Limited joint mobility in diabetes mellitus

INTRODUCTION — Limited joint mobility is common in patients with diabetes mellitus. It is characterized by limitation of joint movement that is most marked in the small joints of the hands, also known as diabetic cheiroarthropathy ("cheiros" is the Greek word for hand) or diabetic stiff hand syndrome [1,2]. Thickening and waxiness of the skin are also common, particularly on the dorsal surface of the fingers, but these skin changes may also occur in the absence of limited joint mobility [3]. The definition of limited joint mobility varies from study to study, with some researchers confining their investigations to the hands, and others including other joints. This topic will review the prevalence, clinical features, and diagnosis of limited joint mobility in patients with diabetes.

PREVALENCE — The reported prevalence of limited joint mobility in diabetes mellitus ranges from 8 to 58 percent [1,4,5]. This variability depends largely upon the population studied, the definition used, and the way in which joint mobility is measured. The prevalence of limited joint mobility appears to be decreasing over time. Estimated prevalence in the 1980s and 1990s ranged from 30 to 40 percent of patients with diabetes, falling to approximately 20 percent in more recent reports. When considering the true prevalence of limited joint mobility, care must be taken to distinguish the syndrome from regional conditions with an increased prevalence in diabetes such as Dupuytren's contracture, flexor tenosynovitis, and trigger finger [5]. (See "Overview of the musculoskeletal complications of diabetes mellitus", section on 'Hand abnormalities'.)

Limited joint mobility occurs in both type 1 and type 2 diabetes [4,6,7]. The risk increases with increasing glycated hemoglobin (A1C) values [8] and the duration of diabetes [4,9-11], although it has been reported early in the course of the disease in some individuals [6]. The prevalence also increases with age and cigarette smoking in patients both with and without diabetes [7,12]. (See 'Associations with other diabetic complications' below.)

Two cross-sectional studies have investigated the prevalence of limited joint mobility in patients with diabetes over time:

●In children and adolescents between the ages of 7 to 18 years, the prevalence of limited joint mobility fell significantly from 31 to 7 percent, between the late 1970s and 1990s [13].

●In adults with type 1 diabetes (mean age 27 years), the prevalence decreased from 43 to 23 percent over the 20-year period between 1982 and 2002 [14].

In both studies, limited joint mobility was associated with longer duration of diabetes. These studies highlight the decline in both prevalence and severity of limited joint mobility between the late 1970s and the early 2000s. The authors of both studies postulated that improvements in long-term glycemic management were responsible for these changes over time [13,14].

Limited joint mobility of the hands can occur in the absence of diabetes as well, with prevalence between 5 and 25 percent in individuals without diabetes [4,6,7].

PATHOGENESIS — The deposition of abnormal collagen in connective tissue around joints (in muscle, tendon, joint capsule, and skin) is thought to contribute to the clinical findings of limited joint mobility. Enzymatic and nonenzymatic glycosylation of collagen, abnormal crosslinking of collagen (which results in resistance to degradation), and increased collagen hydration may all contribute [2,15-17]. In addition, microangiopathy and neuropathy may contribute to contractures via fibrosis and disuse.

Early glycosylation of skin collagen can be decreased by improved glycemic management [15,17]. However, the long-term, cumulative damage due to the binding of advanced glycosylation end-products (AGEs) to collagen is thought to be irreversible.

CLINICAL FEATURES — Limited joint mobility is painless. Patients come to the clinician when stiffness and contractures lead to decreased grip strength, declining ability to do fine movements, and difficulties with hand function [2].

Examination of the hands may show contractures of the proximal interphalangeal and metacarpophalangeal joints. Thickening and waxiness of the skin, particularly on the dorsum of the fingers, sometimes referred to as diabetic sclerodactyly, may or may not be present [18]. The distal interphalangeal joints may also be involved in limited joint mobility, followed less commonly by wrists, elbows, shoulders, knees, feet, and the axial skeleton [19].

