Musculoskeletal Complications
The effects of hyperglycemia are widespread in the human body. It is not surprising that our musculoskeletal system can be affected. Unfortunately, less research has been conducted on these types of complications and clinicians do not often discuss this with patients until an issue arises. Musculoskeletal complications are associated with other complications (e.g. neuropathy) and with longer duration of diabetes, age and high blood glucose levels over time. Intensively managing blood glucose, managing cholesterol and blood pressure, eating a healthy diet, getting regular physical activity, drinking alcohol in moderation, stopping smoking and managing stress are key to prevent and/or delay diabetes complications from developing.
Diabetes Cheiroarthropathy
Diabetes cheiroarthropathy, also known as stiff hand syndrome or diabetic hand syndrome, is associated with age, duration of diabetes and microvascular complications, especially retinopathy. It is the thickening and tightening of the skin on the fingers and back of the hands so they appear thick and waxy. This can cause the fingers and joints to become stiff, limiting movement. The condition isn’t painful but it can reduce grip strength and restrict movement.1,2,3
Facts
- It is seen in up to 50 percent of people with diabetes.
- This seems to occur equally in type 1 and 2 diabetes, but symptoms seem to be more severe in type 1.
Diagnosis is made by a doctor. A quick test is conducted asking the patient to put their hands together as if they were praying (called the “prayer” sign). If the person is unable to flatten their hands together, it is a sign of cheiroarthropathy. Treatment involves intensely managing blood glucose to keep it as close to the target range as possible, sometimes steroids and physical therapy are also recommended depending on the patient.1,2,3
Dupuytren’s Contracture
Dupuytren’s contracture occurs when there is an overproduction of collagen creating nodules and cords in the palm of the hand and fingers. Over time it can lead to the shortening of muscle tissues which forces the joint into a flexed position and limits its movement (i.e., the person cannot fully straighten their hand and their pinky and/or ring finger are bent). It is significantly more common in people with diabetes, longer duration of diabetes and those who are older.10,11
Symptoms include limited movement of the hand/fingers and sometimes pain. Often treatment is not recommended if there is no pain or interference with the use of the hand. If there is pain, a steroid injection may help by reducing inflammation. Surgery may be recommended if the person is unable to grasp objects.10,11
Trigger Finger
Trigger finger, also known as stenosing tenosynovitis, is more common in people with diabetes who also have more severe symptoms than people without diabetes. About 5-10 percent of people with diabetes develop trigger finger. The finger gets stuck or locked in a bent position and sometimes catches and then pops open (which is painful). This condition causes pain and tenderness in the tendon and sometimes there is a nodule at the site of the tendon. If the finger is accidentally straightened it is very painful.12,13
Diagnosis is made through health history and physical exam. Treatment includes steroid injections. Often surgery is needed to release the constricted tendon sheath to free it so the finger is able to move normally.12,13
Carpal Tunnel
Carpal tunnel is known as an entrapment or compression syndrome, because of the pressure on the nerve. It begins slowly and progressively gets worse, due to the excessive pressure on the nerve, limiting hand function. This is more common in people with diabetes than without.14,15
Symptoms include pain, numbness, tingling and weakness in the hands, wrist, and fingers. Diagnosis includes health history, exam and often electrophysiological tests. It usually needs treatment to reduce and/or resolve symptoms since they do not resolve by themselves. Treatment can include wearing a splint and assistive devices, medications and often surgery to release the pressure on the nerve.14,15
Frozen Shoulder
Frozen shoulder, also known as adhesive capsulitis, occurs when the area around the shoulder joint tightens and thickens. This leads to severe pain, stiffness and limited range of motion. There is intense pain and stiffness with upward or behind-the-back motion. This usually only affects one shoulder. Studies suggest that this condition is up to five times more common in people with diabetes than without.5,6,7
Diagnosis includes health history, physical exam and often imaging. Treatment includes physical therapy, anti-inflammatory drugs and steroid injections. Frozen shoulder often resolves after a period of time but some people never gain full function of their shoulder. This condition in some cases may need surgery.5,6,7
Charcot Joint
Charcot joint, also called neuropathic arthropathy or Charcot neuro-osteoarthropathy, most commonly affects the foot (Charcot foot) but the knee and wrist could be affected. In a person who has neuropathy, bone tissue begins to be destroyed in the area of nerve damage which can lead to irreversible foot deformity. Often there is some injury or trauma to the area when symptoms occur.3,4
Early diagnosis is key to stopping or slowing the progression. Unfortunately, there are few early symptoms because of the underlying neuropathy (numbness, tingling and loss of sensation). Usually, people have a red, hot and swollen foot but not much pain when they go to the doctor. Healthy history, blood tests and imaging of the foot will be ordered to diagnose. Weight-bearing (i.e., standing) radiographs of the ankle and foot (special imaging) may be conducted to assess the bone and joint damage.3,4
