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The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus in a Kashmiri Population

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The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus in a Kashmiri Population International Journal of Health Sciences, Qassim University, Vol. 10, No. 1 (Jan-Mar 2016) The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus in a Kashmiri Population Tariq Ahmed Bhat, (1) Shabir Ahmed Dhar, (1) Tahir Ahmed Dar, (1) Muzzaffar Ahmed Naikoo, (1) Mubarik Ahmed Naqqash, (1) Ajaz Bhat, (1) Mohammed Farooq Butt, (2) SKIMS MC Bemina Srinagar Kashmir India (1) GMC Jammu India (2) Abstract Objectives: Diabetes mellitus (DM), is affecting an ever increasing number of people worldwide. Diabetes is associated with several musculoskeletal manifestations. These may involve, the upper as well as the lower limb. We conducted this study to find out the prevalence of musculoskeletal problems in type 2 diabetics in the Kashmiri population. Methodology: The study was conducted on 403 patients with diabetes and 300 controls. All patients underwent screening for any musculoskeletal abnormalities. The patients with musculoskeletal abnormalities were further assessed to find the exact diagnosis according to predefined criteria. Results: The hand was involved in 80 patients [19.8%] in the diabetic group and 15 (5%) patients of the control group. The elbow was affected in 56 patients [14%] in the diabetic group and 24 patients [5.9%] in the non-diabetic group. The shoulder involvement was diagnosed in 61 patients [15%] on the diabetic cohort and 15 patients in the non-diabetic cohort. All the upper limb figures showed a statistically significant difference i.e. P value <0.05. Conclusion: The prevalence of musculoskeletal complications in type 2 diabetics in Kashmir is quite high. Corresponding Author: Shabir Ahmed Dhar MS SKIMS MC Bemina Srinagar, Kashmir, India Cell No. 9419489933, PIN 190017. Email: [email protected] 58 The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus… Introduction As one can appreciate that the hands, Diabetes Mellitus is a very common disorder. shoulders, feet, muscles, and skeleton are The prevalence of diabetes for all age groups some of the frequently affected sites. Although worldwide was estimated to be of 2.8% in 2000 there is often no "cure" for these problems, and is predicted to affect 4.4% in 2030. The total there are treatments available that can number of people with diabetes is projected to significantly improve function and quality of life rise from 171 million in 2000 to 366 million in for diabetics with rheumatologic problems. [5] 2030. [1] The prevalence of these complications in the Diabetes is associated with a number of region of Kashmir is unknown. The aim of this complications including renal disease, study was to find the prevalence of regional peripheral neuropathy, retinopathy, and musculoskeletal manifestations in the Kashmiri vascular events. Due to its multi-systemic population. nature, the development of additional manifestations such as musculoskeletal Material and methods complications is possible. Rheumatic disorders A cross-sectional study was performed in in DM have been associated with disease 403 adult DM patients and 300 non-diabetic duration, degree of metabolic control, and the subjects attending the OPD of the SKIMS MC presence of end organ damage. Bemina from June 2013 to April 2015. DM Musculoskeletal complications of diabetes can patients were ≥30 years old and fulfilled the be grouped into the following categories. [2, 3] National Diabetes Data Group Classification a. consequences of diabetic which defines diabetes as present from any two complications. of the following tests on different days. [6] b. consequences of metabolic (1) Symptoms of diabetes plus casual plasma derangements inherent to diabetes. glucose concentration≥200 mg/dL. c. syndromes that may share etiologic (2) Fasting plasma glucose≥126 mg/dL. mechanisms with microvascular (3) 2-h plasma glucose≥ 200 mg/dL during an disease. oral glucose tolerance test. d. probable associations. For all patients with diabetes a GALS (gait, The complications are also grouped into various arm, legs, spine) screening was performed groups according to the presentation. [3, 4] These which if significant lead to REMS (Regional are examination for musculoskeletal system) and 1. Syndromes of limited joint mobility the following abnormalities were noted. The mainly involve upper limb various rheumatologic manifestations were musculoskeletal structures and seem to diagnosed on the basis of the following clinical be associated with diabetes duration, features. poor metabolic control and presence of Diabetic chieroarthropathy; Two clinical sign microvascular complications. These were essential for the diagnosis: prayer sign include diabetic chieroarthropathy, (the patient is unable to approximate the palmar Dupuytrens contracture, trigger finger surface of the fingers when raising the hands as and adhesive capsulitis. if in prayer) and the tabletop sign (when the 2. Osteoporosis. Which may occur due to patient is asked to lay the palms flat on the the disease but can also be a tabletop he is unable to touch the palmar consequence of the treatment. surface of the fingers to the table). 