Coexisting stenosing flexor tenosynovitis (trigger finger) and Dupuytren's contracture may be present [20]. The findings of limited joint mobility in the hands may be confused with Dupuytren's contracture in some patients (see "Dupuytren's contracture"). Two features may be helpful for distinguishing between them:

●Limited joint mobility involves all four fingers, whereas Dupuytren's contracture more commonly affects just the fourth and fifth digits.

●The taut fibrotic bands characteristic of Dupuytren's contracture are not present in limited joint mobility alone.

While limited joint mobility can affect the shoulders [19], it is important to distinguish between the relatively painless limitation of movement associated with this condition and adhesive capsulitis and rotator cuff disorders, both of which are common in people with diabetes. (See "Overview of the musculoskeletal complications of diabetes mellitus", section on 'Shoulder pain'.)

DIAGNOSIS — Two simple tests are used for diagnosis of limited joint mobility in the hands.

●The "prayer sign" tests the ability to flatten the hands together as in prayer, facilitating recognition of contractures in the metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints (picture 1).

●The "table top test" assesses the ability to flatten the palm against the surface of a table, facilitating recognition of contractures in the metacarpophalangeal joints (picture 2).

Goniometers can also be used to measure flexion and extension of finger and other joints, and they are of particular value in research studies [12]. Sensors and electromagnetic tracking devices have also been used to evaluate limited joint mobility in the shoulder [19]. Findings from the prayer sign have been correlated with range of motion measured by goniometry, supporting the clinical utility of this simple test [21].

Although imaging studies are not typically used to diagnose limited joint mobility, thickening of the flexor tendon sheaths has been noted on ultrasonography [22]. Magnetic resonance imaging (MRI) findings include thickening of the flexor digitorum tendons and enhancement of the tendon sheaths, without involvement of the extensor tendons [23].

ASSOCIATIONS WITH OTHER DIABETIC COMPLICATIONS — Limited joint mobility is strongly associated with the duration of disease [9,11,24]. There are conflicting data on the possible association of limited joint mobility with glycemic management and with microvascular and other complications of diabetes mellitus. Differences in patient populations, the definition of limited joint mobility, joints studied, and the methods of diagnosis contribute to this variability. In addition, there may be differences between longitudinal studies, where diabetes management is assessed over a period of time, and cross-sectional studies that depend on many fewer measurements of A1C.

Duration of diabetes — The risk of developing limited joint mobility increases with the duration of diabetes [9,11,24], and limited joint mobility of the hands is uncommon when the duration of diabetes is less than 5 to 10 years. In a cross-sectional analysis of data from the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study (1217 patients followed for a mean of 24 years), two-thirds of patients had at least one of the following: adhesive capsulitis, Dupuytren's contracture, carpal tunnel syndrome, flexor tenosynovitis, or a positive prayer sign. Stiffness in the hands (positive prayer sign) was seen in 22 percent of patients. [11]. For every 10 years of diabetes duration, the risk of developing one of these musculoskeletal complications increased two- to threefold (odds ratio [OR] 2.53 to 2.87 in multivariate analyses).

Glycemic management — Whether glycemic management and limited joint mobility are correlated is controversial [9,10]. Although biochemical theories and some clinical evidence suggest that good glycemic management may prevent or minimize limited joint mobility [15,17], other reports have shown no association [6,9,25]. A large cross-sectional study of 335 adolescents and adults with type 1 diabetes found no evidence for an association between A1C and limited joint mobility [24], while in the larger, longer duration, and more extensively characterized DCCT/EDIC study cohort, limited joint mobility was related to higher levels of glycemia [11]. Another prospective study that followed 479 children from diagnosis of type 1 diabetes over a median 10.9 years showed that 35 percent developed limited joint mobility at a median age of 13 years and duration of diabetes of 5.2 years [26]. The risk of developing limited joint mobility was related to puberty and higher A1C levels. Methodological differences, as discussed above, may be responsible for some of the variation in the different studies.

Microvascular complications — There are reports supporting the association of the disorder with retinopathy [4,10,11,27], nephropathy [4,10,26], and neuropathy [11], findings that have not been confirmed in other studies [9,25].

