Musculoskeletal Disorders and Diabetes

Musculoskeletal Disorders Diabetes

Summary

Diabetes can influence the development and severity of many musculoskeletal disorders. These are conditions that adversely affect muscles and bones.

The higher incidence of musculoskeletal disorders in people with diabetes appears to be partly a result of damage caused by high levels of glucose (blood sugar). In addition to damaging nerves and blood vessels, excess glucose (hyperglycemia) increases the risk of infections and alters the amount and structure of protein and collagen (fibrous protein that strengthens tissue) in a person’s body. Reduced bone density may also occur with diabetes, and is another risk factor for certain musculoskeletal disorders.

Musculoskeletal disorders associated with diabetes can be grouped into four categories:

  • Collagen disorders. Diabetes may cause excessive accumulation of collagen, which can restrict the joints and may cause musculoskeletal disorders such as stiff-hand syndrome and frozen shoulder.
  • Neuromuscular disorders. Nerve damage (neuropathy), a common complication of diabetes, can restrict muscle and body movement. Patients with diabetes may be more susceptible to musculoskeletal disorders that involve nerve damage, such as carpal tunnel syndrome, sciatica, restless leg syndrome, Charcot foot and complex regional pain syndrome.
    Diabetic Neuropathy
  • Autoimmune disorders. People with type 1 diabetes (an autoimmune disorder) have an increased risk of developing other autoimmune diseases, such as rheumatoid arthritis and lupus.
  • Bone and other disorders. People with diabetes have an increased risk of bone loss (e.g., diabetic osteopathy, osteoporosis) and fractures. They may also be more likely to develop other musculoskeletal disorders such as osteoarthritis, gout and myofascial pain syndrome.

Diagnosis of musculoskeletal disorders associated with diabetes may vary, depending on the disorder suspected. After the initial physical examination and compilation of the patient’s medical history, additional tests may include a comprehensive foot exam, neurological examination, and various blood tests, urine tests or imaging tests.

In addition, a patient’s diabetes may conflict with some treatments for musculoskeletal disorders. As a result, patients may have to consult with their physician about adjusting their treatment regimen before using medications designed to treat musculoskeletal disorders.

About musculoskeletal disorders & diabetes

Musculoskeletal disorders are ailments that affect the muscles and bones. People with diabetes are more likely than nondiabetics to be afflicted with some of these disorders. Although the exact reason for this increased risk is not completely understood, it is believed to be partly a result of damage related to high glucose (blood sugar) levels.  

Diabetes is associated with several metabolic disturbances that can alter connective tissue or otherwise can lead to musculoskeletal disorders. Hyperglycemia (excess glucose) and other diabetes-associated metabolic disturbances may lead to conditions such as:

  • Nerve damage (neuropathy)
  • Vascular (blood vessel) damage
  • Change in amount or structure of protein in the body (e.g., glycosylation, when proteins are coated with glucose)
  • Increased levels of collagen (fibrous protein that strengthens tissue) in the body
  • Hyperuricemia (increased levels of a waste product called uric acid)
  • Reduced bone density (particularly with type 1 diabetes)
  • Susceptibility to infection (e.g., osteomyelitis)

The above possible complications of diabetes may also put a person at riskof developing certain musculoskeletal disorders. Musculoskeletal disorders associated with diabetes can be grouped into four categories:

  • Collagen disorders. Collagen is a fibrous protein found in bone, cartilage, tendon and other connective tissue. Excessive amounts of collagen may accumulate as a result of diabetes, restricting joint movement.
  • Neuromuscular disorders. These involve disorders of the nerves and muscles. Nerve damage is a common complication of diabetes and can adversely affect the movement of muscles and body parts.
  • Autoimmune disorders. People with type 1 diabetes (an autoimmune disorder) have an increased risk of developing other types of autoimmune diseases that can affect the muscles and bones.
  • Bone and other disorders. People with diabetes have an increased risk of bone loss and fractures, as well as other musculoskeletal disorders.

