Musculoskeletal Manifestations of Diabetes Mellitus

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Musculoskeletal Manifestations of Diabetes
Mellitus

• Dr. Jeremy Gilbert
• Rheumatology Rounds
• April 19, 2005

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Diabetes is common

• The micro and macrovascular complications of
  diabetes are well described in the literature
• Recognizing the musculoskeletal manifestations of
  diabetes is an important component in evaluating
  patients with diabetes
• The morbidity due to these conditions can be very
  severe

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Outline of MSK Complications of Diabetes

• Consequences of diabetic complications
• Consequences of metabolic derangements related to
  diabetes
• Syndromes whose etiology has similar mechanisms
  to microvascular disease

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Consequences of diabetic complications

• - Diabetic Muscle Infarction
• - Neuropathic Arthropathy

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Diabetic Muscle Infarction

• Rare
• More common in Type 1 Diabetes
• Most often in patient with long duration of
  diabetes and with poor glycemic control
• Mean age 43
• Average duration of diabetes 14 years
• Painful muscle swelling, usually in thigh
• Mass expands over days to weeks

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Diabetic Muscle Infarction

• CK may be normal or increased
• Diagnosis often requires biopsy to r/o myositis,
  phlebitis or hemorrhage
• Condition is a complication of advanced
  atherosclerosis
• Treatment is rest and analgesia
• Good prognosis

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Neuropathic Arthropathy(AKA Charcot Joint)

• First described in 1868 by Jean Martin Charcot in
  patients with tabes dorsalis
• Destructive arthropathy in diseases which impair
  sensory function, but maintain normal motor
  function
• Present in 0.1-0.4 of patients with diabetes
• Usually in ages 50-69 years old

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Charcot Joint

• Most common in MTPs, tarso-metatarsals, tarsus,
  ankle and interphalageal joints
• Single, painless, swollen, deformed joint in
  setting of peripheral neuropathy
• Periarticular soft tissues loosen thereby causing
  joint laxity and subluxation
• Repetitive microtrauma with weight bearing
  damages the joint

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Chronic Charcot
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Outline

• Consequences of diabetic complications
• Consequences of metabolic derangements related to
  diabetes
• Syndromes whose etiology has similar mechanisms
  to microvascular disease

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Consequences of metabolic derangements related to
diabetes

• DISH
• Osteopenia

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Diffuse Idiopathic Skeletal Hyperostosis (DISH)

• More common in Type 2 Diabetes
• Occurs in 13 - 49 of patients with diabetes
• Occurs in 1.6 - 13 of otherwise healthy patients
• Excessive bone growth in entheseal regions
• It is a systemic condition
• Also associated with hypermetabolic syndrome
  high uric acid, obesity, dyslipidemia

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Mechanism of DISH

• Chronic elevation in insulin and insulin-like
  growth factors facilitates calcification and
  ossification of ligaments and entheseal regions
• These regions are often subject to increased
  mechanical stress

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Osteopenia

• Risk in Diabetics is controversial
• Type 1 DM tend to have lower BMD
• Type 2 DM, post-menopausal women are at greater
  risk than age-matched non-DM
• However, a clear relationship between DM and
  decreased BMD has not been established
• Mechanism?? hi ALP, low vit D, decreased Ca
  absorption

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Outline

• Consequences of diabetic complications
• Consequences of metabolic derangements related to
  diabetes
• Syndromes whose etiology has similar mechanisms
  to microvascular disease

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Syndromes whose etiology has similar
mechanismsto microvascular disease

• Carpal tunnel syndrome
• Dupuytrens contracture
• Flexor tenosynovitis
• Adhesive capsulitis
• Limited joint mobility

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Common Characteristics

• More common in patients with long standing and
  poorly controlled diabetes
• More common in Type 1 DM
• Associated with neuropathy, retinopathy and
  nephropathy
• Alterations in connective tissue metabolism with
  increased collagen cross-linkages
• Due to prolonged hyperglycemia and subsequent
  collagen glycosylation

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Relationship of glycemic control and MSK
complications

• Epidemiological study conducted from 1991-1998
• Included 100 patients with T1DM, 100 patients
  with T2DM and 100 controls
• Massachusettes General Hospital
• Prevalence of MSK complications greater in
  patients with DM than controls (36 vs 9)
• Similarly with T1DM compared with T2DM (43
  patients vs 28 patients)
• Am J of Med. 2002. 112 487-490

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Hand Abnormalities

• Related to changes in microvasculature,
  connective tissue and peripheral nerves
• In 100 random diabetic patients in an outpatient
  clinic
• - hand abnormalities in 50
• - more than one abnormality in 26
• - surgery recommended in 50

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Hand Abnormalities

• Carpal Tunnel Syndrome
• Dupuytrens contracture
• Flexor tenosynovitis
• Limited joint mobility
• Each condition present in 20 patients with
  diabetes

