diabetes and rheumatic diseases (nx power lite)
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Diabetes and Rheumatic Diseases
Dr Adel HammoudiDiabetes & Endocrine CenterAl-Noor Specialist HospitalHoly Makkah, KSA.
Introduction
Diabetes Mellitus (DM) is associated with wide variety of Musculoskeletal (MS) problems, some are unique to the disease.
It is important to recognize the various MS manifestations of DM.
The morbidity due to these conditions can be very severe.
Spectrum of rheumatologic diseases in people with DM
Osteoarthritis Carpal Tunnel Syndrome Bone Health and Osteoporosis Diffuse Idiopathic Skeletal
Hyperostosis (DISH) Crystal-induced Arthritis Charcot Arthropathy Tendinopathy
Osteoarthritis
Degenerative joint disease, degenerative arthritis.
Most common rheumatic disease in the general population.
a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone
Asymptomatic or mild, but severe involvement leads to pain, stiffness, and limitation of motion in the affected joints
Knees, hips, and spine
Prevalence of osteoarthritis is higher in young and middle-aged diabetic patients*
Joint damage starts at an earlier age and is much more severe in diabetic than in control patients*
Insulin stimulates cartilage growth. Mediated through insulin-like growth
factor-1*Crisp AJ, Heathcoate JG. Connective tissue abnormalities in diabetes mellitus. J R Coll Physicians 1984;18:132–141.
Treatment: control of pain with acetaminophen or NSAIDs, physical therapy (for the strengthening of muscles and tendons), and TKR
Diabetes may affect the outcomes of therapy in osteoarthritis.
Carpal Tunnel Syndrome
Although not a true neuroarthropathy, the CTS is a frequent cause of hand pain in patients with diabetes.
Compression of median nerve in carpal tunnel.
Numbness, tingling, or burning sensations in the thumb and fingers, pain in the hands or wrists , lost gripping strength.
Weakness and atrophy of the thenar muscles
Diagnosis: history taking, physical examination, Electromyogram and nerve conduction velocity.
14 – 30% of patients with diabetes will develop carpal tunnel syndrome.*
10-15% of patients with carpal tunnel syndrome will have diabetes
*Diabetes Care March 2002 vol. 25 no. 3 565-569
More common in women than men (3:1)
Increased incidence in patients with limited joint mobility.
Treatment: Wrist splinting, NSAIDs, Localized corticosteroid injections and Surgery.
Bone Health and Osteoporosis
Metabolic conditions including diabetes are thought to impair bone homeostasis.
Risk in Diabetics is controversial
Type 1 DM tend to have lower BMD: abnormal bone formation or bone turnover, or both possibly leading to decreased bone mineral density (BMD) and increased marrow adiposity.
Three recent studies contribute to understand this relationship.*
Type 2 DM, post-menopausal women are at greater risk than age-matched non-DM
* Acta Orthop 2007; 78:46-55. Biol Trace Elem Res 2007; 116:321-328. Acta Histochem 2007; 109:304-314.
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Ankylosing hyperostosis, Forestier’s disease.
Characterized by new bone formation, particularly in the thoracolumbar spine.
New bone formation around the hips, knees, and wrists has also been noted.
Mild back pain and stiffness, but range of motion is preserved
More common in Type 2 Diabetes
Occurs in 13 - 49% of patients with diabetes and in 1.6 - 13% of otherwise healthy patients
Also associated with hypermetabolic syndrome: high uric acid, obesity, dyslipidemia
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
Diffuse Idiopathic Skeletal Hyperostosis (DISH). There is flowing ossification (black arrows)that spans more than four contiguous vertebral bodies while the disc height is maintained and the flowing ossification is separated from the anterior aspect of the vertebral body (blue arrows).
Crystal-induced Arthritis
Gout and Hyperuricemia
Gout is an acute and chronic arthritis caused by monosodium urate (MSU) crystals.
Red, tender, hot, swollen joint (acute phase)
Hyperuricemia is a necessary condition for gout,
and is part of the constellation of metabolic syndrome.
Gout, a 1799 caricature by James Gillray
Gout and Hyperuricemia Type II diabetes is also a part of this syndrome an association of gout and type II diabetes
would be expected. Renal insufficiency, a common complication of
diabetes, also predisposes to gout. Whether the onset of diabetes or its
complications exacerbates existent gout or affects outcomes has not been well studied.
Treatment: NSAIDs, steroids, or colchicine Allopurinol or probenicid (long-term prevention)
Calcium pyrophosphate dihydrate deposition (CPPD) Deposition of calcium pyrophosphate
dihydrate crystals in synovial structures. It is more commonly known by alternative
names that specify certain clinical or radiographic findings:
Pseudogout refers to the acute symptoms of joint inflammation or synovitis.
Chondrocalcinosis refers to the radiographic evidence of calcification in hyaline and/or fibrocartilage.