Collagen disorders

Certain collagen disorders that affect the muscles and bones of the body are associated with diabetes. Collagen is a fibrous protein found in bone, cartilage, tendon and other connective tissue. When abnormal levels of collagen accumulate in the skin and tendons (as may occur in patients with diabetes), it can lead to various collagen disorders that impair muscles and body movement.

Collagen disorders associated with diabetes include:

  • Stiff-hand syndrome (cheiroarthropathy). Characterized by thickening and hardening of the skin and an inability to fully extend the fingers. The skin appears tight and waxy. Therapy usually involves analgesics (painkillers) or anti-inflammatories. Good control of glucose (blood sugar) can halt or slow the process but cannot reverse it.
  • Frozen shoulder (adhesive capsulitis). Involves stiffness, pain and restriction in shoulder movement. Although frozen shoulder can occur in nondiabetic people, it is far more common in patients with diabetes. It is unknown whether abnormal glucose levels contribute to frozen shoulder. The condition usually involves contraction of the joint capsule (thin membrane covering a joint) that eventually resolves itself, although it can last one or two years. Treatments include physical therapy, analgesics, corticosteroid injections and surgery. Calcific periarthritis (associated with calcium deposits outside of the shoulder joint) also affects many patients with diabetes, but frequently is asymptomatic.
  • Flexor tenosynovitis. Caused by inflammation or formation of excessive fibrous tissue of the flexor tendons of the fingers. Fingers affected by flexor tenosynovitis lock into place when flexed (bent). Extension of the finger is often painful and may cause a snapping sound. A painful nodular area may be felt along the flexor tendon.  This  collagen disorder most often occurs early in the development of diabetes and is treated with corticosteroid injection or surgery.
  • Dupuytren’s contracture. A thickening of the fibrous connective tissue of the palm of the hand. This leads to skin puckering as well as the bending and shortening of the third (middle) through fifth (pinky) fingers. Dupuytren’s contracture most often affects middle-aged and older men and may also be triggered by excessive consumption of alcohol. It is difficult to treat, although injection therapy or surgery may sometimes be successful.

Neuromuscular disorders

Certain neuromuscular disorders are associated with diabetes. Peripheral neuropathy is a common complication of diabetes. Peripheral neuropathy involves damage to the nerves of the peripheral nervous system, and primarily affects the limbs.  

Nerve damage (neuropathy) is involved in many different neuromuscular disorders that may be associated with diabetes, such as:

  • Charcot foot (Charcot’s arthropathy). Involves damage to the ankle or foot. Patients with diabetes who suffer nerve damage may fail to notice a fracture or other disorder due to insensitivity in the limbs due to peripheral neuropathy. Damage to the ankle or foot can also lead to foot ulcers that become infected. Patients with diabetes are advised to perform daily inspections and foot care, and to see a physician for periodic comprehensive foot exams.
  • Entrapment syndromes. Disorders in which a nerve is compressed or pinched. Entrapment syndromes may be considered a type of focal neuropathy. Examples include carpal tunnel syndrome (in which the median nerve is compressed in the wrist) and sciatica (in which compression of one of the sciatic nerves causes pain in the lower back and leg).
  • Restless legs syndrome (RLS). A condition in which discomfort is perceived in the legs (and occasionally the arms) when at rest, resulting in an urge to move the limbs. RLS disrupts sleep and can lead to daytime fatigue. The cause of primary RLS is unknown. Secondary RLS may result from conditions such as diabetic neuropathy, pregnancy, chronic kidney failure or the use of certain medications.
  • Complex regional pain syndrome (CRPS). A chronic pain disorder that can follow mild or severe trauma or other painful conditions, such as radiculopathy (disease of the spinal nerve roots). CRPS may include allodynia (when normally noninjurious stimuli cause pain) and symptoms of skin flushing, blanching and temperature different from unaffected areas of the body. Patients often avoid using the limb affected by CRPS. Treatment may include physical therapy or analgesics or other medications. CRPS encompasses two disorders formerly known as reflex sympathetic dystrophy (RSD) and causalgia.
  • Bell’s palsy. A temporary form of facial paralysis caused by damage to a facial nerve. Conditions associated with Bell’s palsy include infections, diabetes, headaches and high blood pressure.
  • Parkinson’s disease. A progressive nerve disease marked by tremors and muscular weakness and rigidity. Recent research suggests that people with type 2 diabetes may, for unknown reasons, be more likely than others to develop Parkinson’s disease.

