Version May 2024
INTRODUCTION — A variety of musculoskeletal conditions have been associated with diabetes mellitus (table 1), including several disorders affecting the hands, such as limited joint mobility, stenosing flexor tenosynovitis, Dupuytren's contractures, and diabetic sclerodactyly; the shoulders, such as frozen shoulder (adhesive capsulitis) and rotator cuff tendinopathy; disorders with a major neurologic component, including carpal tunnel syndrome (CTS) and neuropathic arthropathy; and several other conditions.
These musculoskeletal problems are important to recognize because of their impact on quality of life, particularly as many respond to treatment, helping to prevent pain and disability [1].
An overview of the musculoskeletal conditions associated with diabetes is provided here. Many of these musculoskeletal complications of diabetes mellitus are described in more detail separately. These include:
●Carpal tunnel syndrome (see "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome: Treatment and prognosis")
●Limited joint mobility (see "Limited joint mobility in diabetes mellitus")
●Dupuytren's contracture (see "Dupuytren's contracture")
●Shoulder tendinopathy (see "Rotator cuff tendinopathy")
●Adhesive capsulitis (see "Frozen shoulder (adhesive capsulitis)")
●Diabetic neuropathic arthropathy (see "Diabetic neuroarthropathy")
●Bone disease associated with diabetes (see "Bone disease in diabetes mellitus")
●Diabetic muscle infarction (see "Diabetic muscle infarction")
PREVALENCE — Estimates of the prevalence of musculoskeletal problems in patients with diabetes mellitus vary depending upon the definitions used for the problems and the study population with diabetes, which can range from patients with diabetes on an insurance database to primary care cohorts and patients with severe diabetes in a specialized referral setting. For example, a population study in Taiwan found an overall frequency of carpal tunnel syndrome (CTS) among women of 1.05 percent, which was increased by a third in those with diabetes (adjusted odds ratio [OR] 1.32) [2], while clinical examination of 96 people with diabetes in a hospital setting found a prevalence of CTS of 20 percent [3].
In a study that compared 200 patients with type 1 or type 2 diabetes with 100 controls, the prevalence of hand or shoulder disorders was higher in the patients with diabetes (36 versus 9 percent) and correlated with the duration, but not the type, of diabetes [4]. However, a study of patients with type 1 diabetes, with a median duration of diabetes of 49 years, from a specialized diabetic center, showed a lifetime prevalence of 37 percent for CTS and 76 percent for frozen shoulder (adhesive capsulitis) [5].
PATHOGENESIS — The underlying mechanisms by which diabetes results in its musculoskeletal complications are not firmly established; however, a major hypothesis is that the accumulation of advanced glycation end products (AGEs) and their crosslinking of collagen may contribute to the development of such complications, including adhesive capsulitis, tendon degeneration in the rotator cuff, and diabetes-related hand disorders [6]. The accumulation of AGEs could also potentially affect tendon strength and repair [7] and play a role in microvascular complications and inflammation.
Enzymatic and nonenzymatic glycosylation of collagen can increase with both the duration of diabetes and suboptimal diabetic control. Methods of assessing diabetic control are variable between studies. Blood glucose, a single measurement of glycated hemoglobin (HbA1C), and short- and long-term measurements of HbA1C have all been used to assess diabetic control, and findings regarding the relationship of musculoskeletal problems with diabetic control are conflicting [8-10]. Thus, there is ongoing interest in the role of long-term diabetic control, as measured by serial HbA1C levels, and the formation of AGEs in the pathogenesis of these disorders [5].
HAND ABNORMALITIES — Hand abnormalities are common among patients with diabetes, reflecting pathologic changes in the microvasculature, connective tissue, and peripheral nerves. One study, for example, evaluated 100 patients with diabetes selected randomly in an outpatient clinic [11]; hand abnormalities were observed in 50 patients, and more than one abnormality was found in 26. Furthermore, 25 of the 50 patients with hand syndromes had problems of such significance that surgery was recommended. Carpal tunnel syndrome (CTS), Dupuytren's contracture, flexor tenosynovitis, and limited joint mobility were each present in approximately 20 percent [11].
