WORLD CLINICS Diabetology: Complications of Diabetes Viswanathan Mohan, Ranjit Unnikrishnan
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Rheumatological Complications of Diabetes

Debasis Basu MD MBA
Internal Medicine and Diabetes, Apollo Gleneagles Hospital Kolkata, West Bengal, India

ABSTRACT

Musculoskeletal manifestations are an important yet neglected complication of diabetes. They entail much suffering to the patient and are responsible for poor quality of life in majority of cases. The rheumatological manifestations of diabetes are myriad and range from self-limiting disorders to potentially limb-threatening conditions such as Charcot foot. Many of these conditions can be effectively treated if diagnosed early, for which a high index of suspicion and awareness are needed from the part of the clinician.
 
INTRODUCTION
Skeletal involvement in diabetes was first suggested more than 80 years ago, prompted by radiological findings of retarded bone development and bone atrophy in children with type 1 diabetes mellitus (T1DM).1 Diabetes may affect the musculoskeletal system in a number of ways. The metabolic perturbations in diabetes (including glycosylation of proteins; microvascular abnormalities with damage to blood vessels and nerves; and collagen accumulation in skin and periarticular structures) result in changes in the connective tissue. Musculoskeletal complications are most commonly seen in patients with a longstanding history of type T1DM, but they are also seen in patients with type 2 diabetes mellitus (T2DM) (Table 1).2
Some of the complications are directly associated with diabetes, whereas others have a suggested but unproven association. This article will review some of the musculoskeletal and rheumatological manifestations commonly seen in patients with diabetes (Table 2).
Table 1   Prevalence of Musculoskeletal Disorders in Patients With or Without Diabetes2
Musculoskeletal disorder
With diabetes (%)
Without diabetes (%)
Adhesive capsulitis
11–30
2–10
Limited joint mobility
8–50
0–26
Dupuytren's contracture
20–63
5–10
Carpel tunnel syndrome
11–16
2–5
Flexor tenosynovitis
10–12
<1
Diffuse idiopathic skeletal hyperostosis
13–15
2–15
Table 2   Musculoskeletal Manifestations Associated with Diabetes
Conditions unique to diabetes mellitus (DM)
Conditions frequently in DM
Conditions sharing risk factors of DM and metabolic syndrome
  • Diabetes muscle infarction
  • Limited joint mobility
  • Stiff hand syndrome (diabetic cheiroarthropathy)
  • Dupuytren's contracture
  • Stenosing flexor tenosynovitis/trigger finger
  • Frozen shoulder/shoulder adhesive capsulitis
  • Calcific shoulder periarthritis
  • Neuropathic arthropathy
  • Complex regional pain syndrome
  • Carpel tunnel syndrome
  • Muscle cramps
  • Ossification of the posterior longitudinal ligament
  • Forefoot Osteolysis
  • Osteopenia and osteoporosis and special reference to type 1 diabetes mellitus
  • Specific joint abnormalities with and without infection
  • Bone abnormalities associated with antidiabetic medications
  • Diffuse idiopathic skeletal hyperistosis
  • Gout
  • Osteoarthritis
  • Rheumatoid arthritis and other autoimmune inflammatory arthropathy
3  
DIABETIC MUSCLE INFARCTION
Diabetic muscle infarction (DMI) is a rare complication of diabetes mellitus (DM). The etiology of diabetic infarction is unknown, but suggested underlying factors are diffuse diabetic microangiopathy, thromboembolism, hypercoagulability and vascular endothelial damage.3,4 Patients having terminal diabetic nephropathy generally develop DMI and nearly one-fourth of DMI, patients receive renal replacement treatment.5 DMI presents with acute onset of muscle pain and swelling. Eighty percent of cases have thigh muscle involvement; however isolated calf muscle (Figure 1), simultaneous thigh and calf muscle and upper extremity muscle involvement have also been described. A palpable mass has also been reported. Recurrence in the same or different group of muscle has been observed. The mean mortality rate is 10% with DMI within 2 years of the initial diagnosis, wherein mortality were predominantly due to the macrovascular complications.6
There is no specific laboratory marker for DMI. Serum creatine kinase (CK) levels were elevated in slightly fewer than half of those patients for whom a level was reported. Magnetic resonance imaging (MRI) shows typically isointense swelling on T1-weighted images and diffuse heterogenous hyperintensity on T2-weighted images of the affected muscle with surrounding subfascial and subcutaneous edema (Table 3).
Only when diagnosis is uncertain or virtually no to very little improvement has occurred despite 3 weeks of bed rest, opiates, anticoagulants and antiplatelets, muscle biopsy is done. The typical findings reveal muscle fiber ischemic necrosis, tissue edema, phagocytosis of necrotic fibers, reparative granulation tissue and collagen deposition, atherosclerosis and fibrin in small vessels (Figure 2). Muscle biopsy or surgery can delay recovery. DMI is self-limiting and full recovery can be expected over time. Recurrences are common.8
zoom view
Figure 1: A, Physical appearance of the isolated calf muscle (left); B, magnetic resonance imaging (MRI) finding of the same affected leg (right).
4
Table 3   Differential Diagnosis of Diabetic Muscle Infarction7
Infection
  • Pyomyositis
  • Necrotizing fasciitis
  • Cellulitis
  • Abscess
  • Osteomyelitis
Trauma
  • Hematoma
  • Exertional rupture of muscle
  • Myositis ossificans
Vascular
  • Deep vein thrombosis
  • Acute compartment syndrome
Tumor
  • Lymphoma primary muscle
  • Sarcoma, soft tissue
  • Benign muscle tumor
Inflammatory
  • Myositis, focal inflammatory
  • Polymyositis or dermatomyositis
Diabetes related condition
  • Diabetic amyotrophy
Other
  • Rupture Baker cyst
  • Adverse reaction to simvastatin
  • Arterial graft complications
zoom view
Figure 2: Muscle biopsy of diabetic muscle infarction.9
 
