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Musculoskeletal Manifestations of Diabetes Mellitus

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The micro and macrovascular complications of diabetes are well described in the ... SHOULDER ARTHROGRAM. Limited Joint Mobility (AKA Diabetic Cheiroarthopathy) ... – PowerPoint PPT presentation

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Title: Musculoskeletal Manifestations of Diabetes Mellitus


1
Musculoskeletal Manifestations of Diabetes
Mellitus
  • Dr. Jeremy Gilbert
  • Rheumatology Rounds
  • April 19, 2005

2
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

3
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

4
Consequences of diabetic complications
  • - Diabetic Muscle Infarction
  • - Neuropathic Arthropathy

5
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

6
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

7
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

8
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

9
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10
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11
Chronic Charcot
12
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13
Outline
  • Consequences of diabetic complications
  • Consequences of metabolic derangements related to
    diabetes
  • Syndromes whose etiology has similar mechanisms
    to microvascular disease

14
Consequences of metabolic derangements related to
diabetes
  • DISH
  • Osteopenia

15
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

16
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

17
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18
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

19
Outline
  • Consequences of diabetic complications
  • Consequences of metabolic derangements related to
    diabetes
  • Syndromes whose etiology has similar mechanisms
    to microvascular disease

20
Syndromes whose etiology has similar
mechanismsto microvascular disease
  • Carpal tunnel syndrome
  • Dupuytrens contracture
  • Flexor tenosynovitis
  • Adhesive capsulitis
  • Limited joint mobility

21
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

22
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

23
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24
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

25
Hand Abnormalities
  • Carpal Tunnel Syndrome
  • Dupuytrens contracture
  • Flexor tenosynovitis
  • Limited joint mobility
  • Each condition present in 20 patients with
    diabetes

26
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

27
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28
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

29
Dupuytren's Contracture
  • Generally milder in patients with diabetes
    compared to patients with other conditions
  • Treatment Optimize glycemic control,
    physiotherapy
  • Rarely is surgery required

30
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31
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

32
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33
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

34
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

35
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36
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

37
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

38
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

39
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

40
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41
Up to date 2005
42
Other MSK conditions in patients with diabetes
  • Diabetic Sclerodactyly
  • Calcific Shoulder Periarthritis
  • Reflex Sympathetic Dystrophy

43
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)

44
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

45
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46
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

47
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48
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

49
Thank You!
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