Musculoskeletal Conditions
Musculoskeletal conditions (conditions affecting the muscles or skeleton) can affect anyone, but people with diabetes can be at an increased risk of developing them. The reasons for this are not fully understood, but it is thought that raised blood glucose levels may, overtime, cause changes to the naturally occurring protein collagen. Collagen is the main constituent of connective tissue and is present in the skin, cartilage, tendons and ligaments (see definitions below). Glucose can bind to strands of collagen in a process known as glycosylation, and lead to the formation of cross-links with adjacent collagen strands. As a result the whole structure of the skin, or a tendon or ligament, can become thicker and less flexible, and this may lead to, or aggravate, a range of musculoskeletal conditions.
Good blood glucose control can help reduce the risk of developing this type of disorder.
If musculoskeletal conditions do develop then treatment options include resting the affected joint, physiotherapy, anti-inflammatory painkillers, steroid injections (to help reduce any inflammation) and, in extreme cases, surgery. Ultrasound may also sometimes be beneficial - the reasons for this are not fully understood, but it is thought to help reduce inflammation.
Steroid injections can increase blood glucose levels for approximately 24 hours and therefore you may need to carry out blood glucose tests more frequently following an injection. Your diabetes care team will be able to give advice about managing high blood glucose levels.
Limited joint mobility
Limited joint mobility is a type of rheumatism that causes the joints to lose their normal flexibility. Although most common in the hands (where it is also known as diabetic cheiroarthropathy), limited joint mobility can also affect the wrists, elbows, shoulders, knees, ankles and, in some cases, the neck and lower back. A classic sign of cheiroarthropathy is not being able to press the fingers together tightly in a palm to palm ‘prayer sign’. The affected fingers stay permanently bent.
Although in itself limited joint mobility is usually troublesome rather than painful or disabling, it is closely associated with microvascular complications of diabetes - nephropathy (kidney disease) and retinopathy (eye disease). It is particularly important therefore that people with this condition are screened for eye and kidney problems.
There is no specific diagnostic test for limited joint mobility, other than the prayer sign test for cheiroarthropathy, and healthcare professionals will need to consider your symptoms and medical history when diagnosing it. Often the skin appears characteristically thick and waxy on the back of your hand. Other hand conditions may also need to be investigated, eg Dupuytrens contracture and carpal tunnel syndrome (see below), as it is possible that more than one thing is going on.
It is thought that about a third of people with diabetes have some degree of limited joint mobility. Like most complications of diabetes, good blood glucose control will help guard against it, as well as aiding recovery if it has already developed. Your healthcare team may be able to recommend exercises that will help restore some flexibility. Sometimes people are given steroid injections into the affected area and, in more extreme cases, where it is affecting a person’s ability to do day-to-day tasks, surgery may be required.
Dupuytren’s Contracture
Dupuytren’s contracture is a disorder of the hand that is more common amongst people with diabetes. The first sign is often a tender nodule (a small bump) in the palm, near the base of the fingers. It progresses slowly and usually painlessly to cause the fingers to bend inwards towards the palm, so you can no longer fully open your hand.
Scar tissue is thought to accumulate under the skin on the palm (the fascia), thickening and shortening the tissue. This restricts the movement of the tendons, the cord like structures that connect muscle to bone.
Like limited joint mobility, Dupuytren’s contracture can be a marker of microvascular complications (kidney and eye disease).
Physiotherapy may help some people with Dupuytren’s contracture, as may local steroid injections to reduce any inflammation. Ultrasound may also help.
Carpal tunnel syndrome
The symptoms of carpal tunnel syndrome can include pain or numbness in the hand and wrist, and weakness of the muscles in the fingers and thumb. These symptoms are caused by compression of the median nerve (the nerve that supplies the palm and fingers) as it passes through the carpal tunnel in the wrist. The pain (often described as a tingling or burning sensation) is often worse at night and can extend into the whole hand, and even sometimes up the arm into the elbow, shoulder and neck. Sometimes just one hand is affected, sometimes both are.
Carpal tunnel syndrome can be brought on and aggravated by repetitive use (eg typing or using a mouse at the computer), although it is also linked with various underlying conditions, including diabetes. This often leads to the symptoms being mistaken for neuropathy (nerve damage).
A nerve conduction test can be used to measure electrical impulses along the median nerve. A slow impulse speed confirms a diagnosis of carpal tunnel syndrome, although sometimes it will be diagnosed on the strength of symptoms alone.
Sometimes carpal tunnel syndrome goes away without any treatment. In other cases rest and anti-inflammatory painkillers can help. If carpal tunnel syndrome is due to repetitive use then ergonomic advice can help, eg correcting your posture at your workstation. Sometimes splints are used to restrict the movement of the wrist for a number of weeks to give it complete rest. Physiotherapy, including massage of the hand and gentle exercises, can also help, and ultrasound may be beneficial too.
