How should I approach the management of shoulder pain in a patient with a history of diabetes and limited range of motion?

In managing shoulder pain with limited range of motion in a patient with diabetes, a cautious, stepwise approach is recommended, prioritising non-invasive treatments initially and considering the impact of diabetes on treatment choices and risks. Begin with activity modification and analgesia, using paracetamol as first-line pain relief, progressing to NSAIDs if necessary, while carefully considering contraindications and the patient's comorbidities ¹. Physiotherapy should be started as early as possible to maintain and improve shoulder movement, with supervised exercise programmes preferred over simple home exercises to achieve faster improvement in range of motion ¹.

Intra-articular corticosteroid injections can be considered early if conservative measures fail to produce adequate improvement, but in patients with diabetes, these injections should be deferred until blood glucose is well-controlled due to the risk of transient hyperglycaemia lasting 24–48 hours post-injection, and the increased risk of infection must be carefully weighed ¹. Only one corticosteroid injection is generally recommended, with a second injection considered after 6 weeks if there was initial benefit and ongoing need for pain relief to facilitate physiotherapy ¹. If corticosteroid injections do not yield expected benefits, reassessment of diagnosis or referral to secondary care is advised ¹.

Recent clinical trial evidence specifically in diabetic patients with frozen shoulder suggests that intra-articular corticosteroid injections may provide superior pain relief and functional improvement compared to NSAIDs alone, supporting their cautious use when diabetes is well-managed (Dehghan et al., 2013). However, the guideline's emphasis on careful patient selection and glycaemic control remains paramount ¹.

Shared decision-making is essential throughout management, considering symptom severity, functional impairment, and the patient's preferences and quality of life impact ¹. Referral to intermediate care services such as ICATS or to secondary care should be considered if symptoms persist beyond 6 weeks despite non-surgical treatment, if diagnosis is uncertain, or if red flag features or acute rotator cuff tear are suspected ¹.