LIMITED JOINT MOBILITY
Limited joint mobility (LJM) results in painless, noninflammatory limitation of the hand, feet and larger joints. It usually begins in fifth finger, with the limitation then extending radially. These clinical features were previously termed diabetic cheiroarthropathy or diabetic hand syndrome.10,11 Other manifestations of LJM include Dupuytren's disease (DD), shoulder capsulitis (SC),12 flexor tenosynovitis and carpal tunnel syndrome (CTS)
Limited joint mobility is a common complication of DM, occurring in 8–58% of patients; most studies suggest that the prevalence is about 30–40%.13-15 5The prevalence of LJM ranges between 30% and 58% among patients with T1DM and between 45% and 76% among those with T2DM, as compared with between only 4% and 20% among individuals without DM.16-20
The onset of LJM is insidious and may predate the recognition of overt DM. Therefore, an easy clinical assessment for LJM should be a part of the routine assessment of patients with DM, and its presence should alert the physician to the likely presence of microvascular or macrovascular disease or both.21
The first sign is usually a limitation of extension in the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the little finger. Subsequently the disease may progress to radial, distal and proximal joints. Each patient should be asked to tightly approximate the palmar surfaces of the interphalangeal joints of both hands, with the fingers fanned. If such approximation is incomplete, the examiner should confirm the limitation by passively extending the patient's fingers and measure the extension angle using a goniometer. The extensions of the elbow and ankle joints and lateral flexion of the cervical spine are to be also examined. Abnormal joint mobility can be classified according to the following criteria described by Rosenbloom et al.16
  • Mild LJM indicates involvement of one or two PIP joints, one large joint or only the metacarpal-phalangeal joints bilaterally
  • Moderate LJM refers to the involvement of three or more PIP joints or one finger joint and one large joint bilaterally
  • Severe LJM refers to obvious hand deformity at rest or associated cervical spine involvement.
A diagnosis of LJM is made with careful physical examination and exclusion of other conditions in the differential diagnosis. It should be generally high in all patients with DM, especially those who have had the disease for a long duration.
Results of laboratory and radiographic evaluation usually are nonspecific and unremarkable. The erythrocyte sedimentation rate is normal. Ultrasonographic studies show hypoechoic-thickening of the flexor tendon sheaths with thickness of more than 1 mm, compared with a thickness of less than 1 mm in unaffected patients with DM and controls.22 MRI shows thickening and enhancement of the flexor tendon sheaths.23
Two simple clinical tests may be used to detect limitation of joint mobility in the hands (Figure 3).
The prayer sign: The prayer sign is a simple clinical test that may be used to detect LJM in the hands. Inability of the patient to completely close the gaps between opposed palms and fingers when pressing the hands together in a praying position constitutes a positive prayer sign.6
zoom view
Figure 3: The two common clinical tests for determining limited joint mobility (LJM) in hands: A, Prayer sign. B, Hueston tabletop sign.
The Hueston tabletop sign: A patient's inability to make contact with a tabletop with the palmar surface of the fingers is another positive sign of LJM. The examiner may confirm limitation of joint motion with passive extension of the fingers.
 
Differential Diagnosis
These include the following:
  • Dupuytren's contracture
  • Tenosynovitis of the finger flexor tendons
  • Reflex sympathetic dystrophy.
All three conditions may coexist in a single patient, because all three occur more frequently in patients with DM than in the normal population. Other conditions that have a clinical appearance similar to that of LJM include palmar fasciitis or fibromatosis and scleroderma.
 
Dupuytren's Contracture
Dupuytren's contracture or DD is a progressive disease of the palmar fascia which results in shortening, thickening and fibrosis of the fascia and aponeurosis of the palm. The fourth metacarpal is most commonly affected, followed by the fifth, third and second. This condition most commonly begins with thickening of the skin on the palm, resulting in a puckering or dimpled appearance. As the condition progresses, bands of fibrotic tissue form in the palmar area and may travel distal toward the fingers. This tightening and shortening eventually lead to the affected fingers being pulled into flexion.
Diagnosis of DD can be done by physical examination and measurement of the degree of flexion contracture by goniometry. The grading system by Tubiana is the most popular (Figure 4).24
The Hueston tabletop test is a good indication for referral.25 Surgical intervention is the current mainstay treatment for DD.26 Surgery is usually performed when the MCP joint contracture exceeds 40° or when the PIP joint contracture exceeds 20°.277
Staging of Dupuytren's Disease
Stage
Deformity
0
No lesion
N
Palmar nodule without presence of contracture
1
TFD between 0° and 45°
2
TFD between 45° and 90°
3
TFD between 90° and 135°
4