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Introduction
Diabetes Mellitus affects almost every system of the body including musculo-skeletal system. Although the first description of neuropathic joint in diabetes was made in 1936, but it is only in the last two decades that more subtle description of articular features of diabetes have been clearly defined. Still at present there is least awareness in general practitioner and patient about the musculo-skeletal involvement in diabetes. Joint diseases in diabetes is mainly due to either excessive collagen deposition or dysfunction of autonomic nervous system.
Joint Manifestation fall into the following four groups
(I) Joint disease characterised by excessive collagen deposition;
(1) Diabetic Hand Syndrome (Cheiropathy)
Many hand abnormalities occur in diabetic patients either in isolated form or in
combination, for e.g. a common triad of diabetic hand include limited joint mobility, tenosynoviosclerosis and carpel tunnel syndrome.2 The term diabetic hand syndrome is a non-specific term and used when diagnosis of specific abnormality is imprecise or misleading. In diabetes hand may be involved in following ways:
(a) Limited Joint Mobility (L J M)
Patient with L J M may exhibit prayer signl,2 that is when the patient is asked to hold the
palms of hands together, the patient is unable to bring both finger and palm together because of flexor tendon contracture. The mobility is predominantly restricted at metacarpophalengial and proximal interphalengial joints. The skin of the hands may be thick, tight and waxy. L J M is more common in patients with type I diabetes mellitus and occurs in long standing diabetes with microvascular disease. Changes of retinopathy is more in patients with L J M.2
(b) Dupuytrens Disease
Dupuytrens Disease is characterised by thickened plainer fascia, a plamer or digital
nodule, skin tethering, followed by digital contracture. In diabetic Dupuytrens Disease middle and ring finger is mainly affected, while in non diabetics little and ring finger is affected.2 Dupuytrens Disease is a marker of microvascular disease, as the increase prevalence of retinopathy in patients with Dupuytrens Disease is seen.
(c) Tenosynoviosclerosis
The development of tendon nodule due to excessive collagen deposition can cause local
pain and trigger finger,5 that is the finger becomes fixed in flexion. There is increased female preponderance.
(d) Carpal Tunnel Syndrome.
The proposed mechanism for Carpal Tunnel Syndrome in diabetes is excessive collagen,
disposition in flexor retinaculum. About 16% of patients with Carpal Tunnel Syndrome have shown to have diabetes.2
(2) Adhesive capsulitis or shoulder (Frozen shoulder)
Frozen shoulder is characterised by painful restriction of all shoulder movements and little
or no evidence of intraarticular disease.4 The thickened joint capsule is closely adhere to the head of the humerus and the arthroscopy reveals marked reduction in volume of glenohumeral joint.1,2 The condition has recurrent relapsing episode with partial or complete recovery. Some patients with severe disease may become disabled.
(3) Lower Limb
An association between shoulder capsulitis and capsulitis of hip in diabetes has been
proposed. Of 61 patients with shoulder capsulitis 23 had hip restrictions and in 18% this was bilateral 2 (yr)
(II) Joint Diseases in Diabetes associated with Autonomous Dysfunction.
(1) Shoulder Hand Syndrome
Considered as exaggerated form of adhesive capsulitis characterised by adhesive
capsulitis with pain, swelling, dystrophic changes, tenderness, and vasomotor instability of hand. Can be classified into 3 stages. Stage 1 shows pain, tenderness, swelling which lasts for 3-6 months. 2nd stage shows trophic skin changes such as shiny skin and loss of normal wrinkling. This stage also lasts for 3-6 months,final stage shows skin atrophy tender contracture and osteoepnia.
(2) Osteolysis of forefoot
Characterised by osteolysis of metatarsal head producing a sharpened pencil or sucked
candy appearance,2 proximal phalange may be involved in association with varying amount of pain and erythema. The condition may resolve spontaneously or may progress to cause fracture or fragmentation of bone.
(3) Migratory Osterolysis of hip and knee.
Although any joint can be affected by typically large weight bearing joint is involved.
Characteristically hip and knee shows local area of osteopenia associated with significant local pain, usually resolves without any sequelae.
(III) Joint changes due to diabetic polyneuropathy.