Sex may play a role in determining which diabetic complications are present in association with limited joint mobility. In a cross-sectional study in patients with type 1 diabetes, men with limited joint mobility were more likely to have proteinuria, retinopathy, and hypertension than men with normal joint motion; women with limited joint mobility did not have increased rates of these problems [24].

A 15-year prospective study of limited joint mobility in 37 people with type 1 diabetes showed a greater reduction in joint mobility in those with than without microalbuminuria, but no association was seen between limited joint mobility, duration of diabetes, retinopathy, or mean A1C [28].

Macrovascular complications — One study found a relationship between limited joint mobility of the hand and carotid atherosclerosis as assessed by carotid ultrasound in 341 patients with type 2 diabetes [29]. After adjustment for confounding factors such as age, duration of diabetes, and A1C, plaque score positively correlated with limited joint mobility of the hand.

Foot ulcers — A number of factors predispose to foot ulcers in patients with diabetes, including neuropathy, high foot pressures, peripheral vascular disease, and trauma (see "Evaluation of the diabetic foot"). Limited joint mobility in the metatarsophalangeal [30] and the subtalar joints [31,32] can contribute to high foot pressures, contributing to plantar ulceration. More than one-third of adolescents may have limited subtalar motion and approximately 20 percent have limited mobility of the first metatarsophalangeal joint [33]. In addition to these local factors, limited joint mobility of the hand may also be associated with diabetic foot risk [34].

TREATMENT — Limited joint mobility is difficult to treat. Glycemic management should be optimized, although this may be of theoretical rather than practical benefit. In addition, passive palmar stretching and occupational therapy may improve function. Stretching of the toes and subtalar joint has been suggested to reduce the risk of foot ulceration, but this is unproven [33]. Smoking should be discouraged given the potential association with limited joint mobility and its contribution to microvascular disease [7].

Injection of the palmar tendon sheath with corticosteroids was found in one study to improve the contractures of limited joint mobility [35]. This report, however, was difficult to assess because of the frequent coexistence of trigger finger and limited joint mobility. The procedure was painful. Drugs such as penicillamine (which inhibits collagen crosslinking), aminoguanidine (which prevents glycosylation of proteins and diminishes glycosylation-related crosslinking), and the aldose reductase inhibitor sorbinil (which reduces collagen crosslinking) are not recommended [2].

In contrast to the general irreversibility of limited joint mobility, other diabetic hand problems such as Dupuytren's contracture, carpal tunnel, and flexor tenosynovitis that can coexist with it are potentially treatable. Similarly, other diabetic shoulder problems such as adhesive capsulitis and rotator cuff tendinopathy need to be considered and treated. (See "Overview of the musculoskeletal complications of diabetes mellitus".)

SUMMARY

●Pathogenesis – Limited joint mobility is a painless stiffening of the joints seen particularly in the hands of people with both type 1 and type 2 diabetes. The deposition of abnormal collagen in connective tissue around joints is thought to lead to joint stiffening and associated skin changes. (See 'Pathogenesis' above.)

●Prevalence – The prevalence increases with duration of diabetes, and there is some evidence linking limited joint mobility to long-term glycemic management. The prevalence in young people with type 1 diabetes is declining, perhaps reflecting better long-term glycemic management in recent years. (See 'Prevalence' above.)

●Clinical features – Careful clinical evaluation should be performed to exclude treatable diabetic hand problems such as carpal tunnel, flexor tenosynovitis, and Dupuytren's contractures, as well as other treatable causes of shoulder pain and stiffness. (See 'Clinical features' above.)

●Treatment – While good glycemic management and cessation of smoking are not proven to have an impact on limited joint mobility, these measures are reasonable both in view of the pathogenesis of limited joint mobility and for the other benefits to the patient. (See 'Treatment' above.)

Passive palmar stretching and occupational therapy may improve function. (See 'Treatment' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Lesley D Hordon, MD, who contributed to earlier versions of this topic review.