Pyrophosphate arthropathy is a term that may refer to either of the above.
Calcium pyrophosphate dihydrate deposition (CPPD)
The incidence: between 8% and 73% in diabetic patient
0.2% in normal population Diagnosis: Radiography – Xray, CT
scanns, MRIs, ultrasound, and nuclear medicine.
Treatment: For acute pseudogout, intra-articular corticosteroid injection, systemic corticosteroids, NSAIDs.
Lateral view of the right knee shows severe patellofemoral joint space narrowing. This is a classic finding in chondrocalcinosis caused by CPPD.
Radiograph of the wrist and hand showing chondrocalcinosis of the articular disc of the wrist and atypical osteoarthritis involving the metacarpophalangeal joints in a patient with underlying hemochromatosis.
Charcot Arthropathy
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
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
Tendinopathy
Tendinopathies occur frequently in patients with diabetes.
The shoulder and hand are particularly commonly involved.
Painful tendinopathies affect 30-60% of diabetic patients, and cause considerable disability among affected patients
Adhesive Capsulitis of the Shoulder
Frozen shoulder, shoulder periarthritis, obliterative bursitis.
Progressive painful loss of motion in all directions, especially external rotation and abduction.
Joint capsule adheres to humeral head
3 phases: painful, adhesive, resolution
11-30% in diabetics, 2-10% in controls
17% patients with adhesive capsulitis have diabetes Ann Rheum Dis 1996;55:907–14
Adhesive Capsulitis of the Shoulder
Associated with age(T1 & T2DM) and duration of diabetes(T1DM)*
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
*Br J Rheumatol 1986:25:147–151.
Shoulder arthrogram showing a contracted and adherent joint capsule in adhesive capsulitis.
Smith L L et al. Br J Sports Med 2003;37:30-35
Shoulder-Hand Syndrome (SHS)
Characterized by adhesive capsulitis of the shoulder associated with pain, swelling, tenderness, dystrophic skin, and vasomotor instability in the hand.
It is one of a family of disorders that includes reflex sympathetic dystrophy syndrome, major and minor causalgia, Sudeck atrophy, and algodystrophy.
Shoulder-Hand Syndrome (SHS)
severe pain is disproportionate to the findings of the physical examination in association with articular or periarticular swelling.
3 stages:1st (3 to 6 months): pain, tenderness,
swelling, and vasomotor changes2nd (3 to 6 months): trophic skin
changes (shiny skin with loss of normal wrinkling)
Shoulder-Hand Syndrome (SHS)
3rd atrophy of skin and subcutaneous tissue, tendon contractures, and progressive osteopenia
In one study of 108 patients with SHS or related conditions, 7.4% had diabetes*
Treatment: Analgesic, glucocorticoid, regional sympathetic blockade (improvement in 80% of cases)
*Doury P, Dirheimer Y, Pattin S. Algodystrophy: diagnosis and therapy of a frequent disease of the locomotor apparatus. Berlin: Springer-Verlag, 1981.
Diabetic Hand Syndrome (DHS)
Cheiropathy, stiff-hand syndrome, diabetic stiff hand, diabetic contractures, or syndrome of limited joint mobility.
Prevalence is 8 – 53% More common in patients with T1DM Risk increases with poor glycemic
control (↑HbA1c ) and duration of diabetes
Diabetic Hand Syndrome (DHS)
Clinically: stiffness, loss of dexterity, and weakness of hands
The skin on the hands is typically thick, tight, and waxy
Limitation of flexion and extension occurs Usually MCP, PIPs
Decreased grip strength
Diabetic Hand Syndrome (DHS) Diagnosis
“prayer sign” “table top test”
Treatment: optimizing glycemic control and physiotherapy
Diabetic Hand Syndrome (DHS)
Mechanism: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
Dupuytren Disease
Morbus Dupuytren, Dupuytren's disease, or palmar fibromatosis.
Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended.
Fibrosis in and around the palmar fascia with nodule formation
The 3rd and 4th finger most commonly effected in patients with diabetes, compared to the 5th finger in patients without diabetes
Dupuytren Disease
Present in 21- 63% of patients with diabetes Prevalence increases with age
Generally milder in patients with diabetes compared to patients with other conditions
Treatment: Optimize glycemic control, aggressive physiotherapy, NSAIDs, analgesic, Intralesional glucocorticoid injections
Rarely surgery is required
Flexor tenosynovitis
Trigger finger Caused by fibrous tissue proliferation
in the tendon sheath. Limitation of the normal movement of
the tendon. Prevalence 11% in DM patient, < 1% in non-DM Pt.
There is also an increased incidence in people with impaired glucose tolerance.
Associated with the duration of diabetes but not age.
Treatment: local corticosteroid injection.
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
References
Joslin's Diabetes MellitusBritish Journal of Sports
MedicineMedscape.comWikipedia.com
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