(1) Charcot Joint (Neuroarthropathy)
It involves in order to decreasing frequency the tarsometatarsal joints,
metatarsophalangeal joint the ankle and the knee joint rarely upper extermities joint may also involve. Clinically the joint is hot and swollen often with less pain than anticipated.
(2) Clow toe or Hammer Toe
Because of Diabetic polyneuropathy the most common motor alteration occurs due to
paralysis of intrinsic muscles of the feet, results in atrophy if interosseus muscles which is demonstrated by fan sign that is inability to separate the toes.l Such alteration causes foot to adopt unusual position resulting in clow toe or hammer toe deformity.
(IV) Other joint disease associated with diabetes
(1) Positive correlation between diabetes and osteoarthritis has been proposed by
controlled study. Prevalence of osteoarthritis is higher in young and middle aged diabetic patients and joint damage started at earlier age and more sever than controls.
(2) Rheumatoid Arthritis
About 13% of rheumatoid arthritis patients have first or second degree relative with IDDM.2
(3) Gout and Hyperuricemia.
Gout may be a rare complication of diabetic ketoacidosis, as the ketone bodies inhibit
renal tubular secretion of Uric acid, dehydration and increased catabolism also play a role. Except diabetic ketoacidosis there is no increase risk of gout in diabetic patients.1,2
(4) Calcium Pyrophosphate deposition arthropathy.
Earlier description of Calcium Pyrophosphate deposition arthropathy reported association
with diabetes. But it has not been confirmed in large controlled study.
Bone changes in diabetes
In IDDM patients, diabetic osteoepnia occurs. In adults bone mass is related to
endogenous insulin level, in IDDM children the forearm corticle bone density reveal an 8% reduction and trabicular bone density shows 14% reduction when compared with age and sex matched control. By contrast NIDDM patient seems to develop hyperosteosis. Hyperosteosis may involve Spine, Knee, Hip, Wrist, Calcification of pelvic ligament, Ostitis condensens ilii and hyperosteosis frontalis interna.
The most common form of hyperosteosis disseminated ideopathy skeletal hyperosteosis
(DISH) or ankylosing hyperosteosis of spine also known as forestiers disease.1,2 The condition is often asymptomatic or may cause mild back pain and stiff pain, but range of motion is preserved. The spinal involvement in decreasing order of frequency is thoracic spine, cervical spine and lumbar spine.
In DISH wide spread osseous changes may also be detected around the acetabulum
knees and wrist.
Effect of diabetes on growth of child
Before discovery of insulin growth failure was common in IDDM children. An extreme example is Mausiac Syndrome which is characterised by delayed puberty, obesity and hepatomegaly, now successfully treated with appropriate insulin administration.. Now a days growth failure is uncommon in IDDM children except those with chronic under insulinisation. A significant increase in insulin dose (1.0+-0.2 unit /kg/day to 1.3 +- 0.2 unit /kg/day) is associated with increase in growth velocity and high rate of insulin administration during adolescence can be associated with supra-normal growth rate.
The effect of diabetes on sexual development is not well studied. Recent study shows that
as many as 33% of boys and 20% of girls have delayed skeletal maturation, suggested delayed sexual development.
Conclusion
It has been clear that large number of musculoskeletal syndrome are associated with
diabetes mellitus. These disorders not only increases the disability of patients but some of the musculoskeletal syndrome has definite correlation with other diabetic complication. For e.g. relationship between L J M and retionopathy has been well established. Finally diabetes must be considered in differential diagnosis of musculoskeletal syndrome when other sign and symptoms suggestive of diabetes is present.
REFERENCES
(1) Susan R Kropp, Lee S. Simon. Joint and Bone Manifestation of Diabetes Mellitus,
Joslin's Diabetes. 1996, 912-921.
(2) Adrian J. Crisp, Connective tissue and Joint disease in Diabetes Mellitus; Text book
of Diabetes, 762-770.
(3) William L. Clarke, Mary Lee Vance - Growth and The Child with Diabetes Mellitus,
Diabetes care, Vol-16. Dec-1993; 101-104.
(4) M. Barry, J.R. Jenner, ABC of Rheumatology. BMJ March 1995; Vol.11 : 64- 68.
(5) Michael Shipley, ABC of Rheumatology - April 1995, Vol.11. 175-179.
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