musculoskeletal disorders in diabetes mellitus, shariati hospital, physical medicine and rehabilitation,

1. Shariati Hospital
Endocrinology and Metabolism Research Center (EMRC)
Tehran University of Medical Sciences (TUMS)
02/04/2016
19th Annual Iranian Congress of PM&R

2. Diabetes Mellitus; the third most populous country
(more than 350 million people)
A chronic metabolic disease of high morbidity and
mortality which has become a public health problem.
Alarm: increasing of Type 2 DM at
younger ages because of lifestyle
behaviors such as limited physical
activity, excessive food intake,
and greater prevalence of obesity.

3. Upper
extremity
Adhesive capsulitis, calcific periarthritis in shoulder,
Dupuytren contracture, limited joint mobility, carpal tunnel
syndrome, flexor tenosyinovitis, complex regional pain
syndrome
Lower
extremity
Hip avascular necrosis (AVN), restless leg syndrome (RLS),
posterior tibial tendon rupture, Charcot’s arthropathy,
osteoarthritis, diabetic muscle infarction, diabetic foot,
adhesive capsulitis of hip, femoral and peroneal
mononeuropathies,, hammer toe, mallet and claw toe, limb
amputations
Spine Diffuse idiopathic skeletal hyperostosis (DISH),
radiculopathies, Lumbosacral spondylosis (OA)
Totally Osteopenia, sarcopenia

4. Painful restricted shoulder with normal radiographs
2 to 4 times more common in women than men
Most frequently between 40 and 60 years of age
Usually an idiopathic condition (Primary)
Associated with: DM, inflammatory arthritis, trauma,
prolonged immobilization, thyroid disease, CVA, MI, or
autoimmune disease

5. Stages 1 and 2:
Physical modalities and acupuncture
Anti-inflammatories and analgesics
Intra-articular or subacromial injections
Activity modification
Postural retraining
Therapeutic exercises
Stages 3 and 4:
Advanced exercises
Capsular hydrodilatation, manipulation under anesthesia, and
arthroscopic lysis (refractory cases)
(passive and active assisted ROM, isometrics, &
CKC)

6. Pain is often aggravated by elevation of the arm above shoulder
level or by lying on the shoulder.
Usually calcific deposits visible on X-ray and ultrasound
Treatment
Dietary calcium restriction
Extracorporeal shock wave therapy
Medications
Physical modalities
Injections, needling, and lavage
Corticosteroid injections
Surgery [with high success rates (around 90%) in refractories]

7. Approximately 16-42% of adult with DM
Fibrosis in and around the palmar fascia, with nodule formation
and contracture of the palmar fascia leading to flexion contractures
of the digits (MCP & PIP).
Associated with: age, sex (men),
duration of diabetes, racial and genetic
factors, chronic liver disease
Risk factors: repetitive handling tasks or vibration, other localized
fibroses, cigarette smoking and alcohol consumption, use of
anticonvulsants
Mostly fourth and fifth fingers
Alarm: malignant neoplasm

8. Conventional noninvasive treatment
Physical modalities
Splint
Continuous passive traction
Adaptive equipment
Procedures
Fasciotomy with closed needle and
collagenase injections, prolotherapy, steroid
injection
Surgery

9. Nodule formation, pain and locking phenomena.
Mostly the ring finger, middle finger, and thumb
which is typically at the MCP joint with bilateral
involvement.
Approximately 20% of adult with DM

10. Rest from provocative activities
Local steroid injection (A-1 pulley)
Splint or buddy taping
(for 4 to 6 weeks)
Wearing padded gloves
Physical modalities
NSAIDs
Surgery
(refractory cases )

11. Painless stiffening of the joints due to
thickening and waxiness the dorsal surface of
the fingers (like Sclerodermia)
The prevalence in DM: 8 to 58%
Associated with: Age, the duration of diabetes,
glycemic level (A1C), cigarette smoking,
microvascular complications.

