History

Fact Explanation
History of diabetes mellitus Patients have a long history of diabetes mellitus (DM). Patients with type 1 DM are at higher risk than the patients with type 2 DM, because of the long duration of disease. [1]
Stiff hands Diabetic cheiroarthropathy affecting the hands causes stiff hands with limited joint mobility later progressing to deformed hands due to contractures. [1,3,5]
Symptoms of trigger finger Patients complain of catching sensation and associated pain while they try to flex the affected finger. This is due to the disparity in the sizes of the flexor tendon and the retinacular pulley system. Patients might have noticed a palpable nodule over the affected finger joint. It can affect any finger but index, thumb, middle, or ring finger involvement is common. [1,5]
Flexed ring finger Patients with DM can develop Dupuytren’s contractures, which results in semiflexed ring finger. This commonly involves the ring finger but can affect other fingers as well. Dupuytren's contractures can be seen in 16% to 42% of patients with DM. [1,5]
Symptoms of carpal tunnel syndrome (CTS) Patients with DM can develop CTS due to compression of the median nerve. The symptoms include burning sensation, paresthesias, or sensory loss over the first three fingers and the lateral half of the fourth finger. Pain is much prominent during night time and while doing activities which involve flexion and extension of the wrist. With advanced disease patients may complain of motor weakness, and might drop the objects from the affected hand. [1]
Shoulder stiffness 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. [1,4]
Symptoms of Charcot arthropathy (neuropathic arthropathy) Diabetic neuropathy leading to arthropathy and joint deformities in the feet is referred to Charcot arthropathy. Diabetic neuropathy (sensory, motor and autonomic) causes repetitive and unnoticed microtrauma. This leads to degenerative arthritis and severe destruction of the joints in the feet, affecting about 0.1% to 0.4% of diabetic patients. Affected patients complain of sensory loss over the feet, and joint deformities. [1,2]
Symptoms of diffuse idiopathic skeletal hyperostosis (DISH) Patients with DISH complain of stiffness over the back, specially over the neck and decreased range of motion of the spine. This is common in obese patients with type 2 DM. [1]
References
  1. KIM R. P., EDELMAN S. V., KIM D. D.. Musculoskeletal Complications of Diabetes Mellitus. Clinical Diabetes [online] 2001 July, 19(3):132-135 [viewed 31 July 2014] Available from: doi:10.2337/diaclin.19.3.132
  2. ROGERS L. C., FRYKBERG R. G., ARMSTRONG D. G., BOULTON A. J. M., EDMONDS M., VAN G. H., HARTEMANN A., GAME F., JEFFCOATE W., JIRKOVSKA A., JUDE E., MORBACH S., MORRISON W. B., PINZUR M., PITOCCO D., SANDERS L., WUKICH D. K., UCCIOLI L.. The Charcot Foot in Diabetes. Diabetes Care [online] December, 34(9):2123-2129 [viewed 03 August 2014] Available from: doi:10.2337/dc11-0844
  3. CHERQAOUI R, MCKENZIE S, NUNLEE-BLAND G. Diabetic Cheiroarthropathy: A Case Report and Review of the Literature Case Rep Endocrinol [online] 2013:257028 [viewed 03 August 2014] Available from: doi:10.1155/2013/257028
  4. NAGY MT, MACFARLANE RJ, KHAN Y, WASEEM M. The Frozen Shoulder: Myths and Realities Open Orthop J [online] :352-355 [viewed 03 August 2014] Available from: doi:10.2174/1874325001307010352
  5. ABATE M, SCHIAVONE C, SALINI V, ANDIA I. Management of limited joint mobility in diabetic patients Diabetes Metab Syndr Obes [online] :197-207 [viewed 03 August 2014] Available from: doi:10.2147/DMSO.S33943

