get frozen shoulders as well. And in fact, it can happen, like I said, for other reasons. There's other risk factors, one of them being thyroid disorders as well. So I don't want to make it sound like diabetes is the only issue here. But in this thawing phase is when the pain starts to reduce and, over time, you'll get things that approach normal range of motion and function. What I think is important is that if you don't address some of the underlying metabolic problems, that thawing phase may end up in a place that's still not perfect or still not very good. And so that's why I think it's important to get to both. We also know that this process can take up to two years if you just let it play out naturally. But if you are a little more aggressive about treatment and physical therapy, you can get that to speed up quite significantly within four to six months.
Joey Wahler: And so after treatment, whether it be after it entirely or during the latter stages when it started to take hold, what benefits do patients experience?
Dr. Jai Iyengar: Yeah. So I think the biggest one would be restoration of kind of a pain-free normal shoulder range of motion and functional activities that no longer hurt. So that's the main benefit that they experience. In some cases as well, there's also a significant return of strength as that progresses. They feel like their shoulder strength kind of gets back to normal.
Joey Wahler: So if someone comes to you with frozen shoulder, do you now, as a matter of course, typically recommend that they have a blood work up and be checked for some underlying condition?
Dr. Jai Iyengar: Yeah, so that's exactly right. That's something that I do now routinely, which I was not doing before, is I will order them a basic diabetes screening test. I'll order them basic thyroid panel because those are the two kind of bigger risk factors. And then, I'll also screen them pretty carefully. I'll ask them about any other risk factors they might have that might be contributing to this as a causative factor. So, I'm much more aggressive about getting a history of anything abnormal in their metabolism. Again, that's something that I was not doing when I first started practice that I'm definitely doing now.
Joey Wahler: Interesting. And then, in summation here, doc, what's your message to those listening that may in fact have frozen shoulder?
Dr. Jai Iyengar: Yeah. I think the number one thing is, you know, if you have this condition or you've been diagnosed with this condition, make sure that you've been screened for these underlying problems. Get your sugar levels checked, get your thyroid function checked and then definitely get it treated. I think that with the current treatment protocols, you can achieve a resolution or symptom-free resolution, you know, in 80% of cases or more. It's very rare this require a surgery if this is treated thoroughly. So I think get it checked out, see your shoulder specialist and hopefully you can avoid a surgery.
Joey Wahler: Indeed. And folks, we trust you're now more familiar with that relationship between metabolic disorders and frozen shoulder. Dr. Jai Iyengar, thanks so much again and keep up the great work.
Dr. Jai Iyengar: I appreciate it. Thank you, Joey.
Joey Wahler: Same here. And for more information, please do visit dignityhealth.org/stockton/ortho. . Again, dignityhealth.org/S-T-O-C-K-T-O-N/O-R-T-H-O. If you found this podcast helpful, please do share it on your social media. And thanks again for listening to Hello Healthy, a Dignity Health podcast. Hoping your health is good health, I'm Joey Wahler.