|Year : 2014 | Volume
| Issue : 1 | Page : 12-14
Rheumatological manifestations of type 2 diabetes and its relationship to glycemic control and duration of diabetes
Sumesh Raj1, GV Rajan2, Rajesh Vijayan3, Reshma Sugathan4
1 Department of Internal Medicine, Sree Gokulam Medical College, Trivandrum, Kerala, India
2 Department of Internal Medicine, Cosmopolitan Hospital, Trivandrum, Kerala, India
3 Department of Orthopaedics Sree Gokulam Medical College, Trivandrum, Kerala, India
4 Department of Anaesthesia Medical College, Kottayam, Kerala, India
|Date of Web Publication||20-Mar-2014|
Medical and Diabetic Centre, Remya, PRRA-136, Pazhaya Road, Medical College PO, Trivandrum - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
Background: While so much emphasis is given to micro and macro vascular complications of diabetes, other long-term complications especially musculoskeletal are often overlooked and underappreciated. This study investigates the prevalence of joint complications among patients with type 2 diabetes mellitus and to examine their relationship with duration of diabetes and glycemic control. Materials and Methods: The presence of various rheumatological complications were assessed in 763 type 2 diabetes patients and their age and sex-matched non-diabetic controls. The relationship between these complications and duration of diabetes and long-term glycemic control was determined. Results: Frozen shoulder (15.6%), LJM syndrome (30.1%), carpal tunnel syndrome (10.2%), trigger finger (9%), DISH (26%) and dupuytren's contracture (12%) were significantly more prevalent in the diabetic than the control group. Prevalence of OA did not show any significant difference between the two groups. The risk of rheumatological complications increased with deteriorating glycemic control. Conclusion: Periarthritis, diabetic cheiroarthropathy, dupuytren's contracture, carpal tunnel syndrome, trigger finger and DISH are the most prevalent rheumatological complications n the study diabetic population.
Keywords: Prevalence, rheumatological complications, type 2 diabetes
|How to cite this article:|
Raj S, Rajan G V, Vijayan R, Sugathan R. Rheumatological manifestations of type 2 diabetes and its relationship to glycemic control and duration of diabetes. Sahel Med J 2014;17:12-4
|How to cite this URL:|
Raj S, Rajan G V, Vijayan R, Sugathan R. Rheumatological manifestations of type 2 diabetes and its relationship to glycemic control and duration of diabetes. Sahel Med J [serial online] 2014 [cited 2022 Jun 27];17:12-4. Available from: https://www.smjonline.org/text.asp?2014/17/1/12/129146
| Introduction|| |
Although the precise etiology of diabetes-associated musculoskeletal disorders remains uncertain, there is evidence that hyperglycemia may accelerate non-enzymatic glycosylation and abnormal collagen deposition in periarticular connective tissues, which alters the structural matrix and mechanical properties of these tissues leading to diffuse arthrofibrosis. , While so much emphasis is given toward micro and macro vascular complications of diabetes, other long-term complications are often overlooked and underappreciated. These include the musculoskeletal manifestations of diabetes like limited joint mobility (LJM) syndrome (diabetic cheiroarthropathy), frozen shoulder, carpal tunnel syndrome and other rare complications.  When compared with the general population, patients with type 2 diabetes mellitus are 5 times more likely to have frozen shoulder and they have an increased risk for bilateral carpel tunnel syndrome.  LJM has even been linked to a greater risk for microvascular complications.  In addition, these musculoskeletal complications can contribute to less physical activity and worsening of the disease state, especially glycaemic control.
| Materials and Methods|| |
We carried out a multicenter cross-sectional observational study involving 763 diabetic patients treated in medicine and orthopedic departments of Sree Gokulam Medical College, Trivandrum, India and Medical and Diabetes Center, Trivandrum, India for a period of 15 months from 2012 January to 2013 March. Age and sex matched normal healthy controls, who where non-diabetic as per the American Diabetic Association diagnostic criteria for diabetes, were selected. Written consent was obtained from all subjects. Patients with documented diabetic nephropathy and those primarily diagnosed as having rheumatoid arthritis, systemic lupus erythromatosis and other connective tissue disorders as well as those end stage renal disease were excluded. Data collected included age, sex, body mass index and duration of diabetes. Routine investigations including complete blood count, urine analysis, fasting and post-prandial plasma glucose, serum uric acid and urea, creatinine, calcium and lipid profile were done. Long-term glycemic control was assessed by hemoglobin A1c (HbA1c) levels. Only those patients with normal renal parameters, uric acid and calcium were considered for inclusion in the study. Skiagrams of the involved joints were done. A serum uric acid level up to 7.0 mg/dl in adult men and post-menopausal.
