History

Fact Explanation
Pain Affected muscle groups can become extremely painful. Patients complain of aching or burning pain. Initially the pain is localized to the back, hip, or thigh. [1,2,3,4]
Weakness Patients complain of acute or subacute unilateral or asymmetrical weakness of the quadriceps muscles and or shoulder girdle. [1,2,4]
Reduced muscle bulk Some patients may complain of reduced muscle bulk in the legs and in the shoulder girdle due to muscle wasting. [1,2,4]
Recent loss of weight Patients with diabetic amyotrophy may complain of recent weight loss. Weight loss is an initial presenting complain of diabetes mellitus as well. [2,4]
History of diabetes mellitus Elderly patients with type 2 diabetes mellitus, and patients with type 1 diabetes mellitus can develop diabetic amyotrophy, especially if the blood sugar control is poor. [2,3,4]
Evidence of diabetic neuropathy Some patients may complain of coexisting diabetic neuropathy as well. Burning pain, tingling sensations, parasthesiae, hyperasthesiae, and deep aching pain are complains of diabetic neuropathy. [3]
References
  1. GARLAND H. Diabetic Amyotrophy Br Med J [online] 1955 Nov 26, 2(4951):1287-1290 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1981646
  2. COURTNEY A E. Human immunoglobulin for diabetic amyotrophy---a promising prospect?. [online] 2001 May, 77(907):326-328 [viewed 24 September 2014] Available from: doi:10.1136/pmj.77.907.326
  3. BOULTON A. J.M., VINIK A. I., AREZZO J. C., BRIL V., FELDMAN E. L., FREEMAN R., MALIK R. A., MASER R. E., SOSENKO J. M., ZIEGLER D.. Diabetic Neuropathies: A statement by the American Diabetes Association. Diabetes Care [online] 2005 April, 28(4):956-962 [viewed 24 September 2014] Available from: doi:10.2337/diacare.28.4.956
  4. SERBAN A, UDREA G. Rheumatic manifestations in diabetic patients J Med Life [online] 2012 Sep 15, 5(3):252-257 [viewed 24 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464992
  5. LLEWELYN J G.. THE DIABETIC NEUROPATHIES: TYPES, DIAGNOSIS AND MANAGEMENT. [online] 2003 June, 74(90002):15ii-19 [viewed 25 September 2014] Available from: doi:10.1136/jnnp.74.suppl_2.ii15

Examination

Fact Explanation
BMI Most of the patients with diabetes are obese. [3]
Waist to hip ratio Increased waist to hip ratio is associated with increased risk of diabetes. [4]
Muscle wasting Quadriceps muscles of the thigh and muscles of the shoulder girdle shows asymmetrical wasting. [1,2]
Muscle weakness Diabetic amyotrophy results in weakness of the affected muscles of the hip joint and shoulder girdle. [2]
Absent tendon reflexes The deep tendon reflexes are either reduced or absent. [1,2]
Extensor plantar response Extensor plantar response can be detected in some patients. [1]
Blood pressure Hypertension is a common recognized complication of diabetes. [5]
Sensory impairment Distal polyneuropathy may cause sensory loss over the hands and feet (glove and stocking distribution). Isolated cranial nerve palsies or peripheral nerve palsies can also be associated with diabetic neuropathy. [6]
Examination of foot Foot examination is important in patients with diabetes as foot deformities, pressure ulcers and callosities can be associated with neuropathy. Atherosclerosis involving the lower limb vessels (peripheral vascular disease) results in ischemic changes (dry skin, scanty hair, cold foot) and absent or diminished lower limb pulses. [7]
References
  1. GARLAND H. Diabetic Amyotrophy Br Med J [online] 1955 Nov 26, 2(4951):1287-1290 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1981646
  2. COURTNEY A E. Human immunoglobulin for diabetic amyotrophy---a promising prospect?. [online] 2001 May, 77(907):326-328 [viewed 24 September 2014] Available from: doi:10.1136/pmj.77.907.326
  3. HOSSAIN PARVEZ, KAWAR BISHER, EL NAHAS MEGUID. Obesity and Diabetes in the Developing World — A Growing Challenge. N Engl J Med [online] 2007 January, 356(3):213-215 [viewed 25 September 2014] Available from: doi:10.1056/NEJMp068177
  4. QIAO Q., KEINANEN-KIUKAANNIEMI S., KIVELA S.-L.. Association of waist to hip ratio with diabetes among middle-aged subjects with impaired glucose tolerance. The European Journal of Public Health [online] 1997 March, 7(1):106-108 [viewed 25 September 2014] Available from: doi:10.1093/eurpub/7.1.106
  5. SOWERS J. R., EPSTEIN M.. Diabetes Mellitus and Associated Hypertension, Vascular Disease, and Nephropathy : An Update. Hypertension [online] 1995 December, 26(6):869-879 [viewed 25 September 2014] Available from: doi:10.1161/01.HYP.26.6.869
  6. LLEWELYN J G.. THE DIABETIC NEUROPATHIES: TYPES, DIAGNOSIS AND MANAGEMENT. [online] 2003 June, 74(90002):15ii-19 [viewed 25 September 2014] Available from: doi:10.1136/jnnp.74.suppl_2.ii15
  7. Preventive Foot Care in People With Diabetes. Diabetes Care [online] 2003 January, 26(90001):78S-79 [viewed 25 September 2014] Available from: doi:10.2337/diacare.26.2007.S78

