By

Aminu ArzetDepartment of Internal Medicine,

Nelson Mandela School of Medicine,University of Kwazulu Natal

Durban.

13th October, 2014

Introduction Diabetes is a systemic disease characterized by hyperglycemia that has both acute and chronic biochemical and anatomical complications, which affect various organs/systems of the body.

Musculoskeletal system can be affected in various ways in DM patients.

Pathogenesis is diverse and not fully understood.

Introduction Continuation

Some of the Musculoskeletal complications are related to micro and macro vascular complications of DM, and are due to poor Glycemic control.

The complications are commoner in longstanding Type 1 DM, but also seen in type2 DM.

PathophysiologyMany mechanisms may contribute to the musculoskeletal complications.

The mechanisms are divided into 4 main categories as fallows;

1. Abnormality in the connective tissue, as a result of deposition of abnormal amount of connective tissue material, due to proliferation of myofibroblast.

Pathophysiology Continuation

The connective tissue is abnormal due to excess deposition of advanced glycation end product(AGE) in patients with poorly controlled DM.

Conditions associated with this include; limited joint mobility, shoulder/hand syndrome, palmar flexor tenosynovitis (trigger finger), Dupuytren's disease, adhesive capsulitis of the shoulder, and carpel tunnel syndrome.

Pathophysiology Continuation

2. Neurovascular complications, which are associated with neuropathic joint disease (Charcoat’s joints), diabetic amyothrophy, and diabetic osteolysis.

3. These are conditions that are genetically linked to DM. Some antigens are shared by type 1 Diabetis and Rheumatoid arthritis (HLADR3 and HLADR4).

Pathophysiology Continuation4.Insulin and Insulin like growth factor(IGf-1) may be raise(type2) or low(type1) in DM pts.

Insulin increases the productions of collagen in general, and proteoglycans in cartilages.

It stimulate osteoblast and inhibit osteoclast

IGf-1 also stimulates osteoblast activity.

Pathophysiology ContinuationDiffuse skeletal hyperostosis (DISH) is seen in insulin resistance, while Osteopaenia and osteoporosis may be linked to low IGf-1 level.

5.General and Central obesity are associated with gout, skeletal hyperostosis, and osteoarthritis.

Metabolic syndrome is associated with increased levels of IGf-1.

Common Complications of DMConnective tissues abnormality

This account for most of musculoskeletal complications seen in Diabetic patiens.

Hands are more affected(> 50%). They include;

Cheiroarthropathy; Also known as Limited joints mobility Dx, Neurophatic arthropathy or Diabetic stiff hand syndrome. It affect small joints and soft tissues of the hand and leads to stiffness/loss of function.

Cheiroarthropathy Continuation It involve destructive / lytic joint changes (Severe destructive degenerative arthritis )

It causes limited mobility of joints (inability to fully flex or extend the fingers) and sclerosis of tendon sheaths.

Its believe to be due to Increased glycosylation of collagen in the skin and periarticular tissue, with decreased collagen degradation, and diabetic microangiopathy /neuropathy .

Cheiroarthropathy Continuation

Flexion contractures of the fingers may develop at advanced stages.

“prayer sign” –patient’s inability to press their palms together completely without a gap remaining, is commonly seen in Cheiroarthropathy.

Rx is glycemic control and physiotheraphy.

Diabetic sclerodactyly

Also known as Scleroederma diabeticorum or type 3 Scleroderma.

Its characterized by thick, tight, waxy skin.

Associated with Microvascular dx and poor glycemic control control.

The distribution of skin involvement differ from scleroderma, by affecting neck, back, intercapsular region, face and chest.

Neurovascular complicationThis may be associated with micro and macro vascular diseases.

It include Neuropathic arthropathy, also known as Charcot joint or diabetic osteoarthropathy.

It causes severe destruction of joints, particularly in the feet.

Neurovascular complication continuation

It occurs as a result of a loss of sensation in the involved joints due to peripheral diabetic neuropathy/ microneuropathy.

The loss of sensation leads to inadvertent and often unnoticed repeated micro-trauma to the joints which leads to the degenerative changes.

Neurovascular complication continuation

The condition is quite rare, affecting less than 1 % of DM patiens. It is seen in both type 1 and type 2 DM.

The diagnosis is made based on radiographic findings(destruction noted on radiographs).

Treatment is generally conservative and often unsatisfactory.

Neurovascular complication continuation

Rx involve Splinting/bracing to protect the area from weight bearing to avoid further damage, and good glycemic control

Low intensity ultra sound/magnetic field to stimulate bone growth could be helpful.

Antibiotics when skin ulcers accompany arthropathy.

