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Diabetes e Condições do Membro Superior

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Why diabetes makes frozen shoulder, trigger finger, carpal tunnel syndrome and Dupuytren's more common, and how it affects healing and surgery.

Updated Aug 2026
Uma gota de glicemia capilar na ponta do dedo ao lado de um pequeno glicosímetro.
O diabetes torna várias condições da mão — dedo em gatilho, síndrome do túnel do carpo, rigidez — mais comuns e de resolução mais lenta. Kieran Hirpara 4.0

Esta página foi traduzida automaticamente e ainda não foi verificada por um médico. A versão em inglês é a versão oficial.

O que você está sentindo

Você pode notar dor no ombro que parece vir do interior profundo da articulação. Em pessoas com diabetes, essa dor pode ser um sinal de ombro congelado. Essa condição endurece a cápsula do ombro, dificultando o movimento. Você também pode perceber que alcançar as costas para fechar um sutiã ou guardar uma camisa dentro da calça se torna muito difícil. A dor frequentemente se intensifica à noite, dificultando o sono de lado.

Os sintomas na mão também podem aparecer sem qualquer lesão. Você pode experimentar dor e inchaço súbitos na mão. Isso é conhecido como mionecrose diabética espontânea. Pode parecer uma infecção ou inflamação, mas surge espontaneamente. Esteja ciente de que as infecções na mão podem se tornar mais graves se seus níveis de açúcar no sangue não estiverem bem controlados. Esse risco foi observado durante a pandemia de COVID-19 e continua sendo importante hoje. Se você tiver doença renal junto com diabetes, seu cirurgião pode recomendar atendimento hospitalar para infecções na mão, em vez de tratá-las em casa.

Formigamento ou dormência na mão e nos dedos é outro problema comum. Isso é frequentemente síndrome do túnel do carpo. Pesquisas mostram que substâncias chamadas produtos finais de glicação avançada se acumulam nos tecidos ao redor dos seus tendões flexores. Esse acúmulo está associado ao desenvolvimento da síndrome do túnel do carpo em pacientes diabéticos. Se você está considerando cirurgia, seu cirurgião desejará monitorar seus níveis de HbA1c primeiro. Isso ajuda a melhorar os resultados cirúrgicos.

A obesidade também pode desempenhar um grande papel. Ela pode ter uma ligação semelhante ou até mais forte com a síndrome do túnel do carpo do que a diabetes isoladamente. Ter tanto obesidade quanto diabetes aumenta o risco, elevando a chance de você desenvolver esses sintomas. Além disso, se você tiver ombro congelado primário, há uma prevalência de 37,5% de pré-diabetes entre os pacientes. Manter seu diabetes sob controle ativo e fazer exercícios regulares para o membro superior pode ajudar a retardar o desgaste do tendão supraespinhal, mesmo que você ainda não tenha dor.

O que está realmente acontecendo

O diabetes altera a forma como o seu corpo processa o açúcar, o que pode danificar os tecidos ao longo do tempo. A hiperglicemia leva ao acúmulo de produtos residuais chamados produtos finais de glicação avançada (AGEs). Essas substâncias pegajosas aderem ao revestimento dos tendões flexores do punho. Esse espessamento comprime o nervo mediano, causando a síndrome do túnel do carpo. É como uma corda que se desfaz e incha dentro de um tubo apertado.

No ombro, o diabetes aumenta o risco de ombro congelado. A cápsula articular é a capa de tecido que envolve a articulação do ombro. Em algumas pessoas com diabetes, essa capa torna-se inflamada e rígida. Essa rigidez limita o movimento e causa dor. É importante notar que 37,5% dos pacientes com ombro congelado primário têm pré-diabetes. Isso significa que o seu açúcar no sangue pode estar mais alto do que o normal, mesmo que você ainda não tenha recebido um diagnóstico de diabetes pleno.

Suas mãos também são vulneráveis. O diabetes pode causar dor e inchaço súbitos na mão sem qualquer lesão. Isso é chamado de mionecrose diabética. Ocorre quando o tecido muscular se decompõe devido ao mau fluxo sanguíneo e aos altos níveis de açúcar. Pode parecer uma infecção ou inflamação, mas é um resultado direto da doença.