Treatment includes offloading (not weight bearing on foot) and casting so the joint cannot move until the swelling goes down or fractures heal. People are closely monitored and assessed for the inflammation and swelling to reduce. Afterward, a brace and/or special footwear is prescribed. Surgery is conducted only if absolutely necessary due to the risks and complications involved in that area (e.g., the foot has neuropathy). Unfortunately, Charcot foot affects the quality of life because mobility and daily activities need to be altered.3,4
Diffuse Idiopathic Skeletal Hyperostosis (DISH)
Diffuse idiopathic skeletal hyperostosis (DISH), also known as Forestier’s disease, occurs when there is a bony hardening of ligaments in the places where they attach to the spine in the upper and mid-back. This less commonly affects the neck and lower back, shoulders, elbow, knees and heels. DISH occurs most commonly in men over 50 years old and is more common in people with type 2 diabetes than those without. The reason for this is not well understood.8,9
DISH often does not have symptoms. Depending on the extent of the disease, people may develop pain and stiffness (especially in the morning) in their upper back. Also, people experience loss of range of motion, difficulty swallowing or hoarse voice and increased risk of spinal fractures. To diagnosis this, the doctor will conduct a health history, do a physical exam and order imaging tests. Early diagnosis is the key to prevent progression to more serious complications.8,9
There is no cure for DISH so managing symptoms is the focus of treatment. It is also recommended to keep blood glucose as close to the target range as possible, lose weight, eat healthily and get regular physical activity to stop and/or delay the progression of the condition as it is associated with diabetes. Physical therapy is recommended to help with range of motion and reduce stiffness. In more severe cases, surgery may be required to remove bone spurs or relieve pressure.8,9
Diabetic Muscle Infarction
Diabetic muscle infarction (DMI), also know as diabetic myonecrosis, is a rare complication of diabetes. This is seen in people with long-term hyperglycemia as well as people who have other complications including nephropathy, retinopathy and/or neuropathy. It usually occurs in the legs.16
Since it is a very rare condition, little research exists and the cause of it is not understood. Symptoms include sudden pain and swelling of the muscle. Diagnosis is made with a health history, lab work and tests to rule out other causes, as well as MRI. Treatment includes keeping blood glucose levels as close to the target range as possible, bed rest and non-steroidal anti-inflammatory medications.16
Osteoporosis
Osteoporosis is a condition that causes the bones to become weak and brittle. In the early stages, there usually are no symptoms. But, as the disease progresses, people lose height, have issues with their posture and fractured bones.17
Osteoporosis has been identified as a complication of both type 1 and type 2 diabetes. It is associated with blood glucose management and a longer duration of disease. People with type 1 diabetes have a risk of breaking a hip 10-15 years earlier than people without diabetes.17
Diagnosis includes a health history and bone densitometry scan to measure the density of the bone. Treatment includes intensive glucose management, weight loss if overweight or obese, eating a healthy diet rich in vitamin D and calcium, regular weight-bearing physical activity (e.g., walking) and stopping smoking. In addition, medication may be used to prevent the progression of bone loss or promote increase bone mass.17
Arthritis
Type 2 diabetes, is a risk factor for developing osteoarthritis (OA). It is a joint disease caused by the breakdown of joint cartilage that can affect any joint in the body. Obesity puts more pressure on joints and is also thought to have a role in the development of osteoarthritis.18,19
People with type 1 and type 2 diabetes have a higher risk of developing rheumatoid arthritis (RA). This autoimmune disease is a chronic inflammatory condition that affects the joints and can also affect other body systems.20
Diagnosis includes health history, physical exam, blood tests and imaging tests. Symptoms can include pain, swelling, stiffness and loss of movement in the joint. Treatment includes intensive glucose management, resting the affected joint, physical therapy, weight loss if overweight or obese, eating a healthy diet, stopping smoking and regular physical activity. Medications may be used to manage pain but surgery may be required depending on the damage to the joint (e.g., knee or hip replacement).
Psychosocial Aspects of Musculoskeletal Complications of Diabetes
Many of the musculoskeletal complications of diabetes can impact a person’s mobility and/or functioning, so it isn’t surprising that it can also affect a person’s quality of life. Little research has been done about the physical and biological aspects of these types of complications and even less on the psychosocial implications. However, from research conducted on neuropathies, being in pain and other diseases limiting mobility quality of life is greatly decreased. People are also more at risk for depression, anxiety and diabetes distress.22
If you have been diagnosed with a musculoskeletal complication, it may be painful, limit your mobility or functioning, and affect your daily living. You may want to get some extra support to help you cope since dealing with a new health condition can be overwhelming and modifying your daily life can be even more difficult. Many people often need extra support in adjusting to their new normal. Talk to your diabetes health care provider about how you are feeling and your worries. They can recommend some practical tips for adjusting to your new norm and also refer you to a mental health provider that has experience in helping patients deal with diabetes complications. Taking care of yourself both medically and psychologically can help improve your overall quality of life as well as your physical and mental health.
