Limited joint mobility in diabetes

Several rheumatologic manifestations are more pronounced in subjects with diabetes, ie, frozen shoulder, rotator cuff tears, Dupuytren’s contracture, trigger finger, cheiroarthropathy in the upper limb, and Achilles tendinopathy and plantar fasciitis in the lower limb. Limited ROM is often significantly affecting ADL, leading to further complications like diabetic foot ulcers and is very difficult to manage or reduce once established.

The most extensive accumulation of AGEs occurs in tissues with low turnover, such as cartilage, bone, and tendon.

This review provides a short description of diabetes-related joint diseases, the specific pathogenetic mechanisms involved, and the role of inflammation, overuse, and genetics, each of which activates a complex sequence of biochemical alterations.

Several pathophysiologic mechanisms appear to be involved in the development of these conditions. These are:

• overuse (as a direct result of neuropathy and obesity, eg Achilles tendinopathy)
• inflammation (shoulder capsulitis)
• trauma (rotator cuff)
• mechanical impingement
• genetics (dysregulated genes lead to uncontrolled fibroblast proliferation)
• immunologic (chronic, low grade, subclinical state of inflammation modulated by cytokines)
• biochemical (specific factors signalling growth factors in Dupuytren)
• endocrine (hyperglycemia causes cheiroarthropathy)

Furthermore, other diabetic complications like central and peripheral neuropathy, microvascular disease, myopathy and renal insufficiency are interacting with quality of connective tissue.

There is a strong relation between diabetic joint disease and glucose levels, duration of disease and age.  Therefore, control of the metabolic disorder is critical. There is some evidence of medication aiming at inhibiting the formation of AGE’s.

Persistent inflammation can be reduced with NSAIDs and corticosteroids, and intra-articular injections of hyaluronic acid are proposed for improving synovial fluid.

High grade mobilization by physiotherapists is effective for capsulitis, and corticosteroid injections  plus tendon release for Dupuytren and trigger finger. However, no systemic or local treatment is satisfactory in reducing cheiroarthopathy.  US and laser offer no added benefits.

Any clinical experience or suggestions to improve impairment and disability resulting form diabetic limited joint movement in the long run?

> From: Abate et al., Diabetes Metab Syndr Obes 6 (2015) 197-207(Epub ahead of print). All rights reserved to The Author(s).Click here for the Pubmed summary.