O mau controle do diabetes também torna as infecções mais difíceis de tratar. Se você desenvolver uma infecção na mão, ela pode ser mais grave. Isso é especialmente verdadeiro se os seus níveis de açúcar no sangue não estiverem bem controlados. A combinação de diabetes e doença renal aumenta o risco de falha do tratamento ambulatorial. Você pode precisar de cuidados hospitalares para eliminar a infecção com segurança.

Finalmente, o diabetes pode enfraquecer o tendão do supraespinhal no seu ombro. Este tendão ajuda a levantar o braço. Mesmo que você ainda não sinta dor, o tendão pode estar em degeneração. O controle ativo do seu diabetes e exercícios regulares do membro superior podem ajudar a atrasar esse dano. Manter o seu açúcar no sangue estável protege a integridade estrutural dos seus tendões e articulações.

O que esperar

O seu prognóstico depende fortemente de quão bem você controla a glicemia. Manter o diabetes sob controle ativo e realizar exercícios regulares da extremidade superior podem ajudar a retardar o desgaste do tendão supraespinhal. Isso é especialmente verdadeiro se você tiver diabetes tipo II, mas ainda não apresentar dor. Se você ignorar essas medidas, a degeneração pode progredir mais rapidamente.

A dor no ombro em pessoas com diabetes pode ser um sinal de ombro congelado. Esta é uma condição em que a articulação do ombro fica rígida e dolorosa. É importante saber que 37,5% dos pacientes com ombro congelado primário também têm pré-diabetes. Isso significa que os seus níveis de glicose no sangue estão mais altos do que o normal, mas ainda não são altos o suficiente para serem chamados de diabetes. O seu cirurgião procurará essa relação ao avaliar a sua dor.

Os sintomas na mão exigem atenção cuidadosa. Se você tiver dor e inchaço súbitos e inexplicáveis na mão sem qualquer lesão, informe o seu médico imediatamente. Isso pode ser mionecrose diabética espontânea, uma condição rara em que o tecido muscular se decompõe. Frequentemente, é confundida com infecção ou inflamação. O diagnóstico precoce é fundamental para evitar confusão com outras condições graves, como infecções ou problemas de fluxo sanguíneo.

As infecções na mão podem se tornar mais graves em pessoas com diabetes, particularmente se o controle da glicose no sangue for inadequado. Esse risco foi destacado durante a pandemia de COVID-19. Se você tiver diabetes e doença renal, o seu risco de falha no tratamento de infecções na mão é maior. O seu cirurgião pode recomendar internação hospitalar em vez de tratamento ambulatorial para garantir que a infecção seja eliminada completamente.

A síndrome do túnel do carpo também é mais comum em pessoas com diabetes. Isso ocorre quando a pressão se acumula sobre o nervo mediano no seu pulso. O acúmulo de certas proteínas nos seus tendões, conhecidas como produtos finais de glicação avançada, desempenha um papel nesse desenvolvimento. Se você precisar de cirurgia para a síndrome do túnel do carpo, o seu cirurgião verificará os seus níveis de glicose no sangue a longo prazo (HbA1c) antes do procedimento. Um bom controle antes da cirurgia leva a melhores resultados.

A obesidade também afeta o seu risco. Ela pode ter uma ligação mais forte com a síndrome do túnel do carpo do que o diabetes isoladamente. Ter tanto obesidade quanto diabetes aumenta ainda mais o seu risco. Gerenciar o seu peso e a glicose no sangue em conjunto oferece a melhor proteção contra essas condições da extremidade superior.

Reviewed by Kieran Hirpara · 13 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

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].
  • 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].
  • 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 [5].
  • The presence of diabetes mellitus rather than its severity was the most important factor for developing trigger digit [7].
  • The prevalence of frozen shoulder is less than previously reported but still greater in diabetic patients [13].
  • Musculoskeletal hand disorders were prevalent in type 2 diabetes mellitus patients in Jordan [37].
  • Both shoulders were involved in 36 patients (4.5 per cent) with periarthritis of the shoulder and there was a high incidence in insulin-dependent diabetics [2].

