Dr Hossein Soleymani Assistant Prof of Rheumatology SSMU, Jan 2015, YAZD, IRAN

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)

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

Condition limited to DM

Diabetic Muscle Infarction

Conditions more frequently in DM  Diabetic cheiroarthrophaty (stiff hand synd)  Trigger finger (flexor tenosynovitis)  Dupuytren’s contracture  Carpal tunnel syndrome  Adhesive shoulder capsulitis (frozen shoulder)Calcific shoulder tendonitis  Reflex sympathetic dystrophy ( shoulder-hand syndrome)  Diabetic osteoarthrophaty or charcot’a or neuropathic arthropathy

Conditions Sharing Risk Factors of DM  Diffuse Idiopathic Skeletal Hyperostosis  Gout/ Pseudogout  Osteoarthritis

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)

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

hand

 Flexion contracture of fingers cause Prayer sign

Cheiroarthropathy

Cheiroarthropathy

 Recommended treatment:  1- Glycemic control  2- Physical therapy  3- NSAIDs with caution

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

Trigger Finger

 Treatments:  1-Change of activity  2- Splint  3- Use of NSAIDs with caution  4- CS injection  5- In severe case surgery

Hand: Dupuytren’s 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

Dupuytren’s contracture

 More in third and fourth finger  More in women  Manifestations are more severe in men

Dupuytren’s contracture

 Treatments:  1- Intralesional injection of CS  2- Surgery  3- Physical therapy  4- Some studies show benefit from injection of collagenase Colstridium Histolyticum

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  Tinel’s sign, Phalen’s test  In dubious case Electrophysiological studies helpfull

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

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

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

Adhesive capsulitis

Treatments:  1- Analgesic  2- Physiotherapy  3- CS injection  4- Arthroscopy release

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

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

Feet: Charcot’s arthropathy

 Diabetic osteoarthropathy  Rare: 0.1% to 0.4%  Both type DM  Average duration 15 years  Advanced peripheral neuropathy

Feet: Charcot’s arthropathy

 Loss of sensation in involved joint  Inadvertent microtrauma to joint  Consecutive degenerative change  Severe destruction, lytic joint changes  Most affect pedal bones

Feet: Charcot’s arthropathy

 Erythema, swelling, hyperpimentation  Purpura, soft tissue ulcer  Joint loosening, instability, joint deformity  Often no history of trauma

Feet: Charcot’s arthropathy

 Diagnosis: based on radiographic findings  Symptoms often milder than view of X-ray  X-raysubluxation, bone fragment, osteolysis  Periosteal reaction, deformity, ankylosis

Feet: Charcot’s arthropathy

 CT sacn is insensitive  MRI and bone scintigraphy adjuncts X-ray  DD: Inflammatory, degenerative, infections, tumors, DVT

Charcot arthropathy

 Treatments:  1- Prevent weight bearing on affected joint  2- Bisphosphanate  3- Calcitonin may be useful

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

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

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

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

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

Other disease with DM

 Osteoporosis: controversy, risk of Fx increased  Osteoarthritis  Hyperurecemia

Thanks For Your Attention