Neurovascular complication continuation

Diabetic amyotrophyDiabetic amyotrophy(proximal diabetic neuropathy) or Lumbosacral radioplexus neuropathy, also called Femoral neuropathy is a neuropathy, caused by ischemia, secondary to inflammatory microvasculopathy

It affects the thighs, hips, buttocks and legs, and ultimately spread to whole body.

Diabetic amyotrophy Continuation

It causes painful muscle wasting and weakness

Can be managed with glycemic control and physiotheraphy.

Anti-inflammatory and immunosuppressive therapeutic agents are beneficial.

Common Conditions associated with Diabetes

Adhesive capsulitis Adhesive capsulitis, or frozen shoulder, occur in 11-30 % of diabetic patients.

It refers to a stiffened glenohumeral joint, usually caused by thickening and contraction of the joint capsule which results in a substantial decrease in capsular volume capacity.

Adhesive capsulitis ContinuationPatients report shoulder stiffness, along with decreased range of motion and pain.

The pain of this conditions is less in DM than that of the general population.

Can also be seen in hyperthyroidism, Addison dx, and parkinsonism.

Its twice as common in diabetic patients.

Adhesive capsulitis Continuation

The decreased range of motion is worst in abduction and external rotation.

Internal rotation is affected least.

Rx is conservative and involves physiotherapy, and use of analgesic.

Complex Regional Pain Syndrome

Formerly called Reflex sympathetic dystrophy or shoulder-hand syndrome(Sudek’s atrophy).

It’s a neurovascular dx associated with localized or diffuse pain in the upper or lower extremity, usually associated with swelling, loss of hair, changes in skin color, changes intemperature, and skin thickening.

Complex Regional Pain Syndrome The pathogenesis of this dx is poorly understood, but recent evidence suggests elevated levels of IgG in the affected extremities.

May occur after minimal trauma, or spontaneously.

Rx include physio,analgesia,antidepressants, sympathetic ganglion blocks,and amputation

Flexor TenosynovitisFlexor tenosynovitis (trigger finger); Patients complaint of a "catching" or "locking" sensation that may be associated with pain in the affected fingers.

Examination shows a palpable nodule and thickening along the affected flexor tendon sheath, overlying palmar aspect of the metacarpophalangeal joint.

Flexor TenosynovitisOccasionally, the locking phenomenon may be reproduced with active or passive finger flexion.

Its incidence is related to the duration of diabetes.

Rx involve injecting corticosteroids into the tendon sheath. If this is unsuccessful, hand surgeon is advisable.

Dupuytren's ContractureIt present with thickening, shortening, fibrosis and nodule formation of the palmar fascia.

Result in flexion contractures of the fingers.

It occur in up to 30 % of diabetic pts.

Ring and middle finger are more affected.

Dupuytren's Contracture Continuation

Monitor this Patients for retinopathy (twice common among them), and diabetic ulcers(5 fold common).

Rx consist of physiotherapy, steroid injections, and Surgical intervention in some severe cases.

Carpal Tunnel SyndromeSeen in 15 – 25 % 0f diabetic patients.

75 % of patients with CTS develop Cheiroarthropathy.

Prevalence increases with disease duration .

Median nerve entrapment is common(different from diabetic neuropathy)

Rx with splint/surgery better and steroid.

Bone metabolism in Diabetic Patients

Diffuse idiopathic skeletal hyperostosis-DISH (Foratier’s dx) is seen in about 26% of Dm patients.

characterized by excessive bone growth and calcification of paraspinal ligaments, due to hyperostosis effect of hyperinsulinaemia (osteoblast stimulation and osteoclast inhibition).

Bone metabolism in Diabetic Patients

The disease is most common in the thoracic spine, cervical spine and finally the lumbar region.

Intervertebral discs, facet joints, and sacroiliac joints are most often unaffected.

In pts with type 2 Dm and metabolic syndrome, increased level of Insulin like growth factor(IGh-1) stimulate borne growth.

Bone metabolism in Diabetic Patients

In type2 Dm,osteoporosis is more prevalent due to lack of IGH-1(which stimulate osteoblast).

Retinopathy is more prevalent in patients with osteoporosis.

Other Diabetic musculoskeletal conditions

Infection of bone and joints is commoner in DM patients (Osteomylelitis)

Gout and pseudo-gout are prevalent, due to insulin resistance or medication, eg diuretics.

ConclusionPatients with Diabetes may presents with variety of Musculoskeletal complications.

Most of these conditions point to long standing disease and poor Glycemic control

Early diagnosis and Rx improve general outcome.

Similar musculoskeletal manifestations may occur in other endocrine/metabolic diseases.

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