Carpal tunnel syndrome — CTS is a disorder typically characterized by hand pain and paresthesia, sometimes with weakness, which is caused by compression of the median nerve between the carpal ligament and other structures within the carpal tunnel. Diabetes is one of a number of coexisting conditions that can be risk factors for the condition. The approach to management is the same in patients with and without diabetes. CTS and its management are described in detail separately. (See "Carpal tunnel syndrome: Clinical manifestations and diagnosis" and "Carpal tunnel syndrome: Treatment and prognosis".)
CTS has been reported in up to 20 percent of patients with diabetes, but the incidence rises to 75 percent in those with limited joint mobility [11,12], while diabetes has been reported in 6 to 17 percent of patients with CTS [13,14]. CTS may also be more common among those with prediabetes than in the general population [15]. A systematic review and meta-analysis found a similar risk of CTS in both type 1 and type 2 diabetes (pooled adjusted odds ratio [OR] 1.69, 95% CI 1.45-1.96) [16].
Two studies comparing patients with and without diabetes undergoing carpal tunnel release showed clinical [17] and neurophysiological [18] outcomes to be similar in both groups, although the patients with diabetes were more likely to report the persistence of cold intolerance. Clinical benefit was maintained five years after surgery in patients with diabetes and comparable to that in patients without diabetes, and cold intolerance in the patients with diabetes improved over that time [19]. A retrospective study of carpal tunnel surgery in 493 patients, including 76 patients with diabetes with and without diabetic polyneuropathy, found that patients with diabetes without polyneuropathy did as well as other healthy patients but patients with diabetes with polyneuropathy had more persistent symptoms after carpal tunnel release [20]. Only 62 percent of the total study population had preoperative electrophysiology. The authors concluded that it was essential to establish whether sensory symptoms in the hands of patients with diabetic polyneuropathy were due to compression of the median nerve rather than the polyneuropathy alone.
Median nerve entrapment in diabetes is presumably due to the connective tissue changes that also lead to limited joint mobility. CTS is associated with the duration of diabetes but not with metabolic control, nephropathy, or retinopathy [11]. An electrophysiological study in patients with type 1 and type 2 diabetes found that asymptomatic median mononeuropathy was more common in patients with diabetes with diabetic polyneuropathy than those without polyneuropathy [21]. Asymptomatic median mononeuropathy was present in 18 percent of those without polyneuropathy, and 28 percent of the total study population. Patients with stage III and IV diabetic polyneuropathy had an increased risk of asymptomatic median mononeuropathy compared with those with stage I diabetic polyneuropathy (five- and fourfold, respectively). (See "Limited joint mobility in diabetes mellitus" and "Carpal tunnel syndrome: Treatment and prognosis".)
Limited joint mobility — Limited joint mobility (previously known as cheiroarthropathy) is common among patients with diabetes mellitus, and occurs in both type 1 and type 2 diabetes. It is characterized by limitation of joint movement that is most marked in the small joints of the hands, although other joints, including shoulders, feet, and ankles, can be affected. The risk increases with increasing glycated hemoglobin (HbA1C) values and the duration of diabetes, but it can be present early in disease and in patients without diabetes. Limited joint mobility in diabetes is discussed in detail separately. (See "Limited joint mobility in diabetes mellitus".)
Thickening and waxiness of the skin are also common in these patients, particularly on the dorsal surface of the fingers, but these skin changes may occur in the absence of limited joint mobility. (See 'Diabetic sclerodactyly' below.)
Dupuytren's — Dupuytren's contracture is characterized by fibrosis in and around the palmar fascia, with nodule formation and contracture of the palmar fascia leading to flexion contractures of the digits. Many associations have been reported, including racial and genetic factors, chronic liver disease, and diabetes [22]. Depending upon the criteria used for diagnosis, Dupuytren's contractures have been reported in 16 to 42 percent of outpatients with diabetes [11,23]. The prevalence increases with age and the duration of diabetes.