Assessment of joint complications
A detailed physical examination of the patients was carried out. Cheiroarthropathy was evaluated by the "prayer sign", in which the patient was asked to touch the palmar surfaces of the interphalangeal joints together with the fingers fanned and the wrist maximally extended. If they were unable to do so, the test was considered to be positive.
The diagnosis of periarthritis (Frozen shoulder) was madein patients with pain in the shoulder for at least 1 month, an inability to lie on the affected shoulder, and restricted active and passive shoulder joint movements in at least three planes. , Diagnosis of dupuytren's contracture was based on one or more of the following features: palmar or digital nodule; tethering of palmar or digital skin; a pretendinous band and a digital flexion contracture. Trigger finger was diagnosed by palpating a nodule or thickened flexor tendon with locking phenomenon during extension or flexion of any finger  diffuse idiopathic skeletal hyperostosis (DISH) Required radiographic finding of new bone formation adjacent to the vertebral body, but separated by a clearly definable space.
| Results|| |
Joint manifestations were present in 331 (43.3%) diabetic patients compared to 54 (7.1%) controls. Overall 244 (31%) diabetic patients had more than one type of rheumatological manifestations. LJM syndrome was seen in 228 (30.1%) diabetic patients compared to 45 (6%) controls, (P < 0.01). Of these 228 patients, 177 (78%) had diabetes for more than 5 years with poor glycemic control (HbA1c > 10%). Dupuytren's contracture was seen in 91 (12%) diabetics compared with only 31 (4%) non-diabetics, (P < 0.001) 7 (21.3%) of whom had impaired glucose tolerance DISH was seen in 198 (26%) diabetics compared to only 19 (2.6%) non-diabetics, (P < 0.001). All diabetics with DISH were above the age of 50 years. 142 (72%) of these 198 diabetics were overweight (body mass index >25 kg/m 2 ). Compared to the controls, patients with diabetes had significantly higher prevalence of Frozen shoulder [119 (15.6%) versus 45 (6%)] (P < 0.001); osteoarthritis (OA) of knee, hip and spine [221 (29%) versus 198 (26%)] (P < 0.08); neuroarthropathy of knees and foot [22 (3%) versus 4 (0.5%)] (P < 0.01); carpal tunnel syndrome [77 (10.2%) versus 22 (3%)] (P < 0.01) and trigger finger [68 (9%) versus 9 (1.2%)] (P < 0.05). Diabetics with Hba1c levels more than 9 had a statistically significant higher prevalence of of rheumatological complications compared to controls (P < 0.05) . There was a statistically significant increase in joint complications when duration of diabetes was more than 5 years (P < 0.01).
Musculoskeletal complications did not show a significant increase in patients with elevated fasting plasma glucose when the duration of disease was <5 years and HbA1c <9%. Gender did not significantly influence the occurrence of musculoskeletal complications.
| Discussion|| |
The present study showed a high prevalence of rheumatological complications in the diabetic population. The association of diabetes and periarthritis is well-documented.  Bridgmen reported incidence of 11% among diabetics.  This is lower than the prevalence of 15.6% in our current study. Syndrome of LJM variously known as diabetic cheiroarthropathy, stiff hand syndrome or diabetic hand syndrome was first described by Jung et al. in adult diabetics  and Grgic et al. in Type 1 diabetes Rosenbloom et al.  who gave LJM syndrome this name recognized its association with type 1 diabetes. LJM is a condition of stiffness principally involving the hands but may occasionally extends to the proximal upper extremities and spine. ,, Most of the studies have suggested a prevalence of about 32% in diabetic population, which is comparable to an overall prevalence of 30.1% observed in the current report. We also observed a positive correlation between rheumatological complications and disease duration and glycemic control. The features of dupuytren's disease consist of palmar and digital nodules and cords, palmar skin tethering and digital contractures.  It has been observed that in the setting of diabetes mellitus, the ring and middle digits are predominantly involved, as opposed to non-diabetics, where the small and ring digits are more commonly involved. , The incidence of dupuytren's disease have been reported to be about 27% among diabetics in various studies. , This is higher than a value of 12% observed in the current report.