Examination

Fact Explanation
Prayer's sign This sign refers to the inability to press the palms together without a gap between them. This is due to sclerosis of the tendon sheaths and fixed flexion or extension deformities. [1]
Skin changes In diabetic cheiroarthropathy, the skin overlying the joints is thick, tight, waxy and sclerosed. This is due to glycosylation of the subcutaneous collagen. [1]
Signs suggestive of trigger finger A nodule can be palpated over the affected metacarpophalangeal joint. The affected flexor tendon sheath is thickened and it can be palpated over the palmar aspect of the hand. Locking sensation can be reproduced by passive flexion of the finger in some patients. [1]
Dupuytren’s contractures Semiflexed ring finger, thickened and shortened palmar fascia can be observed due to Dupuytren's contractures. [1]
Tinel’s sign Tinel’s sign is present in the presence of CTS. Tinel’s sign is positive if paresthesia over the median nerve distribution can be induced by tapping over the median nerve at flexor retinaculum. [1]
Phalen’s test In Phalen’s test, patients are asked to keep the dorsal aspects of the palms touching each other so the wrists are flexed. If paresthesia is reproduced, Phalen's test is positive and it favors the diagnosis of CTS. [1]
Examination of the motor function of the median nerve CTS causes motor weakness of the median nerve distribution. Wasting of the thenar muscles, and reduced muscle power can be elicited in severe CTS. [1]
Examination of the shoulder joint In frozen shoulder, the affected rotator cuff muscles are atrophied. There is limited range of motion in all directions, especially external rotation of the shoulder is completely absent. [3]
Evidence of reflex sympathetic dystrophy Patients with reflex sympathetic dystrophy (shoulder-hand syndrome) the affected limb is swollen. Associated skin changes include changes in hair growth, shiny skin, skin discoloration and temperature changes. Hyperesthesia (increased sensitivity to temperature and touch) and vasomotor instability are other signs of reflex sympathetic dystrophy. [1]
Evidence of peripheral neuropathy Patients with Charcot arthropathy invariably have sensory impairment over the bilateral hands and feet (glove and stocking distribution). Other evidence of neuropathy include skin erythema, swelling, hyperpigmentation, purpura, and soft-tissue ulcers. [1]
Examination of the foot joints Joint swelling, warmth, erythema, increased joint laxity, dislocation and deformities can be detected in Charcot arthropathy. Midfoot collapse in long standing and advanced disease leads to the development of “rocker-bottom” foot. [1,2]
References
  1. KIM R. P., EDELMAN S. V., KIM D. D.. Musculoskeletal Complications of Diabetes Mellitus. Clinical Diabetes [online] 2001 July, 19(3):132-135 [viewed 31 July 2014] Available from: doi:10.2337/diaclin.19.3.132
  2. ROGERS L. C., FRYKBERG R. G., ARMSTRONG D. G., BOULTON A. J. M., EDMONDS M., VAN G. H., HARTEMANN A., GAME F., JEFFCOATE W., JIRKOVSKA A., JUDE E., MORBACH S., MORRISON W. B., PINZUR M., PITOCCO D., SANDERS L., WUKICH D. K., UCCIOLI L.. The Charcot Foot in Diabetes. Diabetes Care [online] December, 34(9):2123-2129 [viewed 03 August 2014] Available from: doi:10.2337/dc11-0844
  3. NAGY MT, MACFARLANE RJ, KHAN Y, WASEEM M. The Frozen Shoulder: Myths and Realities Open Orthop J [online] :352-355 [viewed 03 August 2014] Available from: doi:10.2174/1874325001307010352

Differential Diagnoses

Fact Explanation
Osteoarthritis Obese people are at risk of both type 2 DM and osteoarthritis. Osteoarthritis characteristically affect the weight bearing joints. X-ray film of the affected joints show osteopenia, osteophyte formation, sclerosis and joint space narrowing. [3]
Acute gout Patients with acute gout disease of the foot presents with severe pain, swelling and erythema of the affected joint. The first metatarsal joint is commonly involved. When compared to Charcot foot in diabetes there is no evidence of neuropathy in acute gout and it is usually unilateral. [1]
Cellulitis Cellulitis is common in patients with diabetes, especially if they have poor glycemic control. Acute presentation with erythematous, swollen and painful foot is seen. Fever may also be present. [2]
Osteomyelitis Osteomyelitis also presents with erythematous, swollen and painful foot. Some patients may complain of a discharge due to formation of a fistula. [2]
Other causes of peripheral neuropathy Charcot foot can occur secondary to leprosy, syringomyelia, poliomyelitis, rheumatoid arthritis, multiple sclerosis, congenital neuropathy, traumatic nerve injury, and tertiary syphilis. [2]
References
  1. ROGERS L. C., FRYKBERG R. G., ARMSTRONG D. G., BOULTON A. J. M., EDMONDS M., VAN G. H., HARTEMANN A., GAME F., JEFFCOATE W., JIRKOVSKA A., JUDE E., MORBACH S., MORRISON W. B., PINZUR M., PITOCCO D., SANDERS L., WUKICH D. K., UCCIOLI L.. The Charcot Foot in Diabetes. Diabetes Care [online] December, 34(9):2123-2129 [viewed 03 August 2014] Available from: doi:10.2337/dc11-0844
  2. BOTEK G., ANDERSON M. A., TAYLOR R.. Charcot neuroarthropathy: An often overlooked complication of diabetes. Cleveland Clinic Journal of Medicine [online] December, 77(9):593-599 [viewed 03 August 2014] Available from: doi:10.3949/ccjm.77a.09163
  3. HUNTER DJ, ECKSTEIN F. Exercise and osteoarthritis J Anat [online] 2009 Feb, 214(2):197-207 [viewed 03 August 2014] Available from: doi:10.1111/j.1469-7580.2008.01013.x