Dupuytren's contracture should be distinguished from limited joint mobility in diabetes (see 'Limited joint mobility' above). Limited joint mobility in patients with diabetes involves all fingers except the thumb, whereas Dupuytren's contracture more commonly affects the fourth and fifth digits, with the third finger less likely to be affected, and the index finger and thumb typically spared. In addition, the taut bands or cords and nodules characteristic of Dupuytren's contracture are not seen with limited joint mobility (cheiroarthropathy). Occasionally Dupuytren's contracture may coexist with limited joint mobility.
Dupuytren's contracture, which is managed using the same approach in patients with and without diabetes, is discussed in detail separately. (See "Dupuytren's contracture".)
Trigger finger (stenosing flexor tenosynovitis) — Tenosynovitis of the flexor tendon of the finger (trigger finger) in diabetes is characterized by palpable nodule formation and thickening localized to the flexor tendon or sheath and by locking phenomena. The ring finger, middle finger, and thumb are most often affected, and the condition is sometimes bilateral [24]. Flexor tenosynovitis is discussed in detail separately. (See "Trigger finger (stenosing flexor tenosynovitis)".)
Flexor tenosynovitis has been reported in 5 percent of a series of 250 patients with type 1 diabetes aged 3 to 38 years [24] and in 20 percent of 100 patients with type 1 or 2 diabetes aged 19 to 62 [11]. The prevalence of trigger finger is related to the duration of diabetes but not to metabolic control. Collagen abnormalities induced by diabetes mellitus are thought to be responsible.
One study of over 250,000 patients with diabetes in a large insurance database showed a prevalence of stenosing flexor tenosynovitis (trigger finger) of only 1.5 percent, compared with a prevalence in patients without diabetes of 0.7 percent [25]. In this study, tenosynovitis appeared more commonly in women. Patients with diabetes are more likely than patients without diabetes to have multiple digit involvement with stenosing flexor tenosynovitis, although it can also occur in patients without diabetes; diabetic limited joint mobility has also been associated with multiple digit involvement with stenosing flexor tenosynovitis [26]. (See "Limited joint mobility in diabetes mellitus".)
The approach to treatment of stenosing flexor tenosynovitis in patients with diabetes is similar to that in those without diabetes, with glucocorticoid injection followed by surgery if injection is unsuccessful [27]. Transient hyperglycemia may follow glucocorticoid injection in some patients with diabetes and is dose dependent. The approach to treatment is described in detail separately (see "Trigger finger (stenosing flexor tenosynovitis)", section on 'Treatment'). However, in patients with diabetes, the response to therapy may be reduced compared with patients without diabetes. Although local glucocorticoid injection may be beneficial, patients with diabetes were less likely than controls to respond to glucocorticoid injection [28], and some patients required repeated surgery [24]. In this study, just over 75 percent of patients with diabetes who required surgery responded to surgical treatment, compared with 94 percent of controls, although the difference was not statistically significant. By contrast, a study using an insurance database of 29,722 patients requiring treatment for a single-digit trigger finger showed glucocorticoid injection success rates were similar for patients with (72 percent) and without (73 percent) diabetes. However, the response to injection in patients with diabetes with multiple digits involved was not studied [29].
Diabetic sclerodactyly — Diabetic sclerodactyly is the term most often used to describe the cutaneous sclerosis associated with diabetes, which is characterized by thickening and waxiness of the skin that is most marked on the dorsa of the fingers. It is associated with limited joint mobility, although it can occur without joint involvement (see "Limited joint mobility in diabetes mellitus"). The skin changes superficially resemble those in scleroderma. However, the Raynaud phenomena, ulceration, calcinosis, and tapering are absent, and autoantibodies are negative (pseudoscleroderma) [30,31]. (See "Clinical manifestations and diagnosis of systemic sclerosis (scleroderma) in adults", section on 'Causes of scleroderma-like skin changes'.)
The frequency of skin changes correlates with the duration of diabetes, although skin changes have been described in children with diabetes of recent onset [31]. Other than improving glycemic control, which is of theoretical benefit [28], no treatment exists for this condition.