We also observed a statistically significant higher prevalence of carpal tunnel syndrome, trigger finger and neuropathic joints in diabetic population when compared to controls. A positive correlation has been reported between OA and diabetes. Crisp and Heathcoate, for example reported a higher incidence in young and middle aged diabetics.  Though we observed the presence of OA of knee, hip and spine in 29% of diabetics, this was not statistically significant when compared to controls in our study. Holt reported 25% prevalence of DISH, especially of the spine, and pelvic ligaments among patients with type 2 DM with prevalence of 25%.  In our study, DISH was seen in 26% of diabetics. Most of our DISH patients were overweight and aged above 50 years. We observed a positive correlation between the duration of diabetes with the prevalence of joint complications, irrespective of the type of joint disorder. We also observed an increased prevalence of rheumatological complications in patients with elevated HbA1c levels, denoting a positive correlation with poor long-term glycemic control.
| Conclusion|| |
We observed higher prevalence of rheumatological diseases among diabetes compared with controls. The diseases were also proportionately higher among patients with poor glycemic control. We recommend evaluation for rheumatological complications especially among patients with poorly controlled diabetes.
| References|| |
|1.||Stahl S, Kanter Y, Karnielli E. Outcome of trigger finger treatment in diabetes. J Diabetes Complications 1997;11:287-90. |
|2.||Bridgman JF. Periarthritis of the shoulder and diabetes mellitus. Ann Rheum Dis 1972;31:69-71. |
|3.||Smith LL, Burnet SP, McNeil JD. Musculoskeletal manifestations of diabetes mellitus. Br J Sports Med 2003;37:30-5. |
|4.||Lebiedz-Odrobina D, Kay J. Rheumatic manifestations of diabetes mellitus. Rheum Dis Clin North Am 2010;36:681-99. |
|5.||Fitzcharles MA, Duby S, Waddell RW, Banks E, Karsh J. Limitation of joint mobility (cheiroarthropathy) in adult noninsulin-dependent diabetic patients. Ann Rheum Dis 1984;43:251-4. |
|6.||Rosenbloom AL, Silverstein JH. Connective tissue and joint disease in diabetes mellitus. Endocrinol Metab Clin North Am 1996;25:473-83. |
|7.||Goldberg BA, Scarlat MM, Harryman DT 2 nd . Management of the stiff shoulder. J Orthop Sci 1999;4:462-71. |
|8.||Fitzgibbons PG, Weiss AP. Hand manifestations of diabetes mellitus. J Hand Surg Am 2008;33:771-5. |
|9.||Steinbrocker O, Argyros TG. The shoulder-hand syndrome: Present status as a diagnostic and therapeutic entity. Med Clin North Am 1958;42:1533-53. |
|10.||Jung Y, Hohmann TC, Gerneth JA, Novak J, Wasserman RC, D'Andrea BJ, et al. Diabetic hand syndrome. Metabolism 1971;20:1008-15. |
|11.||Rosenbloom AL, Silverstein JH, Lezotte DC, Richardson K, McCallum M. Limited joint mobility in childhood diabetes mellitus indicates increased risk for microvascular disease. N Engl J Med 1981;305:191-4. |
|12.||Dijs HM, Roofthooft JM, Driessens MF, De Bock PG, Jacobs C, Van Acker KL. Effect of physical therapy on limited joint mobility in the diabetic foot. A pilot study. J Am Podiatr Med Assoc 2000;90:126-32. |
|13.||Abate M, Schiavone C, Pelotti P, Salini V. Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus. Arch Gerontol Geriatr 2011;53:135-40. |
|14.||Jennings AM, Milner PC, Ward JD. Hand abnormalities are associated with the complications of diabetes in type 2 diabetes. Diabet Med 1989;6:43-7. |
|15.||Noble J, Heathcote JG, Cohen H. Diabetes mellitus in the aetiology of Dupuytren's disease. J Bone Joint Surg Br 1984;66:322-5. |
|16.||Gudmundsson KG, ArngrArngrn R, SigfSigfg N, Bj, Bjgfg A, JA, Bjg T. Epidemiology of Dupuytren's disease: Clinical, serological, and social assessment. The Reykjavik Study. J Clin Epidemiol 2000;53:291-6. |
|17.||Sava4 S, KS, K1i BK, Koyuncuounc HR, Uzar E, Celik H, Tamer NM. The effects of the diabetes related soft tissue hand lesions and the reduced hand strength on functional disability of hand in type 2 diabetic patients. Diabetes Res Clin Pract 2007;77:77-83. |
|18.||Bee YM, Ng AC, Goh SY, Tran J, Kek PC, Chua SH, et al. The skin and joint manifestations of diabetes mellitus: Superficial clues to deeper issues. Singapore Med J 2006;47:111-4. |
|19.||Crisp AJ, Heathcote JG. Connective tissue abnormalities in diabetes mellitus. J R Coll Physicians Lond 1984;18:132-41. |
|20.||Holt PJ. Rheumatological manifestations of diabetes mellitus. Clin Rheum Dis 1981;7:723-46. |