Please create a dialogue between a physical therapist and a 52‑year‑old woman with type 2 diabetes mellitus, hypertension, and a four‑month history of right‑shoulder adhesive capsulitis.

Physical Therapist-Patient Dialogue: Adhesive Capsulitis Management in a Diabetic Patient

Physical Therapist (PT): Good morning, Mrs. Johnson. I see from your chart that you're 52 years old with type 2 diabetes and hypertension, and you've been dealing with right shoulder pain and stiffness for about four months now. Your doctor diagnosed you with adhesive capsulitis—what we call frozen shoulder. Before we start, I need to ask you some important questions about your diabetes management.

Patient: Yes, my shoulder has been getting worse. I can barely lift my arm anymore, and it hurts at night.

PT: I understand how frustrating that must be. First, let me explain something crucial: there's a very strong connection between diabetes and frozen shoulder—studies show that 71.5% of patients with adhesive capsulitis have either diabetes or prediabetes, and diabetics are 2-4 times more likely to develop this condition than the general population 1. This means managing your blood sugar is just as important as the exercises we'll do together.

Patient: I didn't know my diabetes could cause shoulder problems.

PT: It's actually quite common. The high blood sugar creates changes in your collagen—the protein that makes up your tendons and joint capsules—causing it to become stiff and build up excessively 2. Tell me, what's your most recent HbA1c level, and are you checking your blood sugar regularly?

Patient: My last HbA1c was 8.2%, I think. I check my sugar sometimes, but not every day.

PT: That HbA1c of 8.2% is concerning because poor glycemic control directly increases your risk of developing adhesive capsulitis and will slow down your recovery 3. We need to work closely with your primary care doctor to get that number closer to 7% or below 4. Better blood sugar control will help your shoulder heal faster and reduce inflammation in the joint capsule 3, 2.

Patient: Okay, I'll talk to my doctor about that. What about my shoulder exercises?

PT: Let me examine your shoulder first. Can you show me how high you can lift your right arm forward? Now to the side? Try to reach behind your back for me.

Patient: demonstrates limited range of motion That's about as far as I can go before it really hurts.

PT: I can see you have significant restriction in all directions—your active and passive range of motion are both limited, which confirms the adhesive capsulitis diagnosis 5, 6. The good news is that physical therapy combined with better diabetes management can help, though I need to be honest: diabetic patients with frozen shoulder often have slower recovery and poorer outcomes compared to non-diabetics, especially with longer-standing diabetes 5, 3.

Patient: How long have you had diabetes?

Patient: About 8 years now.

PT: That duration is a risk factor—the longer you've had diabetes, the higher your risk for developing and having persistent problems with adhesive capsulitis 3. This means we need to be patient and consistent with treatment. Here's what our treatment plan will look like:

First, regarding your overall activity level: The American Diabetes Association recommends 150 minutes per week of moderate-intensity aerobic activity spread over at least 3 days, with no more than 2 consecutive days without activity 7. This could be walking, cycling, or swimming—activities that won't aggravate your shoulder but will help control your blood sugar 4.

Patient: I've been avoiding exercise because my shoulder hurts.

PT: I understand, but physical activity is essential for managing your diabetes and will actually help reduce the inflammation contributing to your frozen shoulder 4. The key is choosing activities that don't stress your shoulder. Walking is perfect—it improves insulin sensitivity and helps with weight management, both of which will support your shoulder recovery 4, 7.

For your shoulder specifically, here's what we'll do:

Phase 1 (Weeks 1-4): Pain Management and Gentle Range of Motion

• Pendulum exercises: 3 times daily, 2 minutes each session. Lean forward, let your arm hang, and gently swing it in small circles 6.
• Passive stretching with a towel or stick: 2 times daily, holding each stretch for 30 seconds without forcing through severe pain 6.
• Critical point: Break up prolonged sitting every 30 minutes—this provides blood glucose benefits and reduces joint stiffness 7.

Patient: What if the exercises hurt?

PT: Some discomfort is expected, but sharp pain means you're pushing too hard. We need to be especially careful because the capsular thickening in your axillary recess—the bottom part of your shoulder joint capsule—directly correlates with your limited range of motion 6. Forcing through severe pain can cause more inflammation and setback your progress 6.

