International Journal of Physical Medicine & Rehabilitation
Open Access

Is There Any Relationship between Frequency of Shoulder Impingement Steroid Injection and Diabetes Mellitus?

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Introduction

Shoulder impingement syndrome is one of the most common musculoskeletal complications of diabetes mellitus [1-8]. It occurs three times more among diabetics compared to non-diabetics [1-8]. This leads to pain and disability [1-3].

Subacromial Steroid injection is one of the most common treatment options for shoulder impingement syndrome and had proven its efficacy [9-12]. Studies had proven that steroid injection is safe and efficacious among diabetic patients [13].

Whether the diabetic status affect the frequency of Shoulder impingement steroid injections as well as the duration between injections were not studied.

Objective

Determine the relationship between frequency of steroid injections, duration between injections and diabetic status among shoulder impingement patients.

Materials and Methods

This was a retrospective study, at outpatient setting. Charts of 412 patients presented with unilateral or bilateral shoulder pain diagnosed as shoulder impingement syndrome and treated with steroid injections over a period of 01/2019-12/2020 were reviewed.

Exclusion criteria: Those having manifestations suggestive of cervical radiculopathy, neuromuscular diseases, or shoulder trauma history.

Reviewing and collecting patient charts data; demographic data including occupation, body mass index, detailed medical history including DM history. Shoulder exam including impingement provocative tests; Hawkins test, Neer’s sign. Neck exam including Spurling test. Full neurological exam.

Main outcome measures

Number of steroid injections received and duration between each injection over past 2 years.

Laboratory results: glycosylated hemoglobin (HgA1c), liver and kidney functions. MRI shoulder results if available

Statistical analysis of the data

Data were fed to the computer using IBM SPSS software package version 24.0.

Qualitative data were described using number and percent. Comparison between different groups regarding categorical variables was tested using Chi-square test.

Quantitative data were described using mean and standard deviation for normally distributed data.

For normally distributed data, comparison between two independent population were done using independent t-test while more than two population were analyzed F-test (ANOVA) to be used.

Significance test results are quoted as two-tailed probabilities. Significance of the obtained results was judged at the 5% level.

Results

Table 1 demonstrates demographic data of the included patients. Mean age 59.4 ± 11.123. All patients were right-handed, Male 37.1%, female 62.9%, Mean Body Mass Index (BMI) 32.2 ± 8.2. majority were manual workers (55.1%). Table 2 presents the incidence of shoulder impingement with different sexes. No significant relationship between shoulder impingement and sex.

Table 1: Demographic and clinical data of the studied group.

Table 2: Relation between incidence of sex and shoulder impingement.

Table 3 demonstrates the relationship between shoulder impingement, BMI, age and HgA1c, with positive significant relationship between BMI, age, and HgA1c.

Table 3: Relation between age, BMI, HgA1c and shoulder impingement.

Table 4 presents the relationship between different categories of HgA1c and shoulder impingement. HgA1c <5.5 has the fewest patients (7.3%), highest number of patients with HgA1c 5.5- 6.0. significant incidence of shoulder impingement with rising category of HgA1c with highest among HgA1c >7 (p=0.0001) with significant bilateral disease. Table 5 demonstrates significant incidence of shoulder impingement among diabetics as compared with non-diabetic according to diagnostic criteria of American diabetic association with set of HgA1c ≥ 6.5 the determining level [14](p=0.011).

Table 4: Demographic and clinical data of the studied group.

Table 5: Relation between incidence of diabetes mellitus and shoulder impingement.

Table 6 documents the number of steroid injections as well as the duration between injections and its relationship to diabetes mellitus. Mean number of injections among diabetics 1.1756 ± 1.17283, non-diabetics 0.6391 ± 0.89051 with positive significance (p=0.0001). Whereas, no significant relation between DM and duration between injections (p=0.129).

Table 6: Relation between number of injections of shoulder and duration between injection and diabetes mellitus.

Discussion

This was a retrospective study after revising the charts of patients diagnosed with shoulder impingement syndrome and evaluating the incidence of DM as categorized by HgA1c and assessing the injection treatment received and how frequent was the injection given and duration between injections. This is considered a continuation of our other studies related to the incidence of diabetes mellitus among shoulder impingement syndrome [8].