Differential Diagnoses

Fact Explanation
Compressive lumbosacral radiculopathy Initial presenting complains of diabetic amyotrophy which include pain in the back, hip or thigh may mimic compressive lumbosacral radiculopathy. [1,2,3]
Chronic inflammatory demyelinating polyneuropathy (CIDP) This is a slowly progressive disease. Patients complain of symmetrical, proximal, and distal muscle weakness with altered sensation. On examination the deep tendon reflexes are either reduced or absent. [1,2,4]
Frozen shoulder About 19% of the patients with DM suffer from frozen shoulder (adhesive capsulitis) and they present with the complain of stiff shoulder joint. Calcific periarthritis of the shoulder is also common in patients with DM. This occurs due to reversible contraction of the joint capsule. [5,6]
Amyotrophic lateral sclerosis Progressive destruction of the anterior horn cells due to ALS, causes weakness of the affected muscles. ALS is irreversible and debilitating. [7]
Guillain-Barre syndrome Guillain-Barre syndrome causes acute, ascending and areflexic paralysis. [8]
References
  1. COURTNEY A E. Human immunoglobulin for diabetic amyotrophy---a promising prospect?. [online] 2001 May, 77(907):326-328 [viewed 24 September 2014] Available from: doi:10.1136/pmj.77.907.326
  2. BOULTON A. J.M., VINIK A. I., AREZZO J. C., BRIL V., FELDMAN E. L., FREEMAN R., MALIK R. A., MASER R. E., SOSENKO J. M., ZIEGLER D.. Diabetic Neuropathies: A statement by the American Diabetes Association. Diabetes Care [online] 2005 April, 28(4):956-962 [viewed 24 September 2014] Available from: doi:10.2337/diacare.28.4.956
  3. STAFFORD M. A., PENG P., HILL D. A.. Sciatica: a review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. British Journal of Anaesthesia [online] 2007 August, 99(4):461-473 [viewed 24 September 2014] Available from: doi:10.1093/bja/aem238
  4. RIPELLINO PAOLO, FLEETWOOD THOMAS, CANTELLO ROBERTO, COMI CRISTOFORO. Treatment of Chronic Inflammatory Demyelinating Polyneuropathy: From Molecular Bases to Practical Considerations. Autoimmune Diseases [online] 2014 December, 2014:1-11 [viewed 24 September 2014] Available from: doi:10.1155/2014/201657
  5. KIM R. P., EDELMAN S. V., KIM D. D.. Musculoskeletal Complications of Diabetes Mellitus. Clinical Diabetes [online] 2001 July, 19(3):132-135 [viewed 24 September 2014] Available from: doi:10.2337/diaclin.19.3.132
  6. THOMAS NAGY MATHIAS. The Frozen Shoulder: Myths and Realities. TOORTHJ [online] 2013 September, 7(1):352-355 [viewed 24 September 2014] Available from: doi:10.2174/1874325001307010352
  7. VENKOVA-HRISTOVA KALINA, CHRISTOV ALEXANDAR, KAMALUDDIN ZARINE, KOBALKA PETER, HENSLEY KENNETH. Progress in Therapy Development for Amyotrophic Lateral Sclerosis. Neurology Research International [online] 2012 December, 2012:1-9 [viewed 24 September 2014] Available from: doi:10.1155/2012/187234
  8. YUKI NOBUHIRO, HARTUNG HANS-PETER. Guillain–Barré Syndrome. N Engl J Med [online] 2012 June, 366(24):2294-2304 [viewed 24 September 2014] Available from: doi:10.1056/NEJMra1114525