Background & Causes

  • Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes are associated [1].
  • There is continuing gradual deterioration of limited joint mobility with increasing duration of disease in diabetes mellitus [6].
  • Finger joint contractures are prevalent only in longstanding diabetics with a disease duration of nine years or more [6].
  • The presence of diabetes mellitus rather than its severity was the most important factor for developing trigger digit after carpal tunnel release [7].
  • Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients [9].
  • Insulin dependence is associated with increased risk of complications after upper extremity surgery in diabetic patients [14].
  • NIDDM patients did not have an increased rate of complications relative to nondiabetic patients [14].
  • Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles [15].
  • In adults with hand syndromes associated with diabetes, disability was related to impaired muscle function and carpal tunnel syndrome [16].
  • Type 2 diabetes may be a cause of frozen shoulder but the effect is not mediated by metabolic health [20].
  • Diabetes is a likely causal risk factor for frozen shoulder, likely through a pathway involving long-term high blood glucose levels [30].
  • Type 2 diabetes does not seem to be a risk factor for carpal tunnel syndrome [32].
  • 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 [33].
  • Molecular and pathological studies in the posterior interosseous nerve provide a potential molecular and pathological basis for the predisposition of diabetic patients to the development of CTS [34].
  • 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 [35].

Symptoms & Presentation

  • There is continuing gradual deterioration with increasing duration of disease in limited joint mobility in diabetes mellitus [6].
  • Shoulder pain and disability are common, and persistent in adults with diabetes [8].
  • Patients with diabetes mellitus reported shoulder pain and/or disability, with 63% (149/236) indicating such issues and a median SPADI score of 10.0 [12].
  • Patients with and without diabetes experienced similar pain except during exertion regarding range of motion recovery in diabetic frozen shoulder [17].
  • 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 [19].
  • Clinicians should consider spontaneous diabetic myonecrosis in diabetic patients with atraumatic acute-onset pain and swelling in the hand to avoid confusion with other inflammatory, infectious, or vascular conditions [21].
  • Diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases following arthroscopic capsular release for shoulder adhesive capsulitis [28].
  • The moderate correlations between upper and lower extremity range of motion, strength, and function suggest a concurrent development of musculoskeletal complications in people with DM [31].

Management

  • Percutaneous release with or without simultaneous corticosteroid injection has shown promising results and is equally effective and safe in diabetics and nondiabetics for the management of trigger finger [23].
  • 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 [25].
  • The best current evidence supports the efficacy of surgical interventions for the management of upper limb conditions in diabetic individuals [10].
  • Additional research is required to determine whether surgical treatment outcomes in diabetics are equivalent to those of nondiabetic patients [10].
  • Additional research is required to determine whether diabetes is associated with an increased risk of complications following surgical intervention [10].
  • Steroid injection into the shoulder causes glycemic changes that are short-lived, mostly limited to the 2-3 days after the injection [26].
  • None of the patients in the study on shoulder steroid injections required any change in antidiabetic treatment [26].
  • Platelet-rich plasma injection is a safe and well-tolerated method for adhesive capsulitis management in diabetic patients [24].
  • When shoulder mobilization was achievable with gentle manipulation under anesthesia, the outcome was satisfactory in both patients with IDDM and those with NIDDM [27].
  • The results of arthroscopic release for frozen shoulder in diabetics were significantly worse than those in non-diabetics six months post-operatively [18].
  • There is a tendency towards persistent limitation of movement two years after arthroscopic release operation for frozen shoulder in diabetic patients [18].
  • Patients with and without diabetes experienced similar pain from frozen shoulder except during exertion [17].
  • Long-term prospective randomised controlled trials on the effects of exercise in preventing musculoskeletal complications and disability in diabetics are needed [11].

Key Considerations

  • There is continuing gradual deterioration of limited joint mobility with increasing duration of disease [6].
  • Additional research is required to determine whether treatment outcomes for diabetic patients are equivalent to those of nondiabetic patients [10].
  • Additional research is required to determine whether diabetes is associated with an increased risk of complications [10].
  • There is a tendency towards persistent limitation of movement two years after arthroscopic release for frozen shoulder in diabetic patients [18].
  • Long-term improvement in patients with diabetes remained after carpal tunnel release to the same extent as for patients without diabetes [36].
  • Patients with diabetes experience more symptoms both before and after open carpal tunnel release [38].
  • Patients with diabetes can expect the same relative improvement from open carpal tunnel release as patients without diabetes [38].
  • More than one third of patients with diabetic hand infections are diabetic [39].
  • Insulin-dependent diabetic patients (NIDDM) did not have an increased rate of complications relative to nondiabetic patients after upper extremity surgery [14].