SHOULDER PAIN — Two main types of shoulder problems, adhesive capsulitis (frozen shoulder) and rotator cuff tendinopathy, have been described in patients with diabetes. (See 'Frozen shoulder (adhesive capsulitis)' below and 'Rotator cuff tendinopathy' below.)
Frozen shoulder (adhesive capsulitis) — Frozen shoulder, which is often associated with severe shoulder pain, is more common in patients with diabetes than those without; it has been defined as a condition of varying severity characterized by the gradual development of global limitation of active and passive shoulder motion with an absence of radiographic findings other than osteopenia. The prevalence of adhesive capsulitis in patients with diabetes depends upon the criteria used for diagnosis and upon the population studied, with typical estimates ranging from approximately 20 to 30 percent. However, it can vary substantially between studies, and many studies do not use radiographs to exclude osteoarthritis (OA). Treatment is similar to that in patients without diabetes. Frozen shoulder is discussed in detail separately. (See "Frozen shoulder (adhesive capsulitis)".)
Adhesive capsulitis has been reported in representative studies in 19 to 29 percent of patients with diabetes compared with approximately 5 percent of controls [8,32]. Conversely, in a series of 60 patients with capsulitis, overt or latent diabetes was found in 17 (28 percent) [33].
In a study of nearly 300 patients with type 2 diabetes, increased age, longer duration of diabetes, the presence of limited joint mobility, and Dupuytren's contractures were associated with an increased risk of painful capsulitis; retinopathy was also more frequent in those with capsulitis, while neuropathy and heavy proteinuria were not [8]. A subsequent study of 865 patients with diabetes found a prevalence of shoulder pain of 26 percent, compared with 5 percent of general medical patients, but only 4 percent of the patients with diabetes fulfilled the strict criteria for adhesive capsulitis used, compared with 0.5 percent of medical patients [34]. Only duration of diabetes was associated with adhesive capsulitis in this study. By contrast, shoulder capsulitis was found in 25 percent of a series of 96 patients with diabetes and was associated with retinopathy and/or neuropathy [3]. In this series, 75 percent of patients with diabetes had locomotor problems, most often with the upper limb, and problems in the shoulder and hand were associated with poorer glycemic control. Two other studies have also linked the risk of adhesive capsulitis to long-term diabetic control. Poor control, as demonstrated by measurements of hemoglobin A1C over many years, was associated with adhesive capsulitis in type 1 [35] and type 1 and type 2 diabetes [36].
A longitudinal population-based study involving 78,827 patients with diabetes and 236,481 age- and sex-matched controls found that 1.2 percent of patients with diabetes developed adhesive capsulitis in a three-year period compared with 0.95 percent of controls [37].
A link between adhesive capsulitis and limited joint mobility has also been postulated, but the data are conflicting [32,38]. An association has been suggested in one report of patients with relatively painless loss of movement. Limited joint mobility can affect the shoulder joint, and some of these subjects may not have had a true capsulitis [38].
Treatment for adhesive capsulitis in people with diabetes is the same as in those without diabetes, with conservative treatment with pain relief, glucocorticoid injection, and physiotherapy as treatment of first choice and surgery reserved for those who do not respond. (See "Frozen shoulder (adhesive capsulitis)", section on 'Management'.)
Although patients with diabetes benefit from arthroscopic release for adhesive capsulitis, results of surgery may not be as good as those seen in patients without diabetes, with fewer patients with diabetes in one prospective study recovering full range of shoulder movement compared with patients without diabetes (71 versus 90 percent) [39]. Postoperative adhesive capsulitis also appears to be more common in patients with diabetes. In a prospective study of 505 patients undergoing elective shoulder surgery, a postoperative frozen shoulder was more common among the 24 patients with diabetes than among the surgical cohort as a whole (30 versus 11 percent) [40].