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Carpal Tunnel Syndrome

• Compression of median nerve in carpal tunnel
• 10-20 of patients with diabetes will develop
  carpal tunnel syndrome
• 10-15 of patients with carpal tunnel syndrome
  will have diabetes
• More common in women than men
• Increased incidence in patients with limited
  joint mobility

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Dupuytrens Contracture

• Fibrosis in and around the palmar fascia with
  nodule formation
• Contraction of the palmar fascia causes flexion
  contractures of digits
• The 3rd and 4th finger most commonly effected in
  patients with diabetes, compared to the 5th
  finger in patients without diabetes
• Present in 15-40 of patients with diabetes
• Prevalence increases with age

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Dupuytren's Contracture

• Generally milder in patients with diabetes
  compared to patients with other conditions
• Treatment Optimize glycemic control,
  physiotherapy
• Rarely is surgery required

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Flexor Tenosynovitis

• Palpable nodule formation and thickening of
  flexor tendon or sheath
• Characterized by locking
• Most common in thumb and 3rd and 4th digits
• Present in 5-20 of patients with diabetes
• Not associated with age

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Adhesive capsulitis (AKA frozen shoulder)

• Progressive painful restriction of shoulder
  movement
• Joint capsule adheres to humeral head
• 3 phases painful, adhesive, resolution
• 10-30 in diabetics, 2-10 in controls
• 17 patients with adhesive capsulitis have
  diabetes
• Associated with age and duration of diabetes
• Ann Rheum Dis 19965590714

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Adhesive Capsulitis

• In a study of 60 diabetics with shoulder pain
• 58 adhesive capsulitis
• 28 had tendinitis
• In diabetics, occurs at younger age, less
  painful, responds less to treatment
• Associated with high morbidity
• Treatment steroid injections in early stages,
  adequate analgesia, exercise
• Resolves over time

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Limited Joint Mobility(AKA Diabetic
Cheiroarthopathy)

• Limited joint movement usually in hands
• Often painless
• Stiffness and contractures lead to poor grip
  strength and difficulty with hand function
• Usually MCP, PIPs
• Less common DIPs, wrists, elbows, shoulders,
  knees, axial skeleton

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Limited Joint Mobility

• Prevalence is 8-58 among diabetics
• Prevalence is 2-25 among non-diabetics
• More common in Type 1 Diabetes
• Risk increases with poor glycemic control (HbA1c)
  and duration of diabetes
• In all patients, increased risk with age and
  smoking
• Treatment optimizing glycemic control and
  physiotherapy

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Mechanism of Limited Joint Mobility

• Deposition of periarticular collagen as seen in
  biopsy
• Glycosylation of collagen, abnormal cross linking
  of collagen and increased collagen hydration all
  contribute
• Microangiopathy and neuropathy may lead to
  contractures via fibrosis and disuse

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Limited Joint mobility

• Diagnosis
• prayer sign
• table top test
• To differentiate from Dupuytrens
• Limited joint mobility usually involves 4 fingers
• Absence of taut fibrotic bands

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Up to date 2005
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Other MSK conditions in patients with diabetes

• Diabetic Sclerodactyly
• Calcific Shoulder Periarthritis
• Reflex Sympathetic Dystrophy

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Diabetic Sclerodactyly

• Thickening and waxiness of skin
• Usually on dorsa of fingers
• Associated with limited joint mobility
• Similar to skin changes of scleroderma
• (absent antibodies, Raynauds, calcinosis,
  ulceration, tapering)

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Calcific Shoulder Periarthritis (CSP)

• Calcium deposits around shoulder on X-ray
• 2/3 Asymptomatic in patients with diabetes
• Study with 900 patients with T2DM, 350 controls
  found 3X prevalence of CSP compared to controls
• Associated with longstanding, poorly controlled
  diabetes
• Also more common in patients with high
  cholesterol and lipid levels
• Proposed mechanism diabetic angiopathy

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Reflex Sympathetic Dystrophy

• Pain with swelling, trophic changes and vasomotor
  disturbance in a localized area
• Cause, pathogenesis and natural history are
  unclear
• Often precipitated by trauma (e.g., surgery,
  fracture)
• Associated with DM, hyperlipidemia,
  hyperthyroidism, hyperparathyroidism
• Usually good prognosis, but some develop chronic
  pain and/or contractures

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Conclusions

• MSK complications related to diabetes is common
  and can lead to severe morbidity
• Having a long duration of diabetes, especially
  with poor glycemic control, increases the risk of
  developing many of these conditions
• Health care teams need to be aware of the
  potential MSK complications in patients with
  diabetes
• Further research is necessary to clearly define
  the relationship between diabetes and its
  associated MSK conditions

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Thank You!