Dr Hossein Soleymani Assistant Prof of Rheumatology SSMU, Jan
2015, YAZD, IRAN
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Introduction MS complaint more frequent Metabolic change in CV
tissue Glycolysation of proteins Microvascular abnormality
Accumulation of extracellular matrix and soft tissue More seen in
longstanding type I Some complications have direct association
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Pathogenesis: An increase in non-enzymatic glycosylation of
collagen fiber Increase collagen crosslink Resistant to enzymatic
digestion Increase in hydration mediated by aldolase reductase
pathway Increased formation Advanced Glycosylation End product
(AGEs)
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Pathogenesis: AGEs causes micro and macro vascular
complications AGEs result from early glycolysation Accumulate in
tissue Damage extra and intra cellular proteins There are receptors
on cell surface for AGEs belong to IG receptors Signaling lead to
cell dysfunction AGEs decrease vascular elasticity
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Condition limited to DM Diabetic Muscle Infarction
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Conditions more frequently in DM Diabetic cheiroarthrophaty
(stiff hand synd) Trigger finger (flexor tenosynovitis) Dupuytrens
contracture Carpal tunnel syndrome Adhesive shoulder capsulitis
(frozen shoulder)Calcific shoulder tendonitis Reflex sympathetic
dystrophy ( shoulder-hand syndrome) Diabetic osteoarthrophaty or
charcota or neuropathic arthropathy
Hand Diabetic cheiroathrophaty or diabetic stiff hand or
limited mobility joint syndrome: 8% to 50% all type I DM,45%-70%
type II Associated and predictor of other complication Thick,
tight, waxy skin, begin in MCP&PIP 5 Like systemic sclerosis
Limited joint mobility( finger flex and extend)
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Cheiroarthropathy Lack of following differentiated from
Scledrema: Raynuads phenomena, dermal atrophy, telangiectasia and
autoantibodies Nail fold capillaroscopic change may be seen Both
type I and type II have higher prevalence retinopathy and
nephropathy
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hand Flexion contracture of fingers cause Prayer sign
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Cheiroarthropathy
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Recommended treatment: 1- Glycemic control 2- Physical therapy
3- NSAIDs with caution
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Hand: Trigger finger Catching sensation or locking phenomena
Pain in affected finger Thumb, then third and forth 5%-36% type I,
II (2% normal) Palpable nodule overlying MCP joint Thickening along
the affected flexor tendon Prevalence related to duration of DM TF
in 3 or more finger highly suggestive for DM
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Trigger Finger Treatments: 1-Change of activity 2- Splint 3-
Use of NSAIDs with caution 4- CS injection 5- In severe case
surgery
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Hand: Dupuytrens contracture Thickening, shortening, fibrosis
of palmar facia Nodule along the facia causes flexion contractures
of the finger Usually fourth but may be seen II to V fingers 16% to
42% of all DM more in eldery May be seen in early stage Prevalence
more in longstanding DM
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Dupuytrens contracture More in third and fourth finger More in
women Manifestations are more severe in men
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Dupuytrens contracture Treatments: 1- Intralesional injection
of CS 2- Surgery 3- Physical therapy 4- Some studies show benefit
from injection of collagenase Colstridium Histolyticum
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Hand: Carpal Tunnel syndrome 20% of diabetic patients more in
women More in obbes Median nerve entrapment Caused by
diabetic-induced connective tissue alteration HX & PE Tinels
sign, Phalens test In dubious case Electrophysiological studies
helpfull
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Carpal tunnel syndrome Treatments: 1- Splint, NSAIDs 2-
Injection CS: response may be temporary and poorer in DM 3- Release
surgery: post operative recovery is worse
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Shoulder: Frozen shoulder Frozen shoulder or adhesive
capsulitis Most common shoulder involvement 10-29% diabetic
patients, bilateral, elderly Stiffness Glenohumeral joint
Reversible contraction joint capsule See in hyperthyroidism,
Addison and Parkinson
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Adhesive capsulitis Progressive and painful manner Pain at
night initially Three phase:(a) Pain (b) Stiffness (c) Recovery
Diagnostic criteria by Pal: Shoulder pain at least one month,
impossibility lying's one shoulder, limited active and passive
movement Decreased range of motion in abduction and external
rotation then internal rotation
Shoulder: Calcific shoulder tendonitis Three times more
frequent in DM (type II) Coexist with adhesive capsulitis Deposit
Ca hydroxy apatite Ca depostion in rotator cuff tendons 60%
asymptomatic
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Sohulder:Reflex sympathetic dystrophy Shoulder-hand synd or
complex regional pain synd Pain from shoulder to hand Swelling of
affected limb Skin change: hair growth, shiny skin, color,
temperature Increased sensitivity to pain and touch Vasomotor
instability Transit patchy osteoporosis
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Feet: Charcots arthropathy Diabetic osteoarthropathy Rare: 0.1%
to 0.4% Both type DM Average duration 15 years Advanced peripheral
neuropathy
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Feet: Charcots arthropathy Loss of sensation in involved joint
Inadvertent microtrauma to joint Consecutive degenerative change
Severe destruction, lytic joint changes Most affect pedal
bones
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Feet: Charcots arthropathy Erythema, swelling, hyperpimentation
Purpura, soft tissue ulcer Joint loosening, instability, joint
deformity Often no history of trauma
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Feet: Charcots arthropathy Diagnosis: based on radiographic
findings Symptoms often milder than view of X-ray X-raysubluxation,
bone fragment, osteolysis Periosteal reaction, deformity,
ankylosis
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Feet: Charcots arthropathy CT sacn is insensitive MRI and bone
scintigraphy adjuncts X-ray DD: Inflammatory, degenerative,
infections, tumors, DVT
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Charcot arthropathy Treatments: 1- Prevent weight bearing on
affected joint 2- Bisphosphanate 3- Calcitonin may be useful
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Muscle: Diabetic muscle infarction Rare condition Spontaneous
infraction with no history of trauma Patients with long history of
poorly controlled DM More in insulin requiring patients Most
patients show microvascular complications like neuropathy,
retinopathy, nephropathy
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Muscle: Diabetic muscle infarction Acute onset of pain and
swelling on affected M Over days to weeks Usually thigh or calf
Varying degree of tenderness CPK may be normal or increased
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Muscle: Diabetic muscle infarction D&D: Tumor, muscle
infection/abscess, localized myositis, osteomyelitis, thrombosis CT
Scan in insensitive MRI show high signals in muscle in T2 When
incisional muscle biopsy? Only to rule out infection and malignancy
(culture for atypical organisms) Treatments: rest, analgesic
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Diffuse Skeletal Disease Diffuse idiopathic skeletal
hyperostosis(DISH) Metaplastic calcification of spinal ligament
Osteophyte formation Disc space, sacroiliac and facet joint: normal
Thoracic spine most commonly affected May be accompanied by
generalized calcification of other ligament
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Diffuse Idiopathic Skeletal Hyperostosis Unknown etiology IN DM
patients more than normal Association with type II DM More in obese
patients Pain is not prominent symptoms Complaint stiffness in neck
and back Decreased range of motion
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Other disease with DM Osteoporosis: controversy, risk of Fx
increased Osteoarthritis Hyperurecemia
