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Complications and Comorbidities> Muscle, Skin and Bone>
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Musculoskeletal Diseases 

Mimi Huizinga, M.D.
02-04-2011

DEFINITION

  • A number of musculoskeletal disorders (MSDs) are associated with diabetes.
  • Joints most often affected include shoulders, hands and feet.
  • Many of the MSDs associated with diabetes are systemic. 
  • Duration of diabetes is a significant risk factor for most MSDs regardless of the type of diabetes.

EPIDEMIOLOGY

  • MSDs common in diabetes. In one study, half of people with diabetes had one MSD affecting the hand and a quarter had 2 MSDs (Gamstedt).
  • Carpal tunnel syndrome: prevalence of 20% in persons with diabetes but can be as high as 75% (Gamstedt, Chaudhuri)
  • Dupuytren's contracture: reported in up to 40% of persons with diabetes (Gamstedt, Noble)
  • Flexor tenosynovitis: "trigger" finger described in up to 20% of persons with diabetes; related to duration of diabetes regardless of glycemic control (Gamstedt)
  • Adhesive capsulitis: reported in 19-29% of persons with diabetes; risk factors include increased age, longer duration of diabetes; Dupuytren's contracture and retinopathy (Pal, Balci)
  • Calcific periarthritis: three times more common in patients with diabetes than in patients without diabetes; associated with older age, longer duration of diabetes and insulin use (Mavrikakis).
  • Limited joint mobility: prevalence ranges from 8-58% depending on population; increased with longer duration of diabetes, worse glycemic control, retinopathy, nephropathy, increasing age and cigarette smoking. See module on "Dermatological manifestations of diabetes" for information on diabetic sclerodactyly (Gamstedt, Arkkila).
  • Stiff-person disease: very rare disease of progressive muscle stiffness in type 1 diabetes (Helfgott).
  • Diabetic muscle infarction: rare complication of diabetes where the muscle infarcts spontaneously (Trujillo-Santos).
  • Osteoarthritis: associated with diabetes likely due to obesity (Hochberg)  Rheumatoid arthritis: chronic inflammation in RA plus chronic glucocorticoid use may increase risk of type 2 diabetes in these patients; no evidence to link T1DM to RA although both may be present in polyglandular autoimmune conditions (Doran, Simard).

DIAGNOSIS

  • Carpal tunnel syndrome: limited joint movement due to median nerve entrapment; Hoffman-Tinnel sign (tapping wrist at median nerve to elicit symptoms) and Phalen sign (acute wrist flexion for 30-60 seconds to elicit symptoms); electrodiagnostic tests that show median nerve dysfunction (Preston).
  • Dupuytren's contracture: joint stiffness of the hand due to fibrosis of palmar fascia and triangular puckering of skin or nodules over flexor tendons without signs of inflammation of the joints; disease course highly variable with regression in up to 10% (Gudmundsson).
  • Flexor tenosynovitis: palpable nodule forms on the flexor tendon; thumb, third and fourth digits are most likely to be involved and may be bilateral (Ryzewicz )
  • Adhesive capsulitis: advanced form of frozen shoulder (a reversible shoulder contraction) where adhesions have formed leading to significant loss of range of motion (abduction and rotation); - demonstration that limited range of motion not due to arthritis or other process (Sheridan).
  • Calcific periarthritis: also known as calcific tendinitis, refers to deposition of calcium hydroxyapatite crystals in tendons around the shoulder joint; diagnosed by presence of calcifications in shoulder tendons on x-ray (Siegal, Mavrikakis).
  • Limited joint mobility: limited movement of joints, especially the small joints of the hands, thought to be due to the glycosylation of collagen; "prayer sign" (unable to flatten hands together) and "table top test" (unable to flatten palm on table top) (Kapoor).
  • Stiff-person disease: diagnoses strongly suggested by the presence of anti-GAD antibodies in type 1 diabetes; physical exam and EMG also useful (Duddy).
  • Diabetic muscle infarction: often a diagnosis of exclusion; creatinine kinase may or may not be elevated; ultrasonography and MR imaging may be useful; muscle biopsy will reveal muscular necrosis and edema with occusional of arterioles (Trujillo-Santos)
  • Osteoarthritis: plain radiographs show deterioration of the joint (Feydy)

SIGNS AND SYMPTOMS

  • Carpal tunnel syndrome: pain and paraesthesia in the thumb, second and third digits, and radial half of the fourth digit
  • Dupuytren's contracture: major symptom is flexor contraction of one or more digits at the metacarpophalangeal joint
  • Flexor tenosynovitis: pain on flexing tendon(s), in hand, with point tenderness
  • Adhesive capsulitis: symptoms include limited and painful range of shoulder motion.
  • Calcific periarthritis: only a third may be symptomatic (shoulder pain)
  • Limited Joint mobility: painless decrease in motion, decreased grip strength (also seen with Dupuytren's contracture)-
  • Stiff-man disease: primarily affects spine and lower extremities and associated with autoimmune diseases (like T1DM) 
  • Diabetic muscle infarction: usually effects lower extremities but may very rarely affect upper extremities. Bilateral in 1/3 of cases, recurrence at same site in 50% of cases; pain, swelling and tenderness and may be associated with a mild fever
  • Osteoarthritis: joint pain; most common site is knee 

CLINICAL TREATMENT

HAND

  • Carpal tunnel syndrome: exclude hypothyroidism; options include splinting wrist, NSAIDs, glucocorticoid injections and surgery.  (Preston)
  • Dupuytren's contracture: for mild disease, passive stretching and lanolin massage; for more advanced disease, glucocorticoid injection of nodules and surgery to release the fascia (Trojian)
  • Flexor tenosynovitis: glucocorticoid injection or surgery; repeat surgeries occasionally necessary (Ryzewicz)
SHOULDER

  • Adhesive capsulitis: physical therapy, glucocorticoid injection, hydroplasty (intraarticular dilation) and, as a last resort, surgery (Sheridan)
  • Calcific periarthritis: joint aspiration, glucocorticoid injection or surgical removal (Siegal)
FEET

GENERAL

  • Limited joint mobility: optimize glycemic control, discontinue smoking, physical therapy for passive stretching. Little evidence exists for drug therapy but penicillamine and aldose reductase inhibitors have been used as well as glucocorticoid injections (Kapoor).
  • Stiff-person disease: most effective treatments are benzodiazepines and exercise (Duddy)
  • Diabetic muscle infarction: best treatment unclear but options include 1) rest and analgesics; 2) antiplatelet agents and/or anti-inflammatories; or 3) surgical removal (Trujillo-Santos)
  • Osteoarthritis: physical therapy, NSAIDs, glucocorticoid injections, surgery for replacement of joint (Crosby)

FOLLOW UP

  • Many treatments require referrals to specialists such as a rheumatologist, dermatologist, orthopedic surgeon or physical therapist.

EXPERT COMMENTS

  • MSDs are commonly seen in diabetes.
  • Good glycemic control, regular physical activity and the cessation of smoking may decrease the risk of some MSDs.
  • Diabetes-associated MSDs should be considered in persons with diabetes who complain of joint pain or decreased movement.
  • Appropriate management often involves referral to a specialist.

REFERENCES


 
 
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