Autoimmune disorders

Some autoimmune disorders that affect the muscles and bones are associated with diabetes. Type 1 diabetes is an autoimmune disorder, meaning the body’s immune system mistakenly attacks healthy body tissues. In people with type 1 diabetes, the immune system attacks the insulin-making beta cells of the pancreas. People with one autoimmune disease are at risk of developing another. Thus, people with type 1 diabetes have an increased risk of developing other types of autoimmune disorders.

Autoimmune disorders that can affect the muscles and bones, and may be associated with diabetes include:

  • Certain thyroid disorders. This may include diseases involving a thyroid gland that becomes underactive (hypothyroidism) or overactive (hyperthyroidism). A thyroid disorder called Hashimoto’s thyroiditis frequently leads to hypothyroidism, and can involve muscle weakness, cramps and fatigue. Graves’ disease, the most common cause of hyperthyroidism, is sometimes marked by muscle weakness, insomnia and unexplained weight loss.
  • Rheumatoid arthritis. A debilitating form of arthritis that swells and damages joints.
  • Lupus. A chronic inflammatory disease that can involve many parts of the body, including the joints, skin, kidneys, blood vessels, heart, lungs and brain. The most common and most serious form of lupus is called systemic lupus erythematosus (SLE). Possible complications include pregnancy difficulties and stroke.
  • Multiple sclerosis (MS). Disease in which the immune system destroys the myelin (a protective sheath) surrounding nerves in the brain and spinal cord. Some cases of MS are mild, but others progressively worsen and cause paralysis.
  • Sjogren’s syndrome. Disease marked by the destruction of the salivary and tear glands. It can also involve damage to the kidneys, pancreas, blood vessels, lungs and other organs.
  • Scleroderma (systemic sclerosis). Chronic disease that tightens and thickens the skin and can damage internal organs.
  • Addison disease. A hormone deficiency caused by autoimmune or other damage to the adrenal glands.
  • Guillain-Barre syndrome. A rare neuromuscular condition in which the immune system attacks nerves of the peripheral nervous system.

Bone and other disorders

Some types of bone disorders are associated with diabetes. Of particular concern to patients with diabetes is bone disease (diabetic osteopathy) and fractures. Multiple recent studies show that women and men with type 1 diabetes or type 2 diabetes are at greater risk for fractures and osteoporosis, a bone-thinning disease most common in postmenopausal women. In addition, studies show that diabetes complicates recovery from joint replacements and surgeries to repair fractures.

Other musculoskeletal disorders linked to diabetes include:

  • Gout. An especially painful form of arthritis involving excess uric acid (hyperuricemia). Uric acid is a waste product that can form needle-like crystals in joints (most often in the big toe) and other tissues. Risk factors for gout include type 2 diabetes and many conditions associated with diabetes, including obesity, high blood pressure, heart disease, kidney disease and hyperlipidemia (unhealthy levels of cholesterol and other blood fats). Excess uric acid also contributes to diabetic patients’ increased risk of kidney stones.
  • Osteoarthritis. The most common form of arthritis, characterized by chronic degeneration of the cartilage of the joints. Conditions that can increase the risk of developing osteoarthritis include other types of arthritis, obesity, diabetic neuropathy and hemochromatosis, a blood disorder that is also a risk factor for diabetes.
  • Diffuse idiopathic skeletal hyperostosis (DISH). Enlargement of the bone, with the spine being most often affected in patients with diabetes.
  • Musculoskeletal infections. These include osteomyelitis, septic arthritis and pyomyositis, a bacterial infection of skeletal muscle. If not resolved, osteomyelitis may lead to gangrene and the need for amputation.
  • Diabetic muscle infarction. A painful muscle disorder featuring edema, pain and tenderness, usually involving the thighs.
  • Myofascial pain syndrome (MPS). A disorder that develops in skeletal muscles and the membranes (fascia) that cover them. Patients have specific areas of deep tenderness, called trigger points, that may occur as a result of trauma, repetitive motion injuries, prolonged improper posture, or diseases such as arthritis, diabetes or hypothyroidism (underactive thyroid gland).
  • Meningitis. Inflammation of the membranes (meninges) that cover the spinal cord and brain. Diabetes and other disorders that impair the immune system increase the risk of meningitis.
  • Acromegaly. An endocrine disorder in which the pituitary gland makes excess growth hormones. Symptoms include abnormal growth of the hands and feet. It can cause many complications including heart disease, high blood pressure, arthritis and carpal tunnel syndrome. Acromegaly is a risk factor for diabetes.

Diagnosis methods

A physician typically begins diagnosis of musculoskeletal disorders associated with diabetes with a physical examination and a review of the patient’s medical history. Depending on the type of condition suspected, a comprehensive foot exam that includes the use of a microfilament, and a neurological examination may be performed. Additional testing may include an electromyography (EMG), a nerve conduction velocity (NCV) test or quantitative sensory testing (QST).

Blood tests and other laboratory tests may also help in diagnosing musculoskeletal conditions associated with diabetes. They may also be used to rule out other causes of a patient’s symptoms. These tests may include:

  • Autoantibody tests may indicate autoimmune disorders such as rheumatoid arthritis, lupus or scleroderma.

  • An electrolyte panel can show mineral deficiencies caused by bone disorders or sarcoidosis.

  • Erythrocyte sedimentation rate (ESR) and rheumatoid factor (RF) tests may be used to identify the presence of inflammation in the body.

  • Thyroid blood tests can help in diagnosing thyroid disorders.

  • Waste product tests or urine tests may reveal kidney damage caused by conditions such as gout, lupus or scleroderma.

Imaging tests are often useful. These may include x-rays, ultrasound, bone scans or other radionuclide imaging, MRI (magnetic resonance imaging), CAT scan (computed axial tomography) or thyroid imaging tests.

Depending on test results, a physician may refer the patient to a specialist such as a rheumatologist (specializing in inflammation or pain in muscles and joints), orthopedist, podiatrist or pain management physician. Referrals for physical therapy or occupational therapy may also be provided. These rehabilitation therapies may offer treatment such as exercise, gait training, activities to improve balance and coordination, therapeutic ultrasound and instruction in the use of adaptive equipment.

Treatment and prevention

Treatment and prevention of musculoskeletal disorders associated with diabetes may come with special precautions. This is particularly true of three groups of medications:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs). This class of over-the-counter and prescription drugs includes aspirin, ibuprofen and naproxen. Side effects include gastrointestinal irritation, which can lead to internal ulceration and bleeding. People with diabetes are even more susceptible to this side effect. Furthermore, aspirin may increase the action of insulin and lead to hypoglycemia. This side effect is a particular concern for people with hypoglycemia unawareness.

    NSAIDs may also damage the kidneys. This is a particular concern for patients who have or are at risk of developing kidney diseases such as proteinuria, diabetic nephropathy or end-stage renal disease (ESRD). Patients taking NSAIDs are advised to ask their physician about having kidney function tests such as microalbuminuria testing or a glomerular filtration rate test.

  • Corticosteroids (glucocorticoids). These medications may be used for their anti-inflammatory and immunosuppressive properties, but they can also cause glucose (blood sugar) to rise. Long-term use of corticosteroids can lead to conditions including diabetes, glaucoma, cataracts, osteoporosis and fractures. Patients with diabetes who have no alternative to using corticosteroids may need to consult their physician about adjusting the dosage or frequency of their insulin or antidiabetic agents. The American College of Rheumatology recommends that people on long-term corticosteroid therapy also take bisphosphonates, a class of drugs that helps to increase bone density.