1. Mary E. Larkin, Annette Barnie, Barbara H. Braffett, Patricia A. Cleary, Lisa Diminick, Judy Harth, Patricia Gatcomb, Ellen Golden, Janie Lipps, Gayle Lorenzi, Carol Mahony, David M. Nathan, the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. Musculoskeletal Complications in Type 1 Diabetes. Diabetes Care Jul 2014, 37 (7) 1863-1869; DOI: 10.2337/dc13-2361
2. Varghese G.I., Mathew M., Marmur E., Varghese M.C. (2017) Dermatological Complications of Diabetes Mellitus; Allergy to Insulin and Oral Agents. In: Poretsky L. (eds) Principles of Diabetes Mellitus. Springer, Cham. https://doi.org/10.1007/978-3-319-20797-1_29-2
3. Petrova, N., and Edmonds, M. (2016) Acute Charcot neuro‐osteoarthropathy. Diabetes Metab Res Rev, 32: 281– 286. doi: 10.1002/dmrr.2734.
4. Raspovic KM, Wukich DK. Self‐reported quality of life in patients with diabetes: a comparison of patients with and without Charcot neuroarthropathy. Foot Ankle Int 35: 195– 200.
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7. Zreik NH, Malik RA, Charalambous CP. Adhesive capsulitis of the shoulder and diabetes: a meta-analysis of prevalence. Muscles Ligaments Tendons J. 2016;6(1):26–34.
8. Mader R, Verlaan JJ, Buskila D. Diffuse idiopathic skeletal hyperostosis: clinical features and pathogenic mechanisms. Nat Rev Rheumatol. 2013 Dec;9(12):741-50. doi: 10.1038/nrrheum.2013.165. Epub 2013 Nov 5. PMID: 24189840.
9. Pillai S and Littlejohn G. Metabolic Factors in Diffuse Idiopathic Skeletal Hyperostosis – A Review of Clinical Data. The Open Rheumatology Journal. 2014; 8:116-128. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4293739/.
10. Chammas M, Bousquet P, Renard E, Poirier JL, Jaffiol C, Allieu Y. Dupuytren’s disease, carpal tunnel syndrome, trigger finger, and diabetes mellitus. J Hand Surg Am. 1995 Jan;20(1):109-14. doi: 10.1016/S0363-5023(05)80068-1. PMID: 7722249.
11. Majjad, A et al. “Musculoskeletal Disorders in Patients with Diabetes Mellitus: A Cross-Sectional Study.” International journal of rheumatology vol. 2018 3839872. 19 Jun. 2018, doi:10.1155/2018/3839872
12. Kuczmarski AS, Harris AP, Gil JA, Weiss AC. Management of Diabetic Trigger Finger. J Hand Surg Am. 2019 Feb;44(2):150-153. doi: 10.1016/j.jhsa.2018.03.045. Epub 2018 May 16. PMID: 29778347.
13. Merry, Stephen P et al. “Trigger Finger? Just Shoot!.” Journal of primary care & community health vol. 11 (2020): 2150132720943345. doi:10.1177/2150132720943345.
14. Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome. Ann Plast Surg. 2002;48(3):269–273.
15. Vinik A, Mehrabyan A, Colen L, Boulton, A. Focal Entrapment Neuropathies in Diabetes. Diabetes Care Jul 2004, 27 (7) 178-1788; DOI: 10.2337/diacare.27.7.1783.
16. Horton, William B et al. “Diabetic muscle infarction: a systematic review.” BMJ open diabetes research & care vol. 3,1 e000082. 24 Apr. 2015, doi:10.1136/bmjdrc-2015-000082
17. Ferrari, S L et al. “Diagnosis and management of bone fragility in diabetes: an emerging challenge.” Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA vol. 29,12 (2018): 2585-2596. doi:10.1007/s00198-018-4650-2
18. Courties A, Sellam J. Osteoarthritis and type 2 diabetes mellitus: What are the links? Diabetes Res Clin Pract. 2016 Dec;122:198-206. doi: 10.1016/j.diabres.2016.10.021. Epub 2016 Nov 5. PMID: 27889689.
19. Veronese N, Cooper C, Reginster JY, Hochberg M, Branco J, Bruyère O, Chapurlat R, Al-Daghri N, Dennison E, Herrero-Beaumont G, Kaux JF, Maheu E, Rizzoli R, Roth R, Rovati LC, Uebelhart D, Vlaskovska M, Scheen A. Type 2 diabetes mellitus and osteoarthritis. Semin Arthritis Rheum. 2019 Aug;49(1):9-19. doi: 10.1016/j.semarthrit.2019.01.005. Epub 2019 Jan 11. PMID: 30712918; PMCID: PMC6642878.
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21. Raspovic KM, Wukich DK. Self-reported quality of life in patients with diabetes: a comparison of patients with and with-out Charcot neuroarthropathy. Foot Ankle Int 35:195–20
22. Young-Hyman D, de Groot M, Hill-Briggs F, Gonzalez JS, Hood K, Peyrot M. Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care. 2016 Dec;39(12):2126-2140. doi: 10.2337/dc16-2053.
Educational content related to diabetes complications is made possible with support from Allergan, an active partner of Beyond Type 1 at the time of publication. Editorial control rests solely on Beyond Type 1.