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)
  • [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. [5] (10.1016/j.jhsa.2017.11.003)
  • [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. [6] (10.1136/ard.44.2.93)
  • [L4] The presence of diabetes mellitus rather than its severity was the most important factor for developing trigger digit. [7] (10.1016/j.jhsa.2013.10.023)
  • [L4] Shoulder pain and disability are common, and persistent in adults with diabetes. [8] (10.1093/rheumatology/ken333)
  • [L3] Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. [9] (10.1016/j.jhsa.2014.01.014)
  • [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. [10] (10.1016/j.jhsa.2011.10.002)
  • [L3] Long-term prospective randomised controlled trials on the effects of exercise in preventing musculoskeletal complications and disability in diabetics are needed. [11] (10.1007/s10067-003-0704-7)
  • [L3] Patients with diabetes mellitus reported shoulder pain and/or disability, with 63% (149/236) indicating such issues and a median SPADI score of 10.0. [12] (10.1016/j.physio.2014.07.003)
  • [L3] The prevalence of frozen shoulder is less than previously reported but still greater in diabetic patients. [13] (10.1016/j.jse.2007.02.133)
  • [L2] The NIDDM patients did not have an increased rate of complications relative to nondiabetic patients. [14] (10.1016/j.jhsa.2018.06.006)
  • [L3] Patients with painful shoulders, irrespective of having type 2 diabetes mellitus, seem to have abnormal shoulder muscles. [15] (10.1186/s12891-022-05627-9)
  • [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)
  • [L3] Patients with and without diabetes experienced similar pain except during exertion. [17] (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. [18] (10.1302/0301-620x.96b10.34476)
  • [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. [19] (10.1016/j.jhsa.2008.01.038)
  • [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. [20] (10.1186/s12891-025-08672-2)
  • [L4] Clinicians should consider this diagnosis in diabetic patients with atraumatic acute-onset pain and swelling in the hand to avoid confusion with other inflammatory, infectious, or vascular conditions. [21] (10.1016/j.jhsg.2021.10.006)
  • [L4] Percutaneous release with or without simultaneous corticosteroid injection has shown promising results and is equally effective and safe in diabetics and nondiabetics. [23] (10.1016/j.jhsa.2018.03.045)
  • [L3] Additionally, it is a safe and well-tolerated method for AC management for diabetic patients. [24] (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. [25] (10.1007/s11552-007-9065-z)
  • [L2] These glycemic changes are short-lived, mostly limited to the 2-3 days after the injection, and none of the patients required any change in antidiabetic treatment. [26] (10.1016/j.jseint.2022.05.016)
  • [L3] When shoulder mobilization was achievable with gentle manipulation under anesthesia, the outcome was satisfactory in both patients with IDDM and those with NIDDM. [27] (10.1067/mse.2002.127301)
  • [L4] However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. [28] (10.1016/j.otsr.2019.02.014)
  • [L1] Diabetes is a likely causal risk factor for frozen shoulder, likely through a pathway involving long-term high blood glucose levels. [30] (10.1371/journal.pgen.1009577)
  • [L4] The moderate correlations between upper and lower extremity range of motion, strength, and function suggest a concurrent development of musculoskeletal complications in people with DM. [31] (10.1016/j.foot.2020.101680)
  • [L3] Type 2 diabetes does not seem to be a risk factor for carpal tunnel syndrome. [32] (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. [33] (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. [34] (10.1007/s00125-014-3271-3)
  • [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. [35] (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. [36] (10.1016/j.jhsa.2014.01.012)
  • [L4] In the present study, musculoskeletal hand disorders were prevalent in T2DM patients in Jordan. [37] (10.1111/1756-185x.12617)
  • [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. [38] (10.1136/bmjopen-2019-030179)
  • [L4] Analysis of the authors' clinical series demonstrates that more than one third of the patients are diabetic. [39] (10.1016/s0749-0712(21)00424-8)

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] 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

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

[7] 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

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

[9] 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

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

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

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

[13] 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

[14] 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

[15] 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

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

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

[18] 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

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

[20] 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

[21] Spontaneous Diabetic Myonecrosis Presenting as Acute Carpal Tunnel Syndrome. Journal of Hand Surgery Global Online. 2022. DOI: 10.1016/j.jhsg.2021.10.006

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

[24] 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

[25] 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

[26] 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

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

[28] 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

[30] 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

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

[32] 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

[33] 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

[34] 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

[35] 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

[36] 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

[37] 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

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

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

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Using Creative Commons Public Licenses

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Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.