  • Antidepressants. People suffering from chronic musculoskeletal disorders have an increased risk of depression, which is also common in people with diabetes. Antidepressants are often prescribed to treat depression and sometimes used to treat chronic pain caused by certain conditions associated with diabetes, including peripheral neuropathy. Research has shown that antidepressants may cause hyperglycemia and be a risk factor for diabetes. Diabetic patients taking antidepressants should inform their physician, who may recommend more frequent glucose monitoring or adjust the patient’s medication.

Other medications that may affect control of glucose or lead to secondary diabetes include some anticonvulsant drugs used to treat peripheral neuropathy and Parkinson’s disease.

The supplement glucosamine is a popular remedy for relieving symptoms of osteoarthritis and other conditions, although research has produced mixed results on its effectiveness. Diabetic patients are advised to consult their physician before taking glucosamine because it may alter glucose levels.

Antidiabetic agents interact well with most other medications, including those used to treat musculoskeletal disorders, but there are exceptions. For example:

  • Biguanides (e.g., metformin) may clash with morphine, an opioid painkiller.

  • Meglitinides may conflict with some antibiotics, anticonvulsants, antifungals, corticosteroids and gout medications.

  • Sulfonylureas may react with some antifungals, antidepressants, corticosteroids and salicylates (aspirin).

  • Thiazolidinediones may interact with some antifungals, corticosteroids and sleep aids.

Exercise, a cornerstone of most diabetes treatment plans, is also commonly recommended to treat or prevent musculoskeletal conditions. For example, weight-bearing exercises such as walking or tennis strengthen bones and reduce the risk of osteoporosis and fractures. All patients, especially those with diabetes, should get clearance from their physician before starting an exercise program. Certain conditions, such as foot ulcers, may rule out some activities.

Diet, another cornerstone of diabetes treatment, may also help prevent some musculoskeletal disorders. For example, adequate intake of calcium and vitamin D can help reduce the risk of osteoporosis and fractures, and a mineral called selenium may lower the risk of osteoarthritis. Patients may wish to ask a dietitian for recommendations on how their diabetic meal plan can also help prevent musculoskeletal disorders.

Avoidance of smoking and restriction of alcohol, which are often recommended for people with diabetes, can also reduce the risk of some musculoskeletal disorders, such as osteoporosis, osteomyelitis, rheumatoid arthritis and gout.

Other diabetes interventions that can help in treating or preventing musculoskeletal disorders include glucose control and regular foot examinations, foot care and skin care.

Patients are advised to ask their physician about how often they may need to undergo screening tests, such as a bone density x-ray scan (also known as DEXA) for osteoporosis or thyroid blood tests for thyroid disorders.

Questions for your doctor

Preparing questions in advance can help patients have more meaningful discussions with healthcare providers regarding their conditions. Patients may wish to ask their doctor the following questions about musculoskeletal disorders and diabetes:

  1. How does my diabetes affect my risk of developing musculoskeletal conditions?
  2. Do I have a musculoskeletal disorder or symptoms that may indicate one?
  3. What diagnostic tests might I need to undergo, and what do they involve?
  4. What do my test results show?
  5. What are my treatment options, and which do you recommend?
  6. Do I need to see a specialist, such as a rheumatologist, orthopedist or physical therapist?
  7. Can medications or other treatments for my musculoskeletal disorder affect my diabetes? Will my diabetes treatment plan need to be adjusted?
  8. Are there any medications or supplements I need to avoid?
  9. Can any treatments or preventive methods for musculoskeletal conditions also help manage my diabetes?
  10. How often should I have a foot exam? Do I need to undergo other regular preventive screenings, such as a bone density test for osteoporosis?
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