Musculoskeletal complications of diabetes: A top-to-toe discussion

Physical activity is one of the cornerstones of management of diabetes. However, there can be musculoskeletal complications of diabetes that limit our patients’ ability to remain physically active.

Why do these musculoskeletal complications occur? Usually, they are due to a combination of factors. With high circulating blood glucose levels, glycosylation of collagen and soft tissues makes them stiffer.

In addition, diabetic small vessel disease and complications of diabetic sensory neuropathy (mainly neuropathic joints) may be contributory. All of the lower-limb complications can be exacerbated by obesity, which is a significant factor, especially in type 2 diabetes.

How common are these manifestations in clinical practice? The table outlines their prevalence.

Moving down the body, the following conditions are relevant.

A useful screen is to get your patient to externally rotate each shoulder simultaneously when their arms are adducted to their side

This is the most disabling of these diabetes-related conditions. Every patient with frozen shoulder should have a blood test to check their HbA1c level, if it has not been checked in the past year or two.

Adhesive capsulitis presents with progressive joint stiffness. A useful screen is to get your patient to externally rotate each shoulder simultaneously when their arms are adducted to their side. If there is reduction of external rotation on the painful side of 10° or more compared with the contralateral side, this provides a useful diagnostic clue but also eliminates the confounding effect of rotator cuff impingement that occurs with abduction or flexion of the shoulder.

The definitive treatment of frozen shoulder is an intra-articular injection of cortisone with local anaesthetic, with or without hydrodilatation. If the injection is performed with ultrasound guidance, this provides reassurance of intra-articular placement of the injection.

The injection should provide reasonable improvement of pain after a few weeks. However, restoration of the range of motion, particularly internal rotation (ie, the ability to perform behind-back activity), may take many months. Post-injection physiotherapy should concentrate on optimising function in the pain-free range. If end-range movement is pushed too hard, this can stir up the pain.

Very occasionally, a second injection will be needed a few months after the first. Rarely, surgical manipulation under anaesthesia can be tried, but this may aggravate the pain in some circumstances.

The prevalence of the following hand conditions increases with the duration of diabetes:

Dupuytren contracture typically affects the ring and middle fingers in patients with diabetes, in contrast to people without diabetes, where the little finger is the most commonly affected digit. Optimisation of glycaemic control and hand therapy are the mainstays of management. If hand function is significantly affected, then surgical intervention may be required.

Diabetic cheiroarthropathy (stiff hand syndrome) is characterised by progressive flexion contractors of all fingers relatively symmetrically. The prayer sign (see photo) may confirm the presence of this condition. Unfortunately, aside from optimising glycaemic control, no other treatment has been found to be reliably helpful. Additional treatable pathology, such as Dupuytren contracture, may coexist.

Flexor tenosynovitis (trigger finger) is usually treated with cortisone injections to the affected flexor tendon sheaths. If triggering persists despite a couple of injections, then surgical intervention may be required.

Carpal tunnel syndrome is also more common in people with diabetes than those who do not have the condition. It is important to intervene before development of thenar muscle atrophy. Management is along standard lines, with night splints and optimisation of ergonomics for those people performing repetitive activities at work. If these measures are not sufficient, then a cortisone injection may be required. In severe cases of carpal tunnel syndrome, surgical release of the transverse carpal ligament may be necessary.

DISH is characterised by metaplastic calcifications of spinal ligaments. This results in progressive loss of movement, especially in the thoracic spine. Physiotherapy to maintain spinal movement and use of simple analgesics or NSAIDs are the mainstays of management. Although the condition is progressive, most patients learn to live their life around it to a reasonable degree.

Charcot joints are most commonly seen in the feet and represent a severe, destructive arthropathy due to sensory neuropathy in the foot. Loss of sensation leads to inadvertent repetitive microtrauma of the joints, resulting in degenerative changes – hence the need to check sensation in the feet at the annual diabetes check-up.

Patients usually prefer soft sporting footwear and should avoid going barefoot. Collaboration with our podiatry colleagues is particularly useful for this condition.

This is a summary of the commonly seen conditions. For more complete information, I recommend the following articles, which provide more detailed information:^1,2 tinyurl.com/MuscDiab1 and tinyurl.com/MuscDiab2.

Chris Milne is a sports physician in Hamilton