3. DISH. Diffuse idiopathic skeletal Dupuytren’s contracture; the presence of a hyperostosis. There is ligamentous palmar or digital nodule, tethering of palmar or ossification of the anterolateral aspect digital skin, a pretendinous band and a digital of the spinal column, sometimes flexion contracture, palpable thickening of the leading to bony ankylosis. palmar fascia, with a flexor deformity of the 4. Neuropathies. These include the second, third, fourth, or fifth fingers. neuropathic arthritis, carpal tunnel Flexor tenosynovitis; Palpable nodule or syndrome, diabetic amyotrophy and thickening flexor tendon, and/or locking during reflex sympathetic dystrophy. extension and flexion of any finger 5. Diabetic muscle infarction. Tariq Ahmed Bhat et al… 59 De Quervain’s tenosynovitis; Pain and the absence of apophyseal joint degeneration tenderness over radial styloid with a positive or sacroiliac inflammatory changes. Finkelstein maneuver. Neuroarthropathy; The diagnosis is based Olecranon bursitis; Pain, tenderness, and on clinical features, laboratory tests and swelling at the location of the olecranon bursa. imaging studies. Clinical features include Lateral epicondilytis; Pain and tenderness erythema, warmth, foot deformity, a medical over the lateral epicondyle with pain against history of long-standing diabetes. Radiographic resistance on wrist extension. aspects are important in diagnosing Charcot Medial epicondilytis; Pain and tenderness neuroarthropathy, although they are not present over the medial epicondyle with pain against in patients with stage 0 disease. resistance on wrist flexion. Carpal tunnel syndrome; was diagnosed by Adhesive capsulitis; Adhesive capsultis was the relevant history, the Tinel sign, triggered by defined as history of unilateral and/or bilateral the percussion of the carpal tunnel [the patient pain in the deltoid area with no history of trauma reports pain resembling an electric sensation and equal restriction of active and passive along the course of the median nerve] and, the glenohumeral movement in a capsular pattern Phalen test - the patient has to hold the hands (external rotation > abduction > internal against each other in full palmar flexion, rotation) paresthesias beginning between 30 to 120 s in Rotator’s cuff tendinitis; Shoulder pain on this position. These findings were confirmed by active abduction (specially 60° and 120°), electrodiagnostic tests. tenderness over the greater tuberosity, and Diabetic amyotrophy; The diagnosis was positive impingement sign. based on a clinical presentation [wasting of the Bicipital tendinitis; Anterior shoulder pain proximal upper or lower extremity muscles or worsened with active flexion, tenderness over the paraspinal muscles, preceded by severe the bicipital groove, and positive Yergason’s pain and dyesthesia of the involved part], the maneuver and/or Speed’s test. presence of diabetes and neural studies. Trochanteric bursitis; Pain and tenderness at Diabetic sclerodactyly was defined as the location of the trochanteric bursa. thickening of the skin on the dorsal aspect of the Pre-patellar bursitis; Pain, tenderness, and hand in association with limited joint mobility in swelling at the location of the pre-patellar bursa. the absence of Raynaud phenomenon, Anserine bursitis Pain, tenderness, and calcinosis, and telangiectasia. swelling at the location of the anserine bursa Diabetic osteolysis was characterized by Osteoporosis; Osteoporosis was diagnosed osteoporosis of the proximal phalanges in the on the basis of Singh’s criteria based on the hands and feet, documented by X-ray trabecular pattern of the proximal femur. radiographs. DISH; The diagnosis of DISH was based on Diabetic muscle infarction was defined as a radiologic features. Radiographic criteria for the palpable painful mass with swelling and diagnosis require the involvement of at least induration of the surrounding tissue without four contiguous thoracic vertebral segments, systemic symptoms, in addition to evidence of preservation of intervertebral disc spaces and edema in the muscle on magnetic resonance imaging. Results Table 1 Number of Patients Diabetics : 403 Non Diabetic: 300 P value Age [average in 51.6 52.1 0.2 years] Male : Female 144/259 104/196 0.9 Disease duration 6.9 yrs [average] - GALS screening 223 [55.33%] 83 [27.6%] <0.001 60 The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus… Average age in years ( P. Value =0.2) 52.2 52.1 52 51.9
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