There was significant high incidence of shoulder impingement among rising categories of HgA1c. With the highest incidence among HgA1c above [7]. This was proven in our first prospective study which was determined high incidence of DM among diabetics [8].

The number of steroid injections was significantly higher among diabetics compared to non-diabetics. This means that the diabetic status i.e. high blood sugar level worsens the condition of shoulder impingement that necessitate more steroid injection.

However, the duration in between injections did not show statistical significance. So, the number of injections is definitely related to how bad is the diabetic status, hence it was significantly more with those who had diabetes. The duration between injections, however, depends on multiple factors, although not studied in the literature yet, but it seems to be affected by personal experience of pain, whether the patient get enrolled after the first injection in programed physiotherapy which will lessen the need of further injection, whether the diabetic status become better controlled. So, it could not be related solely to the diabetic status as frank as the number of injections needed over time.

The suggested mechanism of occurrence of shoulder impingement syndrome as well as other musculoskeletal complications of Diabetes was due to various modification of connective tissue ranging from glycosylation of protein with accumulation of Advanced Glycation End Products (AGEs) to microvascular damage of blood vessels and nerves and deposition of extracellular matrix protein in the skin and periarticular tissue. This could potentially affect tendon strength and repair and play a role in microvascular complication and inflammation [1,2,15,16].

The pathogenic mechanisms of chronic tendinopathy are not fully understood and several major non-mutually exclusive hypotheses including activator of hypoxia-apoptosis- pro-inflammatory cytokines cascade, Neurovascular ingrowth, increased production of neuro-mediators and erroneous stem cell differentiation have been proposed. Diabetes is important risk factors.

BMI the suggested mechanism of shoulder impingement or rotator cuff tendinopathy in case of diabetes mellitus due to various modification of connective tissue ranging from glycosylation of protein with accumulation of advanced glycation end products (AGEs) to microvascular damage of blood vessels and nerves and deposition of extracellular matrix protein in the skin and periarticular tissue. This could potentially affect tendon strength and repair and play a role in microvascular complication and inflammation.

Revising literature regarding HgA1c, and how accurate it is as a tool to measure the diabetic status;Hemoglobin A1c is the measurement of glycosylated hemoglobin and can aid in both the diagnosis and continued management of diabetes mellitus. Accurate Hg A1c is an essential part of decision making in the diagnosis and treatment of type 2 diabetes. Although national standards exist to eliminate technical error with HgA1c testing. Multiple errors whether elevated or decreased HgA1c sometimes happen. Also, some variation with ethnicity and even normal aging have been reported.

Another study comparing between HgA1c and fructosamine which of them is better index of glycemic control in type ii diabetes, serum fructosamine assay can better reflect average blood glucose concentration over the previous 3-6weeks and Hg A1c is better reflective over the previous 8-10 weeks. HgA1c measurement correlate more significantly with home capillary blood glucose levels than the fructosamine assay, even over the previous 2-3 weeks

Revising the literature regarding this context, there are studies that proven the efficacy of shoulder impingement steroid injection as treatment options among diabetics. But there was not particular study that analyzed whether the presence of diabetes affected the number of given steroid injections for each particular patient as well as the duration between such injections.

Bonasia, et al. suggested that subacromial steroid injection is effective short-term treatment in type 2 diabetes patients and recommended close follow up [9].

Pons-Villaneuva concluded that the treatment of shoulder impingement should be tailored and individualized and he suggested no evidence of superiority of physiotherapy vs injection vs NSAIDs vs arthroscopic management in cases of stiff diabetic shoulder [17].

Kaderli, et al. suggested the safety and efficacy of steroid injection among diabetics particularly regarding blood sugar level elevations after the injections [13].

In this study we had detected significant incidence of shoulder impingement among the categories of patients’ prediabetes status, this suggests that the musculoskeletal complications of diabetes particularly shoulder impingement syndrome could take place prior to the discovery of overt diabetic status.

Celik, et al. proposed that subacromial steroid injection among diabetics facilitated the conduction shoulder physiotherapy after control of that pain thus ease the range of motion [12].

Conclusion

In conclusions; steroid injection is a favorable option for shoulder impingement syndrome treatment among diabetics, with a better outcome. The presence of diabetes mellitus among patients with shoulder impingement syndrome entitle more need of steroid injections over time compared to non-diabetics, however, the duration in between steroid injections is not significantly influenced by the presence of diabetes mellitus.

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