Investigations - for Diagnosis

Fact Explanation
Nerve conduction studies (NCS) NCS are useful in diagnosing carpal tunnel syndrome (CTS). Patients with CTS show reduced conduction velocity. [1]
X-ray of the shoulder joint In calcific periarthritis, calcium deposits can be seen around the shoulder joint and over the rotator cuff tendons. Patchy osteoporosis can also be seen in some patients. [1]
X-ray of the feet During the initial stages of the disease X-ray can be either normal or show subtle fractures. Degenerative changes, joint subluxation, fractures, dislocation, osteolysis, periosteal reaction, bony deformity are seen in the X-ray film. Lateral view shows interrupted talo-first metatarsal line due to dislocation of the tarsometatarsal joint. [1,2]
CT scan CT scan of the feet also shows above radiographic changes but in more detail and it help in predicting disease activity. [1]
MRI scan MRI is helpful to evaluate the degree of joint damage. MRI is more sensitive than the X-ray in detecting Charcot joint, and may show abnormalities even if the X-ray film is normal. Degenerative changes, joint deformities and osteolysis can be detected. [1,2] In frozen shoulder the tendons of the rotator cuff muscles are thickened. [4]
X-ray spine Lateral X-ray film of the spine demonstrate calcification of spinal ligaments in diffuse idiopathic skeletal hyperostosis (DISH). [1]
Three-phase bone scan This is sensitive in detecting active bone disease especially during the initial stages of the disease. However in the presence of vasculopathy bone scan may show false negative results. [2] Increased uptake of radioactive substances is seen in frozen shoulder. [4]
Ultrasound scan of the hand Although not specific thickening of the flexor tendon sheath can be seen in ultrasound scan of the patients with diabetic cheiroarthropathy. [3]
References
  1. KIM R. P., EDELMAN S. V., KIM D. D.. Musculoskeletal Complications of Diabetes Mellitus. Clinical Diabetes [online] 2001 July, 19(3):132-135 [viewed 31 July 2014] Available from: doi:10.2337/diaclin.19.3.132
  2. ROGERS L. C., FRYKBERG R. G., ARMSTRONG D. G., BOULTON A. J. M., EDMONDS M., VAN G. H., HARTEMANN A., GAME F., JEFFCOATE W., JIRKOVSKA A., JUDE E., MORBACH S., MORRISON W. B., PINZUR M., PITOCCO D., SANDERS L., WUKICH D. K., UCCIOLI L.. The Charcot Foot in Diabetes. Diabetes Care [online] December, 34(9):2123-2129 [viewed 03 August 2014] Available from: doi:10.2337/dc11-0844
  3. ISMAIL AA, DASGUPTA B, TANQUERAY AB, HAMBLIN JJ. Ultrasonographic features of diabetic cheiroarthropathy. Br J Rheumatol [online] 1996 Jul, 35(7):676-9 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8670603
  4. NAGY MT, MACFARLANE RJ, KHAN Y, WASEEM M. The Frozen Shoulder: Myths and Realities Open Orthop J [online] :352-355 [viewed 03 August 2014] Available from: doi:10.2174/1874325001307010352

