Transcript Diabetes Mellitus and Musculoskeletal System

Dr Hossein Soleymani
Assistant Prof of Rheumatology
SSMU, May 2015, YAZD, IRAN
Introduction
 MS complaint more frequent
 Metabolic change in CV tissue
Glycosylation of proteins
Micro-vascular abnormality
Accumulation of extracellular matrix and soft
tissue
 More seen in longstanding type I
 Some complications have direct association
Pathogenesis:
 An increase in non-enzymatic glycosylation
of collagen fiber
 Increase collagen crosslink
 Resistant to enzymatic digestion
 Increase in hydration mediated by aldolase
reductase pathway
 Increased formation Advanced Glycosylation
End product (AGEs)
Pathogenesis:
 AGEs causes micro and macro vascular
complications
 AGEs result from early glycosylation
 Accumulate in tissue
 Damage extra and intra cellular proteins
 There are receptors on cell surface for AGEs
belong to IG receptors
 Signaling lead to cell dysfunction
 AGEs decrease vascular elasticity
Condition limited to DM
Diabetic Muscle Infarction
Conditions more frequently in DM
 Diabetic cheiroarthrophaty (stiff hand synd)
 Trigger finger (flexor tenosynovitis)
 Dupuytren’s contracture
 Carpal tunnel syndrome
 Adhesive shoulder capsulitis (frozen shoulder)Calcific
shoulder tendonitis
 Reflex sympathetic dystrophy ( shoulder-hand syndrome)
 Diabetic osteoarthrophaty or charcot’a or neuropathic
arthropathy
Conditions Sharing Risk Factors of
DM
 Diffuse Idiopathic Skeletal Hyperostosis
 Gout/ Pseudogout
 Osteoarthritis
Case: 1
 A 56-year-old man , Hs of 15 years uncontrolled DM
complaint stiffness of hand, hand joint had limitation ,
no Raynaud phenomena
Hand
 Diabetic cheiroathrophaty or diabetic stiff hand or
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limited mobility joint syndrome:
8% to 50% all type I DM,45%-70% type II
Associated and predictor of other complication
Thick, tight, waxy skin, begin in MCP&PIP 5
Like systemic sclerosis
Limited joint mobility( finger flex and extend)
Cheiroarthropathy
 Lack of following differentiated from Scledrema:
Raynuads’ phenomena, dermal atrophy, telangiectasia
and autoantibodies
 Nail fold capillaroscopic change may be seen
 Both type I and type II have higher prevalence
retinopathy and nephropathy
hand
 Flexion contracture of
fingers cause Prayer
sign
Cheiroarthropathy
Cheiroarthropathy
 Recommended treatment:
 1- Glycemic control
 2- Physical therapy
 3- NSAIDs with caution
Case: 2
 A 44-year-old woman , Hx of 8 years DM, complaint of
pain in 3,4 Rt fingers, catching or locking of fingers
Hand: Trigger finger
 Catching sensation or locking phenomena
 Pain in affected finger
 Thumb, then third and forth
 5%-36% type I, II (2% normal)
 Palpable nodule overlying MCP joint
 Thickening along the affected flexor tendon
 Prevalence related to duration of DM
 TF in 3 or more finger highly suggestive for DM
Trigger Finger
 Treatments:
 1-Change of activity
 2- Splint
 3- Use of NSAIDs with caution
 4- CS injection
 5- In severe case surgery
Case: 3
 A 65-year-old man , Hx of 14 years DM, retinopathy,
complaints of nodules in palmar aspect of both hand,
difficulties in finger extension
Hand: Dupuytren’s contracture
 Thickening, shortening, fibrosis of palmar facia
 Nodule along the facia
 causes flexion contractures of the finger
 Usually fourth but may be seen II to V fingers
 16% to 42% of all DM more in elderly
 May be seen in early stage
 Prevalence more in longstanding DM
Dupuytren’s contracture
 More in third and fourth finger
 More in women
 Manifestations are more severe in men
Dupuytren’s contracture
 Treatments:
 1- Intralesional injection of CS
 2- Surgery
 3- Physical therapy
 4- Some studies show benefit from injection of
collagenase Colstridium Histolyticum
Case: 4
 A 55-year-old woman HX of 6 years DM, complaint of
Rt hand pain, numbness, radiate to arm, worse at night
Hand: Carpal Tunnel syndrome
 20% of diabetic patients more in women
 More in obese
 Median nerve entrapment
 Caused by diabetic-induced connective tissue
alteration
 HX & PE
 Tinel’s sign, Phalen’s test
 In dubious case Electrophysiological studies helpful
Carpal tunnel syndrome
 Treatments:
 1- Splint, NSAIDs
 2- Injection CS: response may be temporary and
