Annals of African Medicine
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Table of Contents
Year : 2023  |  Volume : 22  |  Issue : 1  |  Page : 45-48  

Shoulder capsulitis: What relation with diabetes mellitus in a moroccan population?

1 Department of Endocrinology, Faculty of Medicine and Pharmacy, Mohammed V Military Academic Hospital, Mohammed V-Souissi University, Rabat, Morocco, North Africa
2 Department of Rheumatology, Faculty of Medicine and Pharmacy, Mohammed V Military Academic Hospital, Mohammed V-Souissi University, Rabat, Morocco, North Africa
3 Department of Community Medicine, Faculty of Medicine and Pharmacy, Mohammed V Military Academic Hospital, Mohammed V-Souissi University, Rabat, Morocco, North Africa
4 Department of Traumatology-Orthopaedics, Faculty of Medicine and Pharmacy, Mohammed V Military Academic Hospital, Mohammed V-Souissi University, Rabat, Morocco, North Africa
5 Department of Vascular Surgery, Faculty of Medicine and Pharmacy, Mohammed V Military Academic Hospital, Mohammed V-Souissi University, Rabat, Morocco, North Africa

Date of Submission30-Sep-2021
Date of Decision11-Dec-2021
Date of Acceptance11-Jan-2022
Date of Web Publication24-Jan-2023

Correspondence Address:
Yassine Errahali
Department of Endocrinology, Mohammed V Military Academic Hospital, Hay Riad, Rabat, Morocco
North Africa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_211_21

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Introduction: Shoulder capsulitis (SC) is a common musculoskeletal complication in patients with diabetes. It can be particularly disabling. It is often overlooked by clinicians. The aim of this study is to evaluate the prevalence of retractile capsulitis and to identify the risk factors in a population of Moroccan diabetic patients. Materials and Methods: We realised a cross-sectional study including patients with diabetes mellitus (DM). We recorded the demographic and diabetic characteristics of our patients. SC and vascular complications were assessed by clinical and para-clinical investigations. The prevalence of SC was calculated. The factors associated with SC were evaluated by suitable statistical tests. Results: Three hundred and Sixty-five patients were included; 84.9% had Type 2 DM (T2DM). The mean age of the participants was 52.6 ± 13.6. Shoulder capsulitis was present in 12.6% of patients. In statistical analysis, age >50 years (P = 0.001), T2DM (P = 0.03), duration of progression >10 years (P = 0.03), dyslipidemia (P = 0.013) and macrovascular complications (P = 0.009) were associated with an increased frequency of SC. Conclusion: This study shows that the prevalence of SC is higher in diabetic patients. Therefore, inclusion of this pathology in the global management of the diabetic patient is necessary.

   Abstract in French 

Introduction: la capsulite rétractile de l'épaule (CR) est une complication musculo-squelettique fréquente chez les patients diabétiques. Elle peut être particulièrement invalidante. Elle est souvent méconnue par les cliniciens. Cette étude a pour objectif d'évaluer la prévalence de la capsulite rétractile et d'identifier les facteurs de risque dans une population de patients diabétiques marocains. Methodes: Une étude transversale incluant des patients diabétiques. Nous avons enregistré les caractéristiques démographiques et les caractéristiques du diabète de nos patients. La CR et les complications vasculaires ont été évalués par des examens cliniques et para cliniques. La prévalence de la CR a été calculée, ensuite les facteurs associés à la CR ont été évalués par des tests statistiques adaptés. Resultat: 365 patients ont été inclus ; 84.9 % avaient un diabète de type 2. L'âge moyen des participants était de 52.6 ±13.6. Une capsulite de l'épaule était présente chez 12,6 % des patients. Dans l'analyse statistique, l'âge supérieur à 50 ans (P=0,001), le diabète de type 2 (P=0.03), la durée d'évolution >10 ans (P=0.03), la dyslipidémie (P=0.013) et les complications macro vasculaires (P=0.009) étaient associées à une fréquence accrue de la capsulite rétractile. Conclusion: cette étude montre que la prévalence de la CR est plus élevée chez les patients diabétiques. D'où la nécessité d'inclure cette pathologie dans la prise en charge globale du patient diabétique, et de la même manière, réaliser un dépistage de diabète chez les patients souffrant d'un capsulite rétractile.
Mots clés: diabète sucré, complications musculo squelettiques, capsulite rétractile.

