Common rheumatologic syndromes in patients with diabetes mellitus:
Intrinsic complications of diabetes mellitus:
- Diabetic stiff hand syndrome (limited joint mobility syndrome, diabetic cheiroarthropathy).
- Neuropathic arthropathy (Charcot joint) and diabetic osteolysis.
- Diabetic amyotrophy.
- Diabetic muscle infarction.
Conditions with increased incidence in diabetes mellitus:
- Adhesive capsulitis of the shoulder (frozen shoulder).
- Calcific shoulder periarthritis (tendinitis).
- Complex regional pain syndrome (shoulder–hand syndrome).
- Flexor tenosynovitis of the hands, A1 Pulley thikcening (trigger fingers).
- Dupuytren’s contracture, palmar fibromatosis
- Carpal tunnel syndrome.
- Diffuse idiopathic skeletal hyperostosis (DISH).
Diabetic stiff hand syndrom:
This syndrome, also known as limited joint mobility syndrome and diabetic cheiroarthropathy, presents with the insidious development of flexion contractures involving the small joints of the hands, starting with the distal interphalangeal joints (DIPs) and proximal interphalangeal joints (PIPs) and moving proximally over time. This condition occurs in both type 1 diabetics (8% to 50%) and type 2 diabetics (increased) and correlates with disease duration, glucose control, and renal/retinal microvascular disease.
The "prayer sign" observed on physical examination reflects the inability to fully extend the joints of the fingers These finger contractures are attributed to excessive glycosylation of dermal and periarticular collagen, decreased collagen degradation, and increased dermal hydration resulting in indurated and thickened skin around the joints. This condition can be confused with scleroderma. Laboratory serologies and hand radiographs are unremarkable. Treatment is physical therapy and control of the underlying diabetes. Contractures usually progress slowly but rarely limit function significantly.
Neuropathic arthropathy, Charcot joint
Occurs in <1% of all diabetics (both type 1 and type 2).
Is a condition specifically occurring in diabetics. The osteolysis is characterized by osteoporosis and variable degrees of resorption of distal metatarsal bones and proximal phalanges in the feet. Pain is variable. Radiographs have a characteristic “licked candy” appearance. The pathogenesis is unclear, as this syndrome can occur at any time during the course of diabetes. The primary consideration in the differential diagnosis is osteomyelitis. Treatment is conservative and includes protected weight-bearing. The process may terminate at any stage and in some cases may completely resolve
with severe pain and dysesthesia involving most commonly the proximal
muscles of the pelvis and thigh. The perispinal and shoulder girdle
muscles can also be involved. The condition may be bilateral in 50% of
cases. Anorexia, weight loss, and unsteady gait owing to muscle wasting
and weakness may be seen. The typical patient is a 50-year-old to
60-year-old man with well-controlled, mild noninsulin-dependent diabetes
mellitus of several years’ duration, although it can be the presenting
sign of diabetes.
Diabetic muscle infarction
Is the spontaneous infarction of muscle. It occurs in long-standing insulin-dependent diabetics with multiple other microvascular complications. Patients present with acute onset of pain and swelling over days to weeks of thigh or calf. Creatine kinase may be elevated. Clinical presentation, laboratory findings, and muscle magnetic resonance imaging help to rule out infection/abscess or malignancy, although an excisional biopsy may be necessary.
Diabetic periarthritis of the shoulder
Is also known as frozen shoulder or adhesive capsulitis. It occurs in 10% to 33% of diabetics and is five times more common in diabetics than in nondiabetics. The typical patient is female with type 2 diabetes of long duration who presents with diffuse soreness and global loss of motion of the shoulder. Some patients have calcific (hydroxyapatite) periarthritis/tendinitis, which is three times more common in diabetics than in patients without diabetes and may increase the risk of developing frozen shoulder.
When a frozen shoulder (with or without calcific periarthritis) is accompanied by vasomotor changes of reflex sympathetic dystrophy/chronic regional pain syndrome, it is known as shoulder–hand syndrome.
Occurs in 5% to 33% of diabetic patients. Females with long-standing diabetes are more commonly affected than males. Patients complain of aching and stiffness in the palmar aspect of the hand. A “trigger” finger may occur as a result of an inflammatory nodule getting caught in the proximal pulley at the base of the finger. The thumb of the dominant hand is most commonly involved (75%), although multiple fingers on both hands can be affected.
Occur in 30% to 60% of patients with type 1 diabetes. Patients present with nodular thickening of the palmar fascia, leading to flexion contractures usually of the fourth and fifth digits. Patients usually have long-standing diabetes, although there is no association with control of the diabetes. The pathogenesis is thought to be a result of contractile myofibroblasts producing increased collagen secondary to microvascular ischemia.
Carpal tunnel syndrome
Commonly (20%) occurs in diabetic patients. Patients present with numbness in the median nerve distribution. Nocturnal paresthesias, hand pain, and pain radiating to the elbow or shoulder (Valleix phenomenon) can also occur. Tinel’s and Phalen’s signs may be positive. Thenar atrophy is a late sign and indicates muscle denervation. The neuropathy may be from extrinsic compression or owing to microvascular disease causing vasa nervorum ischemia.
Is diffuse idiopathic skeletal hyperostosis, also known as Forestier’s disease. It occurs in up to 20% of type 2 diabetic patients who are typically obese and over age 50 years. Patients present with neck and back stiffness associated with loss of motion. Pain is not prominent. Radiographs are diagnostic and consist of at least four vertebrae fused together as a result of ossification of the anterior longitudinal ligament. Disc spaces, apophyseal joints, and sacroiliac joints are normal, helping to separate it from osteoarthritis and ankylosing spondylitis.