Diabetes & The Body

The effect of diabetes on the Musculo-skeletal system

Diabetes may affect the musculoskeletal system in a variety of ways. Although musculoskeletal complications are most commonly seen in patients with a longstanding history of type 1 diabetes, they are also seen in patients with type 2 diabetes. Some of the complications have a known direct association with diabetes, whereas others have a suggested but unproven association.

Effect on hands

Diabetic cheiroarthropathy : This is also known as diabetic stiff hand syndrome or limited joint mobility syndrome, is found in 8–50% of all patients with type 1 diabetes and is also seen in type 2 diabetic patients. The prevalence increases with duration of diabetes. This syndrome is characterized by thick, tight, waxy skin reminiscent of scleroderma. Patients with this have inability to fully flex or extend the fingers. One indication of the presence of this condition is known as the "prayer sign". This is patients’ inability to press their palms together completely without a gap remaining between opposed palms and fingers.

Treatment: Other than optimizing glycemic control there is no specific treatment for diabetic cheiroarthropathy.

Flexor tenosynovitis: This condition is also called trigger finger. Patients complain of a catching sensation or locking phenomenon that may be associated with pain in the affected fingers.This complication is thought to have the same pathogenesis as diabetic cheiroarthropathy, and its prevalence is similarly related to the duration of diabetes.

Treatment: Initial treatment involves injecting local corticosteroids into the tendon sheath. If this is unsuccessful, patients will most likely need to see a hand surgeon for a minor operation that can provide permanent relief.

Other diabetic complications involving the hands include:

• Dupuytren’s contracture
• Carpal tunnel syndrome
• Tinel’s sign

Effect on shoulders

Diabetes can affect the shoulder in several ways.

Frozen shoulder (adhesive capsulitis ): Patients suffering with this condition report shoulder stiffness, along with decreased range of motion.

Treatment: gentle stretching/range of motion exercises and the use of analgesics and/or intra-articular injections, may give some amount of relief to patients with this condition.

Other problems related to the shoulder in diabetics are:

• Calcific periarthritis
• Reflex sympathetic dystrophy

Effect on feet

Diabetic osteoarthropathy : This condition is also called Charcot or neuropathic arthropathy and involves destructive, lytic joint changes. It is a severe, destructive form of degenerative arthritis resulting from a loss of sensation in the involved joints. The condition is seen in both type 1 and type 2 diabetes.

Diabetic peripheral neuropathy is thought to play the greatest pathogenic role in diabetic osteoarthropathy. There may be skin such as erythema, swelling, hyperpigmentation or purpura, and soft-tissue ulcers over the affected area, as well as joint loosening or instability and joint deformities.

Treatment: This involves both splinting/bracing to protect the area from weight bearing and good glycemic control. Podiatrists sometimes use a total-contact cast for acute Charcot joints. This must be applied by an experienced cast technician and monitored and changed frequently. Unfortunately, it carries a fairly high risk of causing new injuries and ulcers because of the tight fit and patients’ underlying neuropathy. Broad-spectrum empiric antibiotics are also frequently used when skin ulcers accompany the arthropathy.

Effect on Muscles

Diabetic muscle infarction is a rare condition. This spontaneous infarction, with no history of trauma, tends to affect patients with a long history of poorly controlled diabetes. It is seen more commonly in patients with insulin-requiring diabetes, and most affected patients have multiple complications such as neuropathy, nephropathy, and retinopathy.

Patients suffering with this experience an acute onset of pain and swelling over days to weeks in the affected muscle groups (usually the thigh or calf) along with varying degrees of tenderness. However, laboratory investigations need to be done to exclude other conditions, such as tumor, muscle infection/abscess, thrombophlebitis/thrombosis, localized myositis, or osteomyelitis.

Treatment : Diabetics affected with this problem need rest and are treated with analgesics to alleviate pain. Although routine daily activities are not harmful to the condition, physical therapy may cause exacerbation. Spontaneous diabetic muscle infarction tends to resolve over a period of weeks to months in most cases.

Effect on skeleton

Diffuse idiopathic skeletal hyperostosis (DISH): This condition is characterized by calcification of spinal ligaments and is diagnosed on lateral spine radiographs along with osteophyte formation. The thoracic spine is most commonly affected. Patients suffering from this condition complain of stiffness in the neck and back with decreased range of motion. It is commonly observed in type 2 diabetics who are obese.

Treatment : Physical therapy and NSAIDs or other analgesics are used to treat this condition. There is no evidence yet that good glycemic control delays the onset of or improves this condition.

Several studies have also reported an association of early osteoarthritis and diabetes. Both large and small joint osteoarthritis have been reported to be increased in type 2 diabetes. Researchers opine that osteoarthritis of the weight-bearing joints in the affected type 2 diabetic patients may be related to their obesity and not to the diabetes itself.

Summary

Despite a plethora of complications of diabetes, the good news is that these are treatable, although to varying degrees, with resultant improvements in quality of life and more independence in activities of daily living. Asking patients about their symptoms and monitoring for signs of musculoskeletal complications can be an invaluable part of overall diabetes care.