Investigations - for Diagnosis

Fact Explanation
Fasting blood sugar Fasting blood sugar of more than 126 mg/dl (7.0 mmol/l) is diagnostic of diabetes mellitus. [3]
Glycosylated hemoglobin (HbA1C) HbA1C of more than 6.5% indicates increased serum glucose and aids in diagnosing diabetes mellitus. Increased levels of HbA1C enables the prediction of macro and micro vascular complications of diabetes. [3,4]
Oral glucose tolerance test Oral glucose tolerance test is helpful in diagnosing diabetes. If the 2hour plasma glucose level is equal or more than 200mg/dl diabetes can be diagnosed. [3]
Cerebro spinal fluid (CSF) full report Some patients may have increased protein concentration in CSF. [1]
Electromyelogram Electromyelogram indicates lesions in the lumbosacral roots, plexus and peripheral nerves. [1,2]
CT/MRI Imaging studies are indicated to rule out cerebral and spinal cord lesions, which can also result in lower limb weakness and wasting. [5]
Nerve conduction studies Affected distal nerves exhibit non-specific abnormalities in the nerve conduction or it can be normal. Nerve conduction studies are helpful in excluding other possible differentials rather than in diagnosing diabetic neuropathy. [6,7]
References
  1. GARLAND H. Diabetic Amyotrophy Br Med J [online] 1955 Nov 26, 2(4951):1287-1290 [viewed 23 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1981646
  2. SERBAN A, UDREA G. Rheumatic manifestations in diabetic patients J Med Life [online] 2012 Sep 15, 5(3):252-257 [viewed 24 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464992
  3. PASNOOR M, DIMACHKIE MM, KLUDING P, BAROHN RJ. DIABETIC NEUROPATHY PART 1: OVERVIEW AND SYMMETRIC PHENOTYPES Neurol Clin [online] 2013 May, 31(2):425-445 [viewed 24 September 2014] Available from: doi:10.1016/j.ncl.2013.02.004
  4. BONORA E., TUOMILEHTO J.. The Pros and Cons of Diagnosing Diabetes With A1C. Diabetes Care [online] December, 34(Supplement_2):S184-S190 [viewed 25 September 2014] Available from: doi:10.2337/dc11-s216
  5. GOLDBERG AL, KERSHAH SM. Advances in Imaging of Vertebral and Spinal Cord Injury J Spinal Cord Med [online] 2010 Apr, 33(2):105-116 [viewed 26 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2869279
  6. LAMONTAGNE A, BUCHTHAL F. Electrophysiological studies in diabetic neuropathy J Neurol Neurosurg Psychiatry [online] 1970 Aug, 33(4):442-452 [viewed 26 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC493498
  7. BANSAL V, KALITA J, MISRA UK. Diabetic neuropathy Postgrad Med J [online] 2006 Feb, 82(964):95-100 [viewed 26 September 2014] Available from: doi:10.1136/pgmj.2005.036137