poorer in DM
 3- Release surgery: post operative recovery is worse
Case: 5
 A 66-year-old man Hx of 15 years uncontrolled DM,
complains of both shoulder pain, worse at night,
problem daily working, joint mobility limited
Shoulder: Frozen shoulder
 Frozen shoulder or adhesive capsulitis
 Most common shoulder involvement
 10-29% diabetic patients, bilateral, elderly
 Stiffness Glenohumeral joint
 Reversible contraction joint capsule
 See in hyperthyroidism, Addison and Parkinson
Adhesive capsulitis
 Progressive and painful manner
 Pain at night initially
 Three phase:(a) Pain (b) Stiffness (c) Recovery
 Diagnostic criteria by Pal: Shoulder pain at least one
month, impossibility lying's one shoulder, limited
active and passive movement
 Decreased range of motion in abduction and external
rotation then internal rotation
Adhesive capsulitis
Treatments:
 1- Analgesic
 2- Physiotherapy
 3- CS injection
 4- Arthroscopy release
Shoulder: Calcific shoulder
tendonitis
 Three times more frequent in DM (type II)
 Coexist with adhesive capsulitis
 Deposit Ca hydroxy apatite
 Ca depostion in rotator cuff tendons
 60% asymptomatic
Sohulder:Reflex sympathetic
dystrophy
 Shoulder-hand synd or complex regional pain synd
 Pain from shoulder to hand
 Swelling of affected limb
 Skin change: hair growth, shiny skin, color, temperature
 Increased sensitivity to pain and touch
 Vasomotor instability
 Transit patchy osteoporosis
Case: 6
 A 58-year-old woman, Hx of 20 years DM, Hx of
neuropathy, complains of swellings in both feet,
deformity, pain in walking and standing, no
tenderness
Feet: Charcot’s arthropathy
 Diabetic osteoarthropathy
 Rare: 0.1% to 0.4%
 Both type DM
 Average duration 15 years
 Advanced peripheral neuropathy
Feet: Charcot’s arthropathy
 Loss of sensation in involved joint
 Inadvertent microtrauma to joint
 Consecutive degenerative change
 Severe destruction, lytic joint changes
 Most affect pedal bones
Feet: Charcot’s arthropathy
 Erythema, swelling, hyperpimentation
 Purpura, soft tissue ulcer
 Joint loosening, instability, joint deformity
 Often no history of trauma
Feet: Charcot’s arthropathy
 Diagnosis: based on radiographic findings
 Symptoms often milder than view of X-ray
 X-raysubluxation, bone fragment, osteolysis
 Periosteal reaction, deformity, ankylosis
Feet: Charcot’s arthropathy
 CT sacn is insensitive
 MRI and bone scintigraphy adjuncts X-ray
 DD: Inflammatory, degenerative, infections, tumors,
DVT
Charcot arthropathy
 Treatments:
 1- Prevent weight bearing on affected joint
 2- Bisphosphanate
 3- Calcitonin may be useful
Muscle: Diabetic muscle infarction
 Rare condition
 Spontaneous infraction with no history of trauma
 Patients with long history of poorly controlled DM
 More in insulin requiring patients
 Most patients show microvascular complications like
neuropathy, retinopathy, nephropathy
Muscle: Diabetic muscle infarction
 Acute onset of pain and swelling on affected M
 Over days to weeks
 Usually thigh or calf
 Varying degree of tenderness
 CPK may be normal or increased
Muscle: Diabetic muscle infarction
 D&D: Tumor, muscle infection/abscess, localized
myositis, osteomyelitis, thrombosis
 CT Scan in insensitive
 MRI show high signals in muscle in T2
 When incisional muscle biopsy?
Only to rule out infection and malignancy
(culture for atypical organisms)
Treatments: rest, analgesic
Case: 7
 A 70-year-old man , Hx of 12 years controlled DM,
complaint of mechanical thoracic pain, tenderness in
thoracic spine , normal ESR, CRP, Hb
Diffuse Skeletal Disease
 Diffuse idiopathic skeletal hyperostosis(DISH)
 Metaplastic calcification of spinal ligament
 Osteophyte formation
 Disc space, sacroiliac and facet joint: normal
 Thoracic spine most commonly affected
 May be accompanied by generalized calcification of other
ligament
Diffuse Idiopathic Skeletal
Hyperostosis
 Unknown etiology
 IN DM patients more than normal
 Association with type II DM
 More in obese patients
 Pain is not prominent symptoms
 Complaint stiffness in neck and back
 Decreased range of motion
Other disease with DM
 Osteoporosis: controversy, risk of Fx increased
 Osteoarthritis
 Hyperurecemia
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