Diabetes Mellitus: Musculoskeletal ManifestationsDz

Synonyms: Cheiroarthropathy, neuropathic joints, Charcot joints, diabetic amyotrophy, syndrome of limited joint mobility.

ICD-9 Codes: Diabetic neuropathic arthropathy, 250.6; diabetic complication NEC, 250.9; diabetic amyotrophy, 250.6 (358.1); arthropathy associated with endocrine disorder, 713.0.

Definition: These are symptomatic abnormalities of skin, bones, joints, and tendons that may be associated with, or result from, type 1 or 2 diabetes mellitus.

Etiology: Some abnormalities result from diabetes-induced nerve and blood vessel damage; others are caused by excess collagen accumulation in periarticular structures and skin, which occurs with aging but is accelerated in diabetics. Others have hypothesized that nonenzymatic glycosylation of proteins leads to accumulation of advanced glycosylation end products that may contribute to the pathology.

Pathology: Skin and tendons show excessive fibrosis owing to collagen accumulation. Muscle biopsy specimens may show type 2 fiber atrophy without significant inflammatory infiltrate.

Demographics: Musculoskeletal manifestations are most common in patients with longstanding type 1 diabetes but may also occur in some patients with type 2 diabetes.

Disease Associations: Associations between diabetes mellitus and gout, CTS, osteoporosis, or hyperostosis (DISH) have been suggested but are not well established.

Clinical Findings: The most common musculoskeletal conditions seen in diabetics include

—Pseudosclerodactyly: Thickened, waxy skin changes are most apparent in the fingers.
—Syndrome of limited joint mobility (cheiroarthropathy or diabetic contractures): The fingers are commonly affected, with stiffness, limited movement and contractures. Flexion contractures of the proximal and distal interphalangeal joints results in the “prayer sign,” an inability to close the gap between opposed palms and fingers. It is associated with advanced disease and diabetic microvascular disease elsewhere.
—Periarthritis: Adhesive capsulitis of the shoulder is commonly seen in patients with type 1 older than 40 years of age. Patients complain of shoulder pain (especially at night) and difficulty raising their arms. Joint examination reveals limited range of motion (especially abduction).
—Dupuytren contractures and trigger fingers are relatively common.
—Neuropathic (Charcot) arthropathy commonly affects the tarsal and metatarsal joints with painless bony hypertrophy. Diagnosis is made by radiography.
—Diabetic neuropathy may cause pain and dysfunction in the extremities and may also lead to symptomatic muscle weakness.
—Diabetic amyotrophy is an asymmetric ischemic myopathy that results in weakness and pain. Diabetic amyotrophy is typically seen in adults over 50 years of age and should be considered with pain, limb girdle muscle atrophy, and fasciculation. Prominent involvement of the iliopsoas, quadriceps, and adductor thigh muscles causes difficulty standing, rising from a seated position, or climbing stairs. The diagnosis may be made by MRI or muscle biopsy.

Uncommon Findings: There are reports of acanthosis nigricans and severe insulin resistance owing to circulating antireceptor antibodies in patients with SLE and scleroderma.

Diagnostic Tests: Muscle biopsy or EMG may be required to confirm tissue involvement. Diagnosis of these manifestations does not depend upon the presence of hyperglycemia or an elevated hemoglobin-A1c.

Keys to Diagnosis: The onset of musculoskeletal symptoms in patients with established type 1 or 2 diabetes mellitus should lead to consideration of one of the above entities.

Differential Diagnosis: Skin changes (pseudosclerodactyly) in diabetics resemble those seen in scleroderma, but abnormalities on nailfold capillaroscopy are absent. Muscle weakness may suggest inflammatory myopathy, but the diabetic form is more likely to be asymmetric. The presence of neuropathic joints and neurologic changes in the extremities may resemble changes seen with syphilis.

Therapy: Some musculoskeletal manifestations may be slowed by improved glycemic control. Physical therapy may be helpful in managing or improving the range of motion in affected shoulders or fingers. Tendinitis is managed symptomatically with NSAIDs and physical therapy, but local application of heat is relatively contraindicated because of safety concerns. Neuropathic joints are treated primarily with rest and local measures to prevent infections.

Prognosis: Some manifestations show improvement or stabilization with improved glycemic control, and radiculopathy or weakness may spontaneously remit. Other problems, notably skin or tendon thickening and neuropathic joint abnormalities, are not likely to improve with glycemic control and may cause permanent dysfunction.

BIBLIOGRAPHY

Crispin JC, Alcocer-Varela J. Rheumatologic manifestations of diabetes mellitus. Am J Med 2003;114:753–757.

Pastan RS, Cohen AS. The rheumatologic manifestations of diabetes mellitus. Med Clin North Am 1978;62:829–839.PMID:308142

Tsokos GC, Gordon P, Antonovych T, et al. Lupus nephritis and other autoimmune features in patients with diabetes mellitus due to autoantibody to insulin receptors. Ann Intern Med 1985;102:176–181.PMID:3966755