Investigations - Followup

Fact Explanation
Fasting blood sugar Fasting blood sugar should be regularly monitored in patients with diabetes. [3]
Glycosylated hemoglobin (HbA1C) Glycemic control over the past 3 months is reflected by the HbA1C value. Higher the HbA1C poor the blood sugar control and higher the risk of developing micro and macro vascular complications of diabetes. [2,7]
Renal function test Renal failure can occur secondary to diabetic nephropathy. Assessment of serum electrolytes and serum creatinine are useful initial investigations to detect renal impairment. [1]
Urinary albumin Microalbuminuria (urinary albumin >20 μg/min and ≤199 μg/min) is an early marker of diabetic nephropathy which is potentially reversible. Macroalbuminuria is diagnosed if urinary albumin excretion is more than 200 μg/min. [1]
ECG Myocardial infarction and myocardial ischemia can occur as a macrovascular complication of diabetes. [4,5]
Ophthalmoscope Ophthalmoscopic examination of the optic fundi will aid in making the diagnosis of diabetic retinopathy. Patients with type 1 diabetes mellitus should be followed up with annual ophthalmoscopic examination. [6]
References
  1. GROSS J. L., DE AZEVEDO M. J., SILVEIRO S. P., CANANI L. H., CARAMORI M. L., ZELMANOVITZ T.. Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care [online] 2005 January, 28(1):164-176 [viewed 24 September 2014] Available from: doi:10.2337/diacare.28.1.164
  2. HIRST JENNIFER A., STEVENS RICHARD J., FARMER ANDREW J., BARENGO NOEL CHRISTOPHER. Changes in HbA1c Level over a 12-Week Follow-up in Patients with Type 2 Diabetes following a Medication Change. PLoS ONE [online] 2014 March [viewed 24 September 2014] Available from: doi:10.1371/journal.pone.0092458
  3. KOVATCHEV BORIS P.. Diabetes Technology: Markers, Monitoring, Assessment, and Control of Blood Glucose Fluctuations in Diabetes. Scientifica [online] 2012 December, 2012:1-14 [viewed 24 September 2014] Available from: doi:10.6064/2012/283821
  4. STERN S., SCLAROWSKY S.. The ECG in Diabetes Mellitus. Circulation [online] December, 120(16):1633-1636 [viewed 24 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.109.897496
  5. NESTO R. W., ZARICH S.. Acute Myocardial Infarction in Diabetes Mellitus : Lessons Learned From ACE Inhibition. Circulation [online] 1998 January, 97(1):12-15 [viewed 24 September 2014] Available from: doi:10.1161/01.CIR.97.1.12
  6. GARG S., DAVIS R. M.. Diabetic Retinopathy Screening Update. Clinical Diabetes [online] December, 27(4):140-145 [viewed 24 September 2014] Available from: doi:10.2337/diaclin.27.4.140
  7. LLEWELYN J G.. THE DIABETIC NEUROPATHIES: TYPES, DIAGNOSIS AND MANAGEMENT. [online] 2003 June, 74(90002):15ii-19 [viewed 25 September 2014] Available from: doi:10.1136/jnnp.74.suppl_2.ii15

Investigations - Screening/Staging

Fact Explanation
Ophthalmoscopic examination Screening for retinopathy should be done with ophthalmoscopic examination of the fundi in patients with diabetes. It should be done within the first 5 years of the diagnosis of type 1 diabetes mellitus. [1]
References
  1. GARG S., DAVIS R. M.. Diabetic Retinopathy Screening Update. Clinical Diabetes [online] December, 27(4):140-145 [viewed 24 September 2014] Available from: doi:10.2337/diaclin.27.4.140

