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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