Rotator cuff tendinopathy — Rotator cuff tendinopathy is more frequent among patients with diabetes. This term comprises symptomatic rotator cuff tendon disorders, most commonly affecting the supraspinatus tendon. These typically result in pain with overhead activities. The management approach is the same as in patients without diabetes. Rotator cuff tendinopathy and its management are discussed in detail separately. (See "Rotator cuff tendinopathy".)
Rotator cuff tendinopathy is common in the general population; the prevalence increases with age in both asymptomatic and symptomatic individuals. A meta-analysis involving 30 studies of 6112 patients found a prevalence of rotator cuff abnormalities of 7.9 percent in the general population aged 40 to 49, which rose steadily with age to 50 percent at age 70 to 79 [41].
The risk is increased and surgery is required more often in patients with diabetes. A case-control study of 5000 patients with rotator cuff tendinopathy found an increased risk compared with age- and sex-matched controls for patients using insulin and those using oral hypoglycemic medications (adjusted odds ratios [OR] 1.77, 95% CI 1.20-2.61, and 1.66, 95% CI 1.48-1.87) [42]. A population-based study showed similar findings, with increased risk associated with both insulin use and diabetes without use of insulin (hazard ratios [HR] 1.43, 95% CI 1.35-1.51, and 1.64, 95% CI, 1.53-1.75) [43]. People with diabetes are more likely to undergo rotator cuff tear repair surgery than controls, as shown in a large case-control study using the Taiwanese health insurance database (adjusted HR 1.33, 95% CI 1.05-1.68) [7]. In one study, soft tissue calcification with shoulder tendinopathy appeared to occur three times more frequently in patients with diabetes than in controls, although only one-third were symptomatic [44]. However, an ultrasound study of patients with and patients without diabetes with chronic shoulder pain showed that, while calcific tendinopathy was more frequent in patients with diabetes, this difference disappeared when data were adjusted for age [45].
NEUROPATHIC ARTHROPATHY — Diabetes mellitus is the disease most commonly associated with neuropathic (Charcot) arthropathy in the western world, although the disorder likely affects less than 1 percent of patients with diabetes annually. In patients with diabetes, loss of sensation to a joint, in combination with mechanical and vascular factors, may result in this chronic, progressive, and destructive arthropathy.
Diabetic neuropathic joint disease most commonly affects the joints of the foot and ankle, although the clinical presentation may vary. It typically affects patients with longstanding diabetes and peripheral neuropathy, affecting patients with both type 1 and type 2 diabetes.
Neuropathic arthropathy (Charcot joint) is discussed separately. (See "Diabetic neuroarthropathy".)
DIABETIC MUSCLE INFARCTION — Spontaneous infarction of muscle is a rare condition that usually affects patients with longstanding and poorly controlled diabetes mellitus. Affected patients present with the acute onset of painful swelling of the thigh or, less commonly, the calf, which then evolves over days or weeks. Diabetic muscle infarction is discussed in detail elsewhere. (See "Diabetic muscle infarction".)
DIABETIC BONE DISEASE — The effects of diabetes on bone are complex. While most studies agree that fracture risk is increased in diabetes, bone mineral density may not reflect bone fragility, particularly in type 2 diabetes. Neuropathy, retinopathy, and cerebrovascular disease also increase the risk of falls. Bone disease in diabetes is discussed in detail separately. (See "Bone disease in diabetes mellitus".)
POSSIBLE RELATIONSHIP WITH DIABETES — The prevalence and possibly the severity of some common disorders that are not generally thought of as complications of diabetes may also be influenced by the presence of diabetes. These include osteoarthritis (OA) and diffuse idiopathic skeletal hyperostosis (DISH). (See 'Osteoarthritis' below and 'Diffuse idiopathic skeletal hyperostosis' below.)