12. Good glycemic control
Physical modalities
Passive palmar stretching
Cessation of smoking
Medications
(penicillamine & aminoguanidine)

13. Overactivity of
the sympathetic nervous
CRPS I (minor or no injury)
CRPS II (causalgia)
Refers to nerve injury
Stage 1: Mild diffuse pain with inflammation
Stage 2: Moderate pain and pallor
Stage 3: Unyielding pain, atrophia, and
contracture

14. Treatment:
Medication (pain reduction)
Intensive PT & OT
Acupuncture, HBOT, and
mirror therapy
Neuromodulation
Pain procedures (blocks)
Percutaneous Surgery
Prevention:
A 50-day regimen of daily vitamin C of at least 500 mg

15. The femoral head is the most common
Caused by various conditions, including trauma, high
doses of corticosteroids, alcohol abuse, diabetes, SLE,
and SCA.
Symptoms: similar to hip OA
Physical findings are largely nonspecific.
In earlier stages:
Plain films and MRI can be normal and
abnormal, respectively
In severe cases: Collapse and OA

16. The treatment of osteonecrosis remains one
of the most controversial subjects
Nonoperative management
Partial WB with crutches, WB as tolerated
Medication
ESWT, electrical stimulation, and
hyperbaric oxygen
pulsed electromagnetic fields
Joint-preserving procedures
Joint replacement

17. Diagnostic criteria for RLS
1. An urge to move the legs
●The urge to move or unpleasant sensations
2. Begin or worsen during periods of rest or inactivity
3. Partially or totally relieved by movement
4. Worse in the evening or night
5. Symptoms are not solely accounted for by another medical or
behavioral condition
Mostly are primary with positive FH but associated conditions
as secondary RLS including iron deficiency, uremia, NP, DM,
SCI, MS, PD, carcinoma, and pregnancy

18. Pharmacologic:
For primary RLS (symptomatic)
For secondary disease
(curative possible).
Nonpharmacologic:
Sleep hygiene measures
Avoidance of caffeine, alcohol, and nicotine
Discontinuation some drugs
Exercise
Physical modalities before bedtime
Acupuncture

19. Diabetic neuropathic joint disease most commonly affects foot and
ankle, (in contrast to tabes dorsalis and syringomyelia)
The most frequently tarsus and tarsometatarsal joints
Uncommon: 0.1% to 0.4%
Typically in longstanding diabetes (>15 years)
The diagnosis should be considered in any patient with diabetes who
presents with a unilateral warm, swollen, erythematous foot, particularly
in the context of peripheral neuropathy and longstanding disease.
Symptoms often milder than view of X-ray.
X-ray:
Subluxation, bone fragment, osteolysis,
periosteal reaction, deformity, ankylosis
Isotope scan and MRI

20. In the earlier stages (acute therapy):
Offloading [non WB and Total contact cast or patellar tendon-bearing
(PTB) brace and Charcot’s restraint orthotic walker (CROW)]
Prefabricated walking braces or orthosis and wheelchair
Bisphosphonate
Intranasal calcitonin
In the later stages (irreversible):
The goal of treatment: correction of tightness, good
podiatry and specialized footwear and orthoses is to
maintain a stable plantigrade foot that is free of
ulceration and infection
Disease of the hindfoot and ankle appears to have a worse prognosis
than disease of the midfoot.
Surgical correction is best avoided in most patients

21. Hammer toe: An abnormal flexion posture at the PIP joint of one
or more of the lesser four toes +/- MTP hyperextension
More commonly in women
The most common of the lesser toe deformities
Contributing factors: long-term wear of poorly fitting shoes,
especially those with tight, narrow toe boxes, overlapping from hallux
valgus, a long second ray, diabetes, connective tissue disease, and
trauma
Claw toe: An abnormal flexion
posture at the DIP and PIP joints
Mallet toe: An abnormal flexion
posture at the DIP joint with normal PIP
and MTP

22. Foot care education
High heel avoidance
Shoes with wide and deep toe box
Stretching and strengthening exercises
Medication
Debridement of calluses
Orthesis
PIP steroid injection
Surgery

23. Noninflammatory disease, with calcification and ossification of spinal
ligaments and of peripheral entheses.
Radiographic changes +/- musculoskeletal symptoms.
Thoracic spine most commonly affected.
Tolerable pain with morning stiffness in neck and back
Radiographs of the thoracic spine as the initial
diagnostic study
Treatment:
Medication
Physical modalities
Peripheral orthotics and injections
Functional exercise programs
(stretching, strengthening, aerobics with swimming)
Surgery: dysphagia and cervical spinal cord compression, root lesion and
TOS, Horner's syndrome, recurrent laryngeal nerve palsy, and vertebral
artery insufficiency

24. Hypoglycemic drugs major interactions:
Methylprednisolone: increased blood glucose
Aspirin: decreased blood sugar
Hyperglycemia after steroid injection:
Intra-articular: peak around 48h, can remain up to 5 days
Epidural: may up to 14 days

25. Thanks For Your Attention