Management - General Measures

Fact Explanation
Health education Patients should be educated about the chronic nature of diabetes and the necessity of life long treatment, life style modifications and long term monitoring of blood sugar control. Health education is important in preventing DM. Adherence to healthy dietary habits (more fruits and vegetables, less fat and sugar) and regular exercise are helpful in primordial prevention. Obesity is an important risk factor associated with development of type 2 DM. Obese patients should be encouraged to lose weight and to achieve normal BMI. [3]
Analgesics Patients who complain of pain can be prescribed analgesics, either systemic or topical. These include tricyclic antidepressants, antiepileptic drugs, serotonin-norepinephrine reuptake inhibitors, opiates and opiate-like substances. Tricyclic antidepressants are considered the first line treatment option in managing neuropathic pain in diabetes. [2]
Glycemic control Blood sugar control should be optimum in patients with diabetes, to delay the progression of the disease and to delay the onset of disease related micro and macrovascular complications. Insulin secretagogues (Sulfonylureas) and metformin are commonly used oral hypoglycemic drugs. Patients with type 2 diabetes mellitus can be treated with oral hypoglycemic drugs. Insulin is the second line treatment option in type 2 diabetes mellitus but the first line treatment in type 1 diabetes mellitus. [1,5]
Physical therapy Physical therapy can improve mobility and strength of affected muscles. [1]
Occupational therapy Occupational therapy makes the patients independent in their day-to-day activities. [1]
Control of other risk factors Hypertension, smoking, and dyslipidemia are associated with poor outcome of diabetes and if not optimized patient can develop other macro and microvascular complications of diabetes. [4]
References
  1. SERBAN A, UDREA G. Rheumatic manifestations in diabetic patients J Med Life [online] 2012 Sep 15, 5(3):252-257 [viewed 24 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464992
  2. LINDSAY TJ, RODGERS BC, SAVATH V, HETTINGER K. Treating diabetic peripheral neuropathic pain. Am Fam Physician [online] 2010 Jul 15, 82(2):151-8 [viewed 24 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20642268
  3. HOSSAIN PARVEZ, KAWAR BISHER, EL NAHAS MEGUID. Obesity and Diabetes in the Developing World — A Growing Challenge. N Engl J Med [online] 2007 January, 356(3):213-215 [viewed 24 September 2014] Available from: doi:10.1056/NEJMp068177
  4. GROSS J. L., DE AZEVEDO M. J., SILVEIRO S. P., CANANI L. H., CARAMORI M. L., ZELMANOVITZ T.. Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. Diabetes Care [online] 2005 January, 28(1):164-176 [viewed 24 September 2014] Available from: doi:10.2337/diacare.28.1.164
  5. BECKER MATTHIJS L., PEARSON EWAN R., TKáč IVAN. Pharmacogenetics of Oral Antidiabetic Drugs. International Journal of Endocrinology [online] 2013 December, 2013:1-10 [viewed 25 September 2014] Available from: doi:10.1155/2013/686315

Management - Specific Treatments

Fact Explanation
Conservative management Diabetic amyotrophy is commonly self-limiting and requires no specific treatment. [1,2]
Intravenous immunoglobin (IVIg) Although not widely used, IVIg (0.4 g/kg twice weekly) when given for several months can improve symptoms and muscle power. [1]
Plasma exchange This is one of the immunomodulatory treatment options for the treatment of diabetic amyotrophy. [1]
Corticosteroids Corticosteroids can also be used in the treatment of the diabetic amyotrophy. Pulsed methylprednisolone is proven to be effective. [1,2]
Immunosuppressive agents Immunosuppressive agents that can be used in the treatment of diabetic amyotrophy include cyclophosphamide and methylprednisolone. [2]
References
  1. COURTNEY A E. Human immunoglobulin for diabetic amyotrophy---a promising prospect?. [online] 2001 May, 77(907):326-328 [viewed 24 September 2014] Available from: doi:10.1136/pmj.77.907.326
  2. SERBAN A, UDREA G. Rheumatic manifestations in diabetic patients J Med Life [online] 2012 Sep 15, 5(3):252-257 [viewed 24 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464992