Musculoskeletal Manifestations of Diabetes Mellitus Dr. Jeremy Gilbert

Musculoskeletal Manifestations of Diabetes Mellitus Dr. Jeremy Gilbert Rheumatology Rounds April 19, 2005 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   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  Consequences of diabetic complications: - Diabetic Muscle Infarction - Neuropathic Arthropathy 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   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    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 Charcot Joint  Most common in MTPs, tarsometatarsals, 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    Chronic Charcot Outline   Consequences of diabetic complications Consequences of metabolic derangements related to diabetes Syndromes whose etiology has similar mechanisms to microvascular disease  Consequences of metabolic derangements related to diabetes:   DISH Osteopenia 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 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  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    Outline   Consequences of diabetic complications Consequences of metabolic derangements related to diabetes Syndromes whose etiology has similar mechanisms to microvascular disease  Syndromes whose etiology has similar mechanisms to microvascular disease Carpal tunnel syndrome Dupuytren’s contracture Flexor tenosynovitis Adhesive capsulitis Limited joint mobility 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  Relationship of glycemic control and MSK complications  Epidemiological study conducted from 19911998 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  Characteristic Male sex Age (yrs) Duration of Diabetes (yrs) Hba1c (yrs) Retinopathy Nephropathy Neuropathy Coronary Artery Disease With MSK Without MSK P Complicatio Complication value ns s (n=71) (n=129) 35 (50) 88 (68) 0.01 51 + 13 50 + 16 0.65 22 + 10 14 + 10 <0.01 8.3 + 1.6 55 (77) 26 (37) 53 (75) 15 (21) 8.0 + 1.5 55 (43) 25 (19) 63 (49) 32 (25) 0.09 <0.01 <0.01 <0.01 0.56 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%  Hand Abnormalities  Carpal Tunnel Syndrome   Dupuytren’s contracture Flexor tenosynovitis Limited joint mobility Each condition present in ~ 20% patients with diabetes  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 Dupuytren’s 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    Dupuytren's Contracture  Generally milder in patients with diabetes compared to patients with other conditions  Treatment: Optimize glycemic control, physiotherapy Rarely is surgery required  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   (AKA “frozen shoulder”)  Adhesive capsulitis 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 1996;55:907–14    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   SHOULDER ARTHROGRAM Br J Sports Med 2003;37:30-35 (AKA Diabetic Cheiroarthopathy)  Limited Joint Mobility 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  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     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 Limited Joint mobility  Diagnosis “prayer sign” “table top test”  To differentiate from Dupuytren’s:   Limited joint mobility usually involves 4 fingers Absence of taut fibrotic bands Up to date 2005 Other MSK conditions in patients with diabetes: Diabetic Sclerodactyly Calcific Shoulder Periarthritis Reflex Sympathetic Dystrophy 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, Raynaud’s, calcinosis, ulceration, tapering) Calcific Shoulder Periarthritis  Calcium deposits around shoulder on X-ray (CSP)   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  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     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  Thank You!