Osteoarthritis — Diabetes may adversely affect cartilage, increasing vulnerability to the development of OA [46]. Much evidence, including at least two meta-analyses [47,48] and a number of other reports [49-56], supports this association, particularly for type 2 diabetes, but there are less data regarding type 1 diabetes, and results of studies are mixed. Some studies, but not all, have controlled for obesity, shown to be a potentially important confounding variable in some analyses. A 2020 metaanalysis, taking body mass index (BMI) into consideration, did not support diabetes as an independent risk factor for OA [57]. The pathogenesis, risk factors, clinical manifestations, and diagnosis of OA are discussed in detail separately. (See "Pathogenesis of osteoarthritis" and "Epidemiology and risk factors for osteoarthritis" and "Clinical manifestations and diagnosis of osteoarthritis".)
The treatment of OA does not differ in patients with and without diabetes and is discussed separately. (See "Overview of the management of osteoarthritis".)
Diffuse idiopathic skeletal hyperostosis — There is limited and conflicting evidence that DISH may be increased in patients with diabetes. DISH is a noninflammatory disorder of unknown etiology, which is principally characterized by calcification and ossification of spinal ligaments and entheses, the regions where tendons and ligaments attach to bone. Symptoms of back and neck pain may be present, but radiographic changes characteristic of DISH may occur in the absence of any musculoskeletal symptoms.
The possible relationship with diabetes and obesity and its occurrence in patients with acromegaly have led to the evaluation of insulin, insulin-like growth factor, and growth hormone in its pathogenesis. DISH is discussed in detail separately. (See "Diffuse idiopathic skeletal hyperostosis (DISH)".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Dupuytren's contracture (The Basics)")
SUMMARY
●A variety of musculoskeletal conditions have been associated with diabetes mellitus (table 1). The prevalence of hand or shoulder disorders is higher in patients with diabetes than in controls and correlates with the duration, but not the type, of diabetes. Hand abnormalities are common, reflecting pathologic changes in the microvasculature, connective tissue, and peripheral nerves. (See 'Introduction' above and 'Hand abnormalities' above.)
●Carpal tunnel syndrome (CTS) has been reported in up to 20 percent of patients with diabetes, but the incidence rises to 75 percent in those with limited joint mobility. Diabetes has been reported in 6 to 17 percent of all cases of CTS. CTS is associated with the duration of diabetes but not with metabolic control, nephropathy, or retinopathy, and it responds well to surgical treatment. (See 'Carpal tunnel syndrome' above and "Carpal tunnel syndrome: Clinical manifestations and diagnosis".)
●Dupuytren's contractures have been reported in approximately 15 to 40 percent of outpatients with diabetes. The prevalence increases with age and the duration of diabetes. (See 'Dupuytren's' above.)
●Tenosynovitis of the flexor tendon of the finger (trigger finger) has been reported in approximately 5 to 20 percent of patients with diabetes and may involve multiple digits. The prevalence of trigger finger is related to the duration of diabetes but not to metabolic control. Treatment is similar to that in patients without diabetes, but is slightly less effective. (See 'Trigger finger (stenosing flexor tenosynovitis)' above.)
●Diabetic sclerodactyly is characterized by thickening and waxiness of the skin most marked on the dorsa of the fingers and is often associated with limited joint mobility. The skin changes resemble those in scleroderma, but other features, such as Raynaud phenomena, ulceration, calcinosis, and tapering, are absent, as are autoantibodies. The frequency of skin changes correlates with the duration of diabetes. (See 'Diabetic sclerodactyly' above.)
●Adhesive capsulitis (frozen shoulder) and rotator cuff tendinopathy are each more common in patients with diabetes than in controls. Increased age, longer duration of diabetes, the presence of limited joint mobility, Dupuytren's contractures, and retinopathy were associated with an increased risk of painful capsulitis in some studies, along with poor diabetic control. (See 'Shoulder pain' above.)
●Type 2 diabetes is associated with an increased risk of osteoarthritis (OA), although the relationship between these conditions is complex and may be mediated by obesity. (See 'Osteoarthritis' above.)
●Other musculoskeletal problems in diabetes may include limited joint mobility, neuropathic arthropathy, bone disease, and diabetic muscle infarction. (See "Limited joint mobility in diabetes mellitus" and "Diabetic neuroarthropathy" and "Bone disease in diabetes mellitus" and "Diabetic muscle infarction".)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
