Shouldn’t it be enough that diabetes can affect the heart, kidneys, eyes, and nerves? Yes, it totally should be, yet when you have high blood sugars circulating throughout your body to tissues, organs, muscles, joints, tendons, and ligaments, you can also develop musculoskeletal problems. We discussed some common musculoskeletal conditions of the hand (stiff hand, trigger finger, carpal tunnel, and Dupuytren’s contracture) in a previous article, and now we’re going to focus on a few other musculoskeletal conditions that can be common in people with diabetes.
Adhesive capsulitis (frozen shoulder) is a condition where the capsule or envelope that surrounds the shoulder joint becomes thickened and stiffens, tightening around the ball (called the head of the humerus) and socket structure of the shoulder joint. This results in restricted range of motion of the shoulder joint. Affected people notice stiffness, decreased movement, and sometimes pain in the shoulder. The cause of this stiffening and contraction of the shoulder joint capsule is not well understood. It has been reported in roughly 20% to 25% of people with diabetes, and is five times more common in people with diabetes than those without diabetes. It is generally reversible and responds well to appropriate treatment.
How to Treat It
Treatment typically involves gentle stretching and range-of-motion exercises, often through physical therapy. Watch Dr. Edelman’s trip to the physical therapist for treatment of his frozen shoulder. Pain-relieving medications and/or steroid injections into the joint may also be used. Another treatment modality sometimes used is shoulder manipulation under anesthesia (MUA) by an orthopedic surgeon. It is a non-invasive procedure where general anesthesia is given, then the surgeon moves the shoulder through its range of motion. Occasionally, arthroscopic capsular release is required.
Reflex Sympathetic Dystrophy (Shoulder-Hand Syndrome)
Reflex sympathetic dystrophy (RSD) is now known as Complex Regional Pain Syndrome (CRPS) but the common name remains “shoulder-hand syndrome.” Typical symptoms include severe pain or a burning sensation in the affected arm from the shoulder down to the hand. There may be associated swelling, skin changes such as shiny skin or discoloration, changes in hair growth, and temperature changes (hot or cold) of the affected area. Increased sensitivity to temperature and touch may also be seen. Trauma may precipitate CRPS, but sometimes, a specific cause cannot be identified. While the arm/hand is the most frequently involved area, other areas can be affected as well.
How to Treat It
Anti-inflammatory medications, other pain relievers, and oral steroids have been used in conjunction with physical therapy for this condition with variable benefit. Sympathetic nerve blocks (blockade of some of the nerves of the sympathetic nervous system that supply the affected area) with an injection of numbing medication, usually performed by an anesthesiologist, may also be helpful.
Musculoskeletal Conditions of the Feet
People with diabetes must be meticulous about foot care. Injuries to the feet often go unnoticed due to decreased sensation in the feet, which is caused by underlying peripheral neuropathy. For this reason, inspecting your feet on a regular basis is critical to prevent infections that may develop without any symptoms.
Diabetic osteoarthropathy (also known as Charcot’s joint or neuropathic arthropathy) is a severe, destructive form of arthritis associated with loss of sensation in a joint due to underlying diabetic peripheral neuropathy. The foot is most commonly affected. Although the exact cause is uncertain, it is suggested that day-to-day microtrauma to the joint, which initially goes unnoticed (due to the decreased sensation), results in injury to the small bones of the foot and the eventual development of significant damage to the bones and joint in the area. Usually there is no history of obvious trauma or injury, such as falling off a curb. There may be skin changes overlying the affected area, including redness, swelling, bruising, and ulcers. This condition is quite rare, affecting approximately one in 700 people with type 1 or type 2 diabetes. The diagnosis is confirmed with x-rays and/or MRI.
How to Treat It
Treatment includes immobilization and avoidance of weight-bearing (“offloading”) on the affected area, appropriate shoes, and possibly bisphosphonate therapy. Surgery is usually avoided in most cases.
Diabetic Muscle Infarction
Diabetic muscle infarction (loss of adequate blood supply to an area of muscle, with resultant damage or death of tissue) is a rare condition. Typical symptoms include the abrupt onset of pain and swelling of the affected muscle area. The thigh is the most commonly affected site although muscle infarction can occur in other areas such as the calf. The cause of diabetic muscle infarction is not well understood at this time. It occurs spontaneously, without a history of trauma, and tends to affect people with a long history of poorly controlled diabetes. This condition is seen more commonly in people using insulin who also have other microvascular complications, such as neuropathy, nephropathy (kidney disease), or retinopathy (eye disease). Investigations such as MRI are done to exclude other conditions, such as tumors, muscle infection or abscess, blood clots, localized muscle inflammation, or infection of the underlying bone. A muscle biopsy may be needed to confirm the diagnosis.
How to Treat It
Treatment consists of rest and pain relief, as well as antiplatelet and/or anti-inflammatory medications. Routine daily activities may be painful but are not thought to be harmful. Physical therapy may cause worsening of spontaneous diabetic muscle infarction. The condition tends to slowly resolve over weeks to months in most cases.
Arthritis is inflammation and damage to a joint (where two bones meet) and osteoarthritis (OA) is the most common form. OA is generally related to “wear and tear” on the joint. Most common symptoms include joint pain which is aggravated by activity and tends to settle with rest. Most frequent joints to be involved are hips, knees, and base of the big toe for the leg and base of the thumb and end joints in the fingers in the hand. While nearly everyone is at risk of getting OA during their lifetime, patients with diabetes, particularly those with type 2 diabetes, may be at higher risk.
How to Treat It
Treatment includes weight control, appropriate exercise (that is a whole topic in itself), and use of pain medication if needed (acetaminophen or anti-inflammatory medications such as ibuprofen – depending on your overall health). Occasionally, medication injections into the joint can be of benefit and when all of this seems insufficient, there are excellent surgical options for many of our joints (especially hips and knees).
Osteoporosis is the loss of bone strength and structure which leads to an increase in the risk of bone fractures (broken bones), including those that occur with really no obvious injury or trauma. Tripping and putting your arms out as you fall should not result in a broken wrist normally but can, if the bone strength is low. While osteoporosis is often noted in women past the age of menopause, it is seen more frequently in patients with diabetes. People with both type 1 and type 2 diabetes should talk to their health care provider (HCP) to see if they are at risk of low bone density.
How to Reduce Risk
The risk of osteoporosis can be minimized by maintaining an active lifestyle, getting the right amount of calcium in your diet, and following guidelines regarding vitamin D intake. There are medications that can be added in some cases.
It’s important to be aware of how diabetes can affect the musculoskeletal system so you can be proactive in terms of trying to prevent issues, and be aware of symptoms if they do develop. If you’re already experiencing symptoms, you should discuss them with your healthcare provider because there are a number of ways to minimize risk to the joints and maximize your ability to still do what you would like to do. There’s also strong evidence to show that good blood sugar control and exercise are very helpful in minimizing some of these issues, and both are just so important for an overall healthy life.
Additional resources on this topic:
Oh My Aching Joints: Musculoskeletal Issues
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