Phase 2 (Weeks 5-12): Progressive Strengthening

• Resistance exercises 2-3 sessions per week on nonconsecutive days using light resistance bands to strengthen the muscles supporting your shoulder 7.
• Continue range-of-motion exercises but gradually increase the stretch 6.
• Add flexibility training 2-3 times weekly—gentle yoga or tai chi can help with both your shoulder and diabetes management 7.

Patient: How will I know if it's working?

PT: We'll monitor your progress at 3-month intervals, assessing pain relief, functional improvement, and working with your doctor to track your glycemic control 7. I'll measure your range of motion at each visit and track your ability to perform daily activities like reaching overhead or behind your back 5, 6.

Important warning: If we don't see significant improvement after 3-6 months of consistent therapy and better diabetes control, you may need additional interventions 7. This could include corticosteroid injections into the joint, though diabetes can affect how well these work 2.

Patient: What else should I be doing at home?

PT: Several things are crucial:

1. Monitor your blood glucose closely, especially around exercise times 4. Physical activity can lower your blood sugar, so check before and after exercise initially 4.

2. Stay well-hydrated—drink 17 ounces of fluid 2 hours before physical activity, and drink frequently during exercise 4. Dehydration affects both blood glucose levels and joint function 4.

3. Avoid physical activity if your fasting glucose is above 250 mg/dL with ketones present, or use caution if above 300 mg/dL without ketones 4. This is a safety issue specific to diabetes 4.

4. Wear a diabetes identification bracelet during exercise 4. Given your hypertension and 8-year diabetes history, you're at higher risk for cardiovascular complications during physical activity 4.

Patient: Should I be worried about my heart?

PT: Given that you're over 35 years old with type 2 diabetes, hypertension, and 8 years of diabetes duration, you meet criteria for cardiovascular risk screening 4. Before we progress to more intensive exercise, I recommend discussing with your doctor whether you need an exercise stress test 4. This is standard precaution for diabetic patients with your risk profile 4.

Also important: Have you had your eyes examined recently? Diabetic retinopathy can be worsened by certain types of strenuous exercise 4. If you have proliferative retinopathy, we need to avoid exercises that involve straining or jarring movements 4.

Patient: I saw the eye doctor last year. Everything was okay then.

PT: Good. Make sure you continue annual eye exams as recommended 4. For your feet, check them daily for blisters or injuries, especially since you'll be increasing your walking 4. Diabetic neuropathy can reduce sensation, so you might not feel injuries developing 4. Wear proper footwear with silica gel or air midsoles and polyester or cotton-polyester blend socks 4.

Patient: This seems like a lot to manage.

PT: I know it feels overwhelming, but the connection between your diabetes control and shoulder recovery means we're actually treating both conditions simultaneously 7, 3. Better blood sugar control reduces inflammation in your shoulder capsule, and the exercise program improves insulin sensitivity while restoring shoulder function 4, 2.

Here's your homework before our next session in one week:

1. Schedule an appointment with your primary care doctor to discuss intensifying your diabetes management—target HbA1c below 7% 4, 3.
2. Start walking 10 minutes daily, gradually increasing as tolerated 7.
3. Perform pendulum exercises 3 times daily 6.
4. Keep a log of your blood glucose readings before and after exercise 4.
5. Check your feet daily and report any injuries 4.

Common pitfalls to avoid:

• Don't assume the shoulder will improve without addressing your diabetes 1, 3. The two conditions are intimately connected 2.
• Don't skip exercises on days when your shoulder feels better—consistency is essential for breaking up the adhesions 6.
• Don't exercise when blood glucose is poorly controlled 4. This can worsen both your diabetes and delay shoulder healing 3.
• Don't ignore new symptoms like chest pain, severe shortness of breath, or dizziness during exercise—stop immediately and seek medical attention 4.

Patient: When will my shoulder be back to normal?

PT: I need to be honest: diabetic patients with adhesive capsulitis typically have slower recovery and may not achieve complete range of motion, especially with your 8-year diabetes duration and current poor glycemic control 5, 3. However, with consistent therapy, better diabetes management, and patience, most patients see significant functional improvement over 6-12 months 5, 6. The key is addressing both the shoulder and the underlying metabolic condition simultaneously 7, 2.

Do you have any questions before we schedule your next appointment?

Patient: No, I think I understand. I'll call my doctor today about my diabetes.

PT: Perfect. Remember, your diabetes management is not separate from your shoulder treatment—it's the foundation of your recovery 3, 2. I'll see you next week, and we'll adjust the program based on how you respond. Bring your blood glucose log with you 4.