Tenosynovitis
Tenosynovitis is where the tendons, the cord like structures connecting muscle to bone, swell. This causes pain and swelling in the affected area of the body, and stiffness in the joint moved by the tendon. Tenosynovitis occurs most commonly in the wrist and hand, and in this case the tendons that swell are those connecting the muscles in the forearm to the bones in the fingers and thumb. These tendons run through a tunnel or sheath. When they swell they sometimes becomes too thick for this tunnel and ‘catch’ on it as you try and move the connected finger or thumb. The fingers feel slow and as if they are in danger of locking up as you attempt to move them. This is known as stenosing tenosynovitis, or trigger finger, and is thought to be more common amongst women than men.
The first sign of trigger finger is often a feeling of tenderness in the palm, directly beneath the affected finger or thumb. Sometimes people don’t notice anything is wrong until the finger is starting to catch or lock.
Trigger finger is aggravated by repetitive use, as each time the tendon catches (the trigger), it leads to more inflammation and swelling. A splint can be used to immobilise the affected finger or thumb in an extended position, so the joint can completely rest. Finger exercises can also be helpful, as can steroid injections, although often the trigger finger will return in time. Sometimes surgery is used to widen the opening of the tunnel or sheath that the tendon is catching on, for a more long-term solution.
Frozen shoulder
Frozen shoulder, also known as adhesive capsulitis, is a condition that can cause pain and stiffness in the shoulder. There is an increased incidence of frozen shoulder in people with diabetes – it is thought to affect 20 per cent of people with diabetes at some stage in their life, compared to just five per cent of people without diabetes. Frozen shoulder often develops after an injury to the shoulder, although sometimes there is no obvious case. Most commonly just one shoulder is affected, although sometimes both will be involved. The severity of the condition varies from person to person.
If someone doesn’t use their shoulder frequently, eg after an injury, scar tissue can form in the shoulder capsule (the thin tissue covering the shoulder joint). As a result the shoulder capsule tissue shortens and thickens, restricting the movement of the shoulder.
The progression of frozen shoulder is often described in three stages. The first stage is when the shoulder aches and feels stiff. The pain often gets worse during this period, which lasts anything from two to nine months, and the pain is often worse at night. The second stage is the ‘adhesive’ stage and can last from four to 12 months. The joint gets stiffer, although the pain may ease a little. As the shoulder is not usually used much during this stage, the muscles may begin to waste. The final stage is the recovery stage - the stiffness slowly goes away and movement increases, although there may still be some pain as you start to use your shoulder more.
Symptoms of frozen shoulder usually go and it is possible to get full use of your shoulder back, however this may take many months (between two and three years from onset on average).
The earlier frozen shoulder is recognised and treated the better. Physiotherapy and regular exercises can help keep the shoulder from stiffening up. Anti-inflammatory pain relief can also be helpful, as can muscle relaxants and local steroid injections to reduce inflammation. In severe cases surgery can be used to relieve symptoms and help restore freedom of movement in the shoulder.
Charcot joint
Charcot joint is often known as Charcot foot, as the foot is the part of the body most likely to be affected, but it can also affect joints in the ankle, knee and, more occasionally, the wrist and hand. Charcot joint usually affects people who have had diabetes some 15 to 20 years and who are over the age of 50.
High blood glucose levels over a long period of time can lead to neuropathy (nerve damage), and this can lead to a loss of sensation in the foot. The motor nerves, responsible for movement, can also become damaged, and as a result the muscles may no longer be able to support the joint properly. Due to the lack of pain perception, minor injuries or traumas, such as a sprain, can go unnoticed and untreated. This can rapidly progress to a state where the joint becomes dislocated and deformed.
Early signs of an injury or trauma to the foot to watch out for include warmth, redness, a strong pulse and swelling around the foot and ankle. As Charcot joint develops, the joint can rapidly become dislocated, unstable or misaligned, leading to further swelling. Bony overgrowths (osteophytes) can also develop. All this can lead to severe deformity of the foot.
Charcot joint will often be apparent from a person’s medical history and symptoms, although x-rays or magnetic resonance imaging are also used to show misalignments and fractures within the joint. X-rays often show localised osteoporosis (loss of bone density) in the affected joint.
The earlier Charcot joint is detected, then the more effective treatment can be, minimising the risk of permanent deformity and of calluses (areas of hard, thickened skin) or ulcers forming. The joint must be stabilised and therefore rest is very important. Total contact casts or special boots may be required to help immobilise the joint.
There is some evidence that bisphosphonates (a family of drugs used to prevent and treat osteoporosis) may help prevent further bone loss in the affected joint.
In severe cases surgery may be necessary to reshape deformities and remove any bony overgrowths. People with charcot joint, or recovering from charcot joint, may require individualised footwear and will need to be referred to a NHS orthotist (someone who designs and fits special footwear).
Connective tissue – the body tissue that surrounds and links together other tissues and organs
Cartilage – a hard, thin layer of tissue that covers the end of a bone in a joint and minimises friction as the bone moves
Tendons – cord like tissues that connect muscle to bone
Ligaments – a flexible and fibrous tissue that attaches bones together in a joint