Investigations - Fitness for Management

Fact Explanation
ECG DM is a risk factor for the development of ischemic heart diseases (a macrovascular complication). If the patient has neuropathy they are at risk of silent infarctions. ECG is helpful to assess the cardiovascular fitness of the patient. [1]
Renal profile Renal failure can occur secondary to diabetic nephropathy. Assessment of serum electrolytes and serum creatinine are useful initial investigations to detect renal impairment. [2]
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. [2]
References
  1. DAVIS TM, COLEMAN RL, HOLMAN RR, UKPDS GROUP. Prognostic significance of silent myocardial infarction in newly diagnosed type 2 diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS) 79. Circulation [online] 2013 Mar 5, 127(9):980-7 [viewed 03 August 2014] Available from: doi:10.1161/CIRCULATIONAHA.112.000908
  2. 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 03 August 2014] Available from: doi:10.2337/diacare.28.1.164

Investigations - Followup

Fact Explanation
Fasting blood sugar Diagnosed patients with DM should monitor fasting blood sugar regularly in order to monitor and achieve optimum control of blood sugar. [1,2]
Glycosylated hemoglobin (HbA1C) Estimation of HbA1C is helpful in evaluating the overall blood sugar control over the past 3 months. [1,2]
References
  1. FLOYD B, CHANDRA P, HALL S, PHILLIPS C, ALEMA-MENSAH E, STRAYHORN G, OFILI EO, UMPIERREZ GE. Comparative analysis of the efficacy of continuous glucose monitoring and self-monitoring of blood glucose in type 1 diabetes mellitus. J Diabetes Sci Technol [online] 2012 Sep 1, 6(5):1094-102 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23063035
  2. CHON S, LEE YJ, FRATERRIGO G, POZZILLI P, CHOI MC, KWON MK, CHIN SO, RHEE SY, OH S, KIM YS, WOO JT. Evaluation of glycemic variability in well-controlled type 2 diabetes mellitus. Diabetes Technol Ther [online] 2013 Jun, 15(6):455-60 [viewed 03 August 2014] Available from: doi:10.1089/dia.2012.0315

Management - General Measures

Fact Explanation
Health education 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.
Good glycemic control Good and strict glycemic control is mandatory in all patients with diagnosed DM. [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. [2]
References
  1. CHERQAOUI R, MCKENZIE S, NUNLEE-BLAND G. Diabetic Cheiroarthropathy: A Case Report and Review of the Literature Case Rep Endocrinol [online] 2013:257028 [viewed 03 August 2014] Available from: doi:10.1155/2013/257028
  2. 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 03 August 2014] Available from: doi:10.2337/diacare.28.1.164

Management - Specific Treatments

Fact Explanation
Management of diabetic cheiroarthropathy Corticosteroid injection in to the tendon is considered an effective early treatment option for trigger finger. If the initial corticosteroid injection fails, making a longitudinal incision over the affected tendon will provide the permanent cure for trigger finger. [1]
Management of Dupuytren's contractures Dupuytren's contractures can also be treated with local corticosteroid injection. Making a surgical incision over the sclerosed palmar fascia can cure Dupuytren's contractures. [1]
Management of carpal tunnel syndrome (CTS) Conservative management is considered the first line treatment option for the management of mild CTS. Patients are advised to use a volar wrist splints during night. Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used as an analgesic. Local injection of corticosteroids can be done if conservative management fails. Surgical decompression of the carpal tunnel is the definitive treatment option. [1]
Management of frozen shoulder Patients with frozen shoulder can be managed with analgesics and stretching exercise to prevent prolong immobilization. [1] Surgical treatment options include capsular distension injections, manipulation under anesthesia and arthroscopic capsular release. [4]
Management of reflex sympathetic dystrophy Analgesics (NSAIDs and opioids) corticosteroids, physiotherapy to the shoulder joint and sympathetic block are indicated treatment options. [1]
Management of Charcot arthropathy Irremovable total contact cast (TCC) is used during the initial stages of the disease to immobilize and to offload the foot. Oral or intravenous bisphosphonates are sometimes used during the early stages. Splinting and bracing can be done to prevent further injuries. Special shoes and boots are used to achieve protective weight bearing. In advanced disease surgical stabilization, exostectomy, lengthening of the Achilles tendon and arthrodesis may be necessary. [1,2,3]
Management of diffuse idiopathic skeletal hyperostosis (DISH) Physiotherapy, and analgesics are used in the treatment of DISH