Every month we examine a long or short term complication of diabetes so that you can better understand how to live a healthy active life. Please use these articles to help you make your doctor’s appointment more profitable for you and your family. The more you know the more information you will come away with during these medical checkups.
So read on about a long term complication you may not know about. I became interested when I thought I had developed Carpal Tunnel Syndrome and visited a specialist for the problem. Luckily, for me, I am fine with no treatment.
For me my pain was a result of a new exercise done poorly, but just looking at the percentages of these syndromes in persons with diabetes will open your eyes and you will pay more attention to musculoskeletal complications.
This month we will share information on hands and shoulders. Next month we will talk about feet, muscles, skeleton, and osteoarthritis so that you will have the entire scoop. Please read on. The information is very interesting.
It is currently thought that diabetes may affect the musculoskeletal systems in various ways. The glycoslation of proteins, microvascular abnormalities due to damage to blood vessels and nerves, and collagen accumulation in the skin and periarticular structures can all result in changes in connective tissue.
Musculoskeletal complications are most often seen in persons with a long-standing history of type 1 diabetes, but they are also seen in those with type 2 diabetes. Some of the complications have a direct association with diabetes, while others have a suggested but unproved association. Here we will review the musculoskeletal and rheumatological aspects commonly seen in persons with diabetes.
Hands are the targets for several diabetes-related complications. Diabetic cheiroarthropathy, also known as diabetic stiff hand syndrome or limited joint mobility, is found in 8-50% of all people with type 1 diabetes and is also seen in those with type 2 diabetes. The prevalence increases with duration of diabetes and this condition is associated with and predictive of other diabetic complications.
This syndrome is characterized by thick, tight, waxy skin reminiscent of scleroderma. Limited joint range of mobility (inability to fully flex or extend the fingers) and sclerosis of tendon sheaths are also present.
The underlying cause is thought to be multifactorial. Increased glycosylation of collagen in the skin and periarticular tissue, decreased collagen degradation, diabetic microangiopathy, and possibly diabetic neuropathy are thought to be some of the contributing factors.
Flexion contractures of the fingers may develop at advanced stages. 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. The specific treatment of diabetic cheiroarthropathy (other than optimizing glycemic control) is unknown.
Flexor tenosynovitis (or trigger finger) is another frequent diabetic complication of the hands. People complain of a catching sensation or locking phenomenon that may be associated with pain in the affected fingers.
Examination shows a palpable nodule, usually in the overlying metacarpophalangeal joint, and thickening along the affected flexor tendon sheath on the palmar aspect of the finger and hand. Also, the locking phenomenon may be reproduced with either active or passive finger flexion. This complication is thought to have the same pathogenisis as diabetic cheirarthropathy, and its prevalence is similarly related to the duration of diabetes.
Initial treatment involves injecting local corticosteroids into the tendon sheath. If this is unsuccessful, patients will most likely need to be seen by a hand surgeon for a minor operation that can provide permanent relief.
This operation consists of a small transverse incision just distal to the flexion crease over the metacarpal head, which exposes the flexor tendons and sheath. A complete longitudinal incision along the thickened fibrous tendon sheath relieves the constriction and allows the finger to move freely.
Dupuytren’s contracture results from a thickening, shortening, and fibrosis of the palmar fascia. Nodule formation along the fascia is seen. Flexion contractures of the fingers may result, usually at the fourth finger, but sometimes involving any of the second through fifth digits.
Dupuytren’s contracture has been reported in 16-42% of diabetic patients. Its pathogenesis is thought to be the same as that for cheiroarthropathy. The prevalence of this condition increases with disease duration, but may also may also be seen early in the course of diabetes. Varied success has been reported with local cortico-steroid injections. Surgical intervention may be needed for severe cases.
Carpal tunnel syndrome (CTS) is seen in up to 20% of diabetic patients. Its specific relationship to diabetes is thought to be a median nerve entrapment caused by the diabetes-induced connective tissue changes mentioned above.
The prevalence of CTS in diabetic persons generally increases with duration of the disease. CTS is usually diagnosed based on history and clinical findings. Classically, people complain of burning, paresthesis, or sensory loss in the median nerve distribution (the first three fingers as well as the radial half of the fourth finger).
They may also complain of pain in the same area, often with radiation proximally into the forearm and arm. The pain may awaken people from sleep and is aggravated by activities involving wrist flexion or extension, such as holding a newspaper or book, typing, driving, or using a knife and fork.
Tinels’ sign (tapping over the median nerve on the volar aspect of the wrist) may be helpful in diagnosis but it is not universally positive. A positive Tinels’ sign produces paresthesias distally in the hand.
Phalen’s test (the wrist flexion test) may also assist in diagnosis, but like Tinel’s, it is somewhat variable. Patients are asked to flex both wrists so that the dorsal of both hands are touching and hold that position for 30-60 seconds.
A positive Phalen’s test consists of paresthesias being reproduced in the hand with this maneuver. it is also important to examine patients for possible motor weakness by median nerve compression. Assessing thinner muscle strength and examining the hand for the presence of the muscle atrophy do this.
It is important that clinicians intercede in CTS before the development of this type of atrophy. Diabetic patients may have paresthesias caused by underlying peripheral neuropathy, and these two entities must be differentiated. Electromyogram/nerve conduction velocity (EMG/NCV) testing can confirm the diagnosis of CTS in uncertain cases and can also help to localize the site of entrapment.
Management of CTS is the same for diabetic patients as for nondiabetic patients. Conservative treatment is tried initially for early or mild cases, using volar wrist splints (particularly at night) with or without nonsteroidal anti-inflammatory drugs (NSAIDs).
Ergonomic adjustment of computer workstations should be made when appropriate. Local corticosteroid injection of the carpal tunnel may be tried as well. Patients with severe or refractory cases, as well as those with thenar atrophy or progressive neurological changes on serial EMG/NCV testing, should be sent for definitive therapy with surgical release of the transverse carpal ligament by a hand surgeon.
Diabetes can affect the shoulder in several ways. First, adhesive capsulitis, or frozen shoulder, has been reported in 19% of diabetic persons. This term refers to a stiffened glenohumeral joint usually caused by a reversible contraction of the joint capsule.
Patients report shoulder stiffness, along with decreased range of motion. Therapy is largely conservative and involves minimizing verimmobilization (gentle stretching/range of motion exercises) and the use of analgesics and/or intra-articular injections.
Calcific periathritis of the shoulder is also seen in diabetes, where it is roughly three times more common than in people who do not have diabetes. Shoulder radiographs show calcium deposits outside of the joint, often in the area of the rotator tendons. However, in up to two-thirds of the cases, this condition is asymptomatic in diabetes.
Reflex sympathetic dystrophy, also known as “shoulder-hand syndrome”, is seen in diabetic patients, although whether it occurs with increased frequency is controversial. It may be associated with adhesive capsulitis (with or without calcific periarthritis).
Patents may complain of pain from the shoulder to hand in the affected limb. Classical examination findings include swelling of the affected limb/area, skin changes (changes in hair growth, shiny skin, color and temperature), increased sensitivity to temperature and touch, and vasomotor instability.
Transient, patchy osteoporosis is often seen. Early intervention is important. NSAIDs, other analgesics, and corticosteroids have been used with physical therapy, and sympathetic blocks may be helpful.