1. Diabetes and Rheumatic Diseases Dr Adel Hammoudi Diabetes & Endocrine Center Al-Noor Specialist Hospital Holy Makkah, KSA.

3. It is important to recognize the various MS manifestations of DM.

5. Osteoarthritis

6. Degenerative joint disease, degenerative arthritis. Most common rheumatic disease in the general population. a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone Asymptomatic or mild, but severe involvement leads to pain, stiffness, and limitation of motion in the affected joints Knees, hips, and spine

7. Prevalence of osteoarthritis is higher in young and middle-aged diabetic patients* Joint damage starts at an earlier age and is much more severe in diabetic than in control patients* Insulin stimulates cartilage growth. Mediated through insulin-like growth factor-1 *Crisp AJ, Heathcoate JG. Connective tissue abnormalities in diabetes mellitus. J R Coll Physicians 1984;18:132–141.

9. Treatment: control of pain with acetaminophen or NSAIDs, physical therapy (for the strengthening of muscles and tendons), and TKR Diabetes may affect the outcomes of therapy in osteoarthritis.

10. Carpal Tunnel Syndrome

14. 14 – 30% of patients with diabetes will develop carpal tunnel syndrome.*

15. 10-15% of patients with carpal tunnel syndrome will have diabetes*Diabetes Care March 2002 vol. 25 no. 3 565-569

17. Increased incidence in patients with limited joint mobility.

19. Bone Health and Osteoporosis

20. Metabolic conditions including diabetes are thought to impair bone homeostasis. Risk in Diabetics is controversial Type 1 DM tend to have lower BMD: abnormal bone formation or bone turnover, or both possibly leading to decreased bone mineral density (BMD) and increased marrow adiposity.

22. Type 2 DM, post-menopausal women are at greater risk than age-matched non-DM*ActaOrthop 2007; 78:46-55. Biol Trace Elem Res 2007; 116:321-328. ActaHistochem 2007; 109:304-314.

23. Diffuse Idiopathic Skeletal Hyperostosis (DISH)

24. Ankylosing hyperostosis, Forestier’s disease. Characterized by new bone formation, particularly in the thoracolumbar spine. New bone formation around the hips, knees, and wrists has also been noted. Mild back pain and stiffness, but range of motion is preserved More common in Type 2 Diabetes

26. Also associated with hypermetabolic syndrome: high uric acid, obesity, dyslipidemia

27. Chronic elevation in insulin and insulin-like growth factors facilitates calcification and ossification of ligaments and entheseal regions

30. Crystal-induced Arthritis

31. Gout and Hyperuricemia Gout is an acute and chronic arthritis caused by monosodium urate (MSU) crystals. Red, tender, hot, swollen joint (acute phase) Hyperuricemia is a necessary condition for gout, and is part of the constellation of metabolic syndrome. Gout, a 1799 caricature by James Gillray

32. Gout and Hyperuricemia Type II diabetes is also a part of this syndrome an association of gout and type II diabetes would be expected. Renal insufficiency, a common complication of diabetes, also predisposes to gout. Whether the onset of diabetes or its complications exacerbates existent gout or affects outcomes has not been well studied. Treatment: NSAIDs, steroids, or colchicine Allopurinol or probenicid (long-term prevention)

35. Chondrocalcinosis refers to the radiographic evidence of calcification in hyaline and/or fibrocartilage.

37. Radiograph of the wrist and hand showing chondrocalcinosis of the articular disc of the wrist and atypical osteoarthritis involving the metacarpophalangeal joints in a patient with underlying hemochromatosis. Lateral view of the right knee shows severe patellofemoral joint space narrowing. This is a classic finding in chondrocalcinosis caused by CPPD.

38. Charcot Arthropathy

40. Destructive arthropathy in diseases which impair sensory function, but maintain normal motor function

41. Present in 0.1-0.4% of patients with diabetes

47. Tendinopathy

48. Tendinopathies occur frequently in patients with diabetes. The shoulder and hand are particularly commonly involved. Painful tendinopathies affect 30-60% of diabetic patients, and cause considerable disability among affected patients

50. Progressive painful loss of motion in all directions, especially external rotation and abduction.

51. Joint capsule adheres to humeral head

52. 3 phases: painful, adhesive, resolution

53. 11-30% in diabetics, 2-10% in controls

54. 17% patients with adhesive capsulitis have diabetesAnn Rheum Dis 1996;55:907–14

55. Adhesive Capsulitis of the Shoulder Associated with age(T1 & T2DM) and duration of diabetes(T1DM)* In diabetics, occurs at younger age, less painful, responds less to treatment Associated with high morbidity Treatment: steroid injections in early stages, adequate analgesia, exercise Resolves over time *Br J Rheumatol 1986:25:147–151.

56. Shoulder arthrogram showing a contracted and adherent joint capsule in adhesive capsulitis. Smith L L et al. Br J Sports Med 2003;37:30-35

57. Shoulder-Hand Syndrome (SHS) Characterized by adhesive capsulitis of the shoulder associated with pain, swelling, tenderness, dystrophic skin, and vasomotor instability in the hand. It is one of a family of disorders that includes reflex sympathetic dystrophy syndrome, major and minor causalgia, Sudeck atrophy, and algodystrophy.

60. Diabetic Hand Syndrome (DHS) Cheiropathy, stiff-hand syndrome, diabetic stiff hand, diabetic contractures, or syndrome of limited joint mobility. Prevalence is 8 – 53% More common in patients with T1DM Risk increases with poor glycemic control (↑HbA1c ) and duration of diabetes

61. Diabetic Hand Syndrome (DHS) Clinically: stiffness, loss of dexterity, and weakness of hands The skin on the hands is typically thick, tight, and waxy Limitation of flexion and extension occurs Usually MCP, PIPs Decreased grip strength

62. Diabetic Hand Syndrome (DHS) Diagnosis “prayer sign” “table top test” Treatment: optimizing glycemic control and physiotherapy

64. Deposition of periarticular collagen as seen in biopsy

65. Glycosylation of collagen, abnormal cross linking of collagen and increased collagen hydration all contribute

67. Dupuytren Disease Present in 21- 63% of patients with diabetes Prevalence increases with age Generally milder in patients with diabetes compared to patients with other conditions Treatment: Optimize glycemic control, aggressive physiotherapy, NSAIDs, analgesic, Intralesional glucocorticoid injections Rarely surgery is required

71. Caused by fibrous tissue proliferation in the tendon sheath.

72. Limitation of the normal movement of the tendon.

73. Prevalence 11% in DM patient, < 1% in non-DM Pt.

74. There is also an increased incidence in people with impaired glucose tolerance. Associated with the duration of diabetes but not age. Treatment: local corticosteroid injection.

75. Conclusions MSK complications related to diabetes is common and can lead to severe morbidity Having a long duration of diabetes, especially with poor glycemic control, increases the risk of developing many of these conditions Health care teams need to be aware of the potential MSK complications in patients with diabetes Further research is necessary to clearly define the relationship between diabetes and its associated MSK conditions

76. References Joslin's Diabetes Mellitus British Journal of Sports Medicine Medscape.com Wikipedia.com

77. THANK YOU!