Keywords: Diabetes mellitus, musculoskeletal complication, shoulder capsulitis

How to cite this article:
Errahali Y, Majjad A, Issouani J, Kasouati J, Benomar AH, Zoulati M, Chakdoufi S, Toufik H, Boussouga M, Bezza A, Guerboub AA. Shoulder capsulitis: What relation with diabetes mellitus in a moroccan population?. Ann Afr Med 2023;22:45-8

How to cite this URL:
Errahali Y, Majjad A, Issouani J, Kasouati J, Benomar AH, Zoulati M, Chakdoufi S, Toufik H, Boussouga M, Bezza A, Guerboub AA. Shoulder capsulitis: What relation with diabetes mellitus in a moroccan population?. Ann Afr Med [serial online] 2023 [cited 2023 Jan 29];22:45-8. Available from:

   Introduction Top

Retractile capsulitis (SC) is one of the most common shoulder pathologies encountered in clinical practice.[1] Several characteristics have been reported as risk factors for SC, including age, female gender, dyslipidemia, thyroid abnormalities and diabetes.[2],[3],[4] Diabetes is the most frequently cited risk factor.[5] The prevalence of SC in diabetic patients varies, according to studies, between 11% and 40%, compared to 3%–5% in the general population.[6],[7] The pathophysiology behind SC in diabetic patients is not well elucidated. Diabetes is a chronic metabolic disorder characterized by chronic hyperglycemia. Elevated glucose levels can affect cellular function and alter the extracellular matrix components of connective tissue, causing damage.[8] Unlike the vascular complications of diabetes, which have been widely studied, SC has been neglected until now. This study was conducted to assess the prevalence of SC in Moroccan diabetic patients, its associated factors and its relationship with other diabetic complications, including micro and macro vascular complications.

   Materials and Methods Top

Presentation of the study

A cross-sectional study was conducted between January 2020 and March 2021. We recruted patients with diabetes mellitus (DM) (Type 1 and Type 2) seen in the department of endocrinology. Included patients had a history of DM for at least 1 year, diagnosed according to the American diabetes association (ADA) definition as a fasting plasma glucose level of ≥126 mg/dl and/or hemoglobin A1C (HbA1c) ≥6.5%.[9] We excluded patients with a history of shoulder trauma, recent thoracic surgery, radiotherapy, pacemaker wear, patients with thyroid disorders, pulmonary neoplasia, breast cancer, central or peripheral nervous system disease, chronic rheumatic disease and end-stage renal disease. Ethical approval has been obtained from the local ethics committee.

Study methods

For all patients included in the study, we recorded the following parameters:

  • Demographic and anthropometric characteristics: Age, sex, and body mass index (BMI)
  • Clinical characteristics: Type and duration of DM (in years), antidiabetic treatments
  • Biological characteristics: HbA1c level and lipid profile. Dyslipidemia was defined according to the criteria of the ADA.[10] DM was considered controlled if the HbA1c level at target according to ADA criteria.[11]
  • Vascular complications of DM: Microvascular complications (retinopathy, nephropathy and neuropathy) and macrovascular complications (coronary artery disease, peripheral artery disease and history of stroke).

The diagnosis of shoulder capsulitis was based on the limitation of active and passive movements of the shoulder joint in all directions, especially rotational movements.

Statistical analysis

The data were collected on paper and then transformed into electronic format on an Excel file. Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS, version 13, Chicago, SPSS Inc.,). Quantitative variables were expressed as means and standard deviation or median and quartiles according to their distribution. Qualitative variables were expressed as numbers and percentages. The univariate analysis was performed using the appropriate statistical tests according to the conditions of statistical use of each test. A value of P < 0.05 was considered statistically significant.

   Results Top

Population characteristics

Three hundred and sixty-five patients with DM were included. The mean age of the participants was 52.6 ± 13.6 years. Men accounted for 184 (50.4%) and women for 181 (49.6). 310 patients (84.9%) had Type 2 DM (T2DM) while 55 (15.1%) had Type 1 DM (T1DM). The median duration of DM was 8 years.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] Forty-six per cent (46%) of our patients had more than 10 years of DM. Forty-nine per cent (49%) were treated with insulin ± oral hypoglycemic agent. The mean HbA1c value was 8.5% ± 1.9%. Poor glycemic control was noted in 77.8% of all patients. The mean BMI was 26.4 ± 3.6 kg/m2. Forty-six point three percent (46.3%) of patients were overweight, while 15.3% were obese. In this study, 145 patients (39.7%) had dyslipidemia and 148 (40.5%) had one or more microvascular complications of DM. They were dominated by retinopathy in 27.1% of cases, nephropathy and neuropathy were observed, respectively, in 16.7% and 12.3% of our patients. Sixteen patients (4.4%) had macrovascular complications of DM (coronary artery disease, peripheral artery disease, and history of stroke) [Table 1].
Table 1: Descriptive characteristics of study population (n=365)

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Link between the SC and the different characteristics studied

There were 46 patients with SC among a total of 365 cases, i.e., a prevalence of 12.6%. They predominated in T2DM with 44 (14.2%) cases against 2 (3.6%) in T1DM. Feminine predominance with a sex ratio of 0.84. The prevalence of retractile capsulitis was higher in patients over 50-year-old (P = 0.001), with a long history of DM (P = 0.03). The occurrence of dyslipidemia and macro angiopathy were also associated with SC (P = 0.013 and P = 0.009, respectively). The prevalence rates according to patient demographic and clinical characteristics are presented in [Table 2].
Table 2: Prevalence of shoulder capsulitis according to sociodemographics, vascular complications, and other relevant variables in patients with diabetes mellitus

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   Discussion Top

This study aimed to evaluate the prevalence of SC in Moroccan DM patients and its associated factors. The association between DM and SC is well established.[7],[11] In our study, SC was present in 12.6% of cases. In a meta-analysis by Zreik et al.,[13] the overall mean prevalence of SC in DM was 13.4%. Additionally, Inayat F, in 2017, conducted a study of 80 DM patients and found the prevalence of SC to be 41.3%.[14] Another similar study conducted by Easmin in 2017 which involved 125 prediabetic patients found the prevalence of SC in these patients to be 14.40%.[15] Previous studies have reported variable prevalence rates of shoulder SC ranging from 11% to 19% in DM patients, compared with 2%–3% in age-matched controls.[16]

In this study, advanced age, duration of DM, and the presence of macrovascular complications were associated with an increased risk of developing SC. Most of them had T2DM. This association with T2DM may be partially explained by the advanced age and high prevalence of overweight in this population. In addition, there was no association between HbA1c level and SC. These results are similar to some previous studies.[17],[18],[19] Cagliero et al. reported a strong correlation between SC and microangiopathic complications.[20] Nevertheless, this association was not confirmed by our report. Rather, it is macro angiopathy that seems to be related to an excess risk of SC occurrence. There are very few data on the associations between SC and macroangiopathy. Arkkila et al.[21] found a higher risk of coronary heart disease and cerebrovascular disease in T2DM patients with SC, but SC in T1DM patients was not related to established macrovascular disease.[22]

Finally, this work has some potential limitations. This is an observational study, and some additional confounding factors such as smoking and physical activity were not taken into account.

   Conclusion Top

In our study, SC is more common in patients with DM. We suggest that shoulder examination be included in a routine evaluation of patients with DM. Similarly, screening for DM should be performed in patients with SC. Larger multicenter studies are needed to determine the pathophysiologic mechanism of this complication in order to optimize management in this population.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Aydeniz A, Gursoy S, Guney E. Which musculoskeletal complications are most frequently seen in type 2 diabetes mellitus? J Int Med Res 2008;36:505-11.  Back to cited text no. 2
Huang YP, Fann CY, Chiu YH, Yen MF, Chen LS, Chen HH, et al. Association of diabetes mellitus with the risk of developing adhesive capsulitis of the shoulder: A longitudinal population-based followup study. Arthritis Care Res 2013;65:1197-202.  Back to cited text no. 3
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Risk Factors for Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis. Available from: [Last accessed on 2021 May 24].  Back to cited text no. 5
Hsu JE, Anakwenze OA, Warrender WJ, Abboud JA. Current review of adhesive capsulitis. J Shoulder Elbow Surg 2011;20:502-14.  Back to cited text no. 6
Cho CH, Jin HJ, Kim DH. Comparison of clinical outcomes between idiopathic frozen shoulder and diabetic frozen shoulder after a single ultrasound-guided intra-articular corticosteroid injection. Diagnostics (Basel) 2020;10:E370.  Back to cited text no. 7
Sanguineti R, Puddu A, Mach F, Montecucco F, Viviani GL. Advanced glycation end products play adverse proinflammatory activities in osteoporosis. Mediators Inflamm 2014;2014:975872.  Back to cited text no. 8
American Diabetes Association. 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes – 2021. Diabetes Care 2021;44 Suppl 1:S15-33.  Back to cited text no. 9
American Diabetes Association. 6. Glycemic targets: Standards of medical care in diabetes – 2020. Diabetes Care 2020;43 Suppl 1:S66-76.  Back to cited text no. 10
Thomas SJ, McDougall C, Brown ID, Jaberoo MC, Stearns A, Ashraf R, et al. Prevalence of symptoms and signs of shoulder problems in people with diabetes mellitus. J Shoulder Elbow Surg 2007;16:748-51.  Back to cited text no. 11
American Diabetes Association. 10. Cardiovascular disease and risk management: Standards of medical care in diabetes – 2020. Diabetes Care 2020;43 Suppl 1:S111-34.  Back to cited text no. 12
Zreik NH, Malik RA, Charalambous CP. Adhesive capsulitis of the shoulder and diabetes: A meta-analysis of prevalence. Muscles Ligaments Tendons J 2016;6:26-34.  Back to cited text no. 13
Inayat F, Ali NS, Shahid H, Younus F. Prevalence and determinants of frozen shoulder in patients with diabetes: A single center experience from Pakistan. Cureus 2017;9:e1544.  Back to cited text no. 14
Doly EA. Prevalence of frozen shoulder among diabetes mellitus patients: A cross cut survey. Orthop Rheumatol Open Access J 2017;9:38-40. [doi: 10.19080/OROAJ.2017.09.555759].  Back to cited text no. 15
Abate M, Schiavone C, Salini V. Sonographic evaluation of the shoulder in asymptomatic elderly subjects with diabetes. BMC Musculoskelet Disord 2010;11:278.  Back to cited text no. 16
Arkkila PE, Kantola IM, Viikari JS, Rönnemaa T. Shoulder capsulitis in type I and II diabetic patients: Association with diabetic complications and related diseases. Ann Rheum Dis 1996;55:907-14.  Back to cited text no. 17
Prevalance of Frozen Shoulder in Diabetic Patients (40- 60 Year). Available from: [Last accessed on 2021 Jun 08].  Back to cited text no. 18
Georgiannos D, Markopoulos G, Devetzi E, Bisbinas I. Adhesive capsulitis of the shoulder. Is there consensus regarding the treatment? A comprehensive review. Open Orthop J 2017;11:65-76.  Back to cited text no. 19
Cagliero E, Apruzzese W, Perlmutter GS, Nathan DM. Musculoskeletal disorders of the hand and shoulder in patients with diabetes mellitus. Am J Med 2002;112:487-90.  Back to cited text no. 20
Arkkila PE, Kantola IM, Viikari JS. Limited joint mobility in non-insulin-dependent diabetic (NIDDM) patients: Correlation to control of diabetes, atherosclerotic vascular disease, and other diabetic complications. J Diabetes Complications 1997;11:208-17.  Back to cited text no. 21
Frost D, Beischer W. Limited joint mobility in type 1 diabetic patients: Associations with microangiopathy and subclinical macroangiopathy are different in men and women. Diabetes Care 2001;24:95-9.  Back to cited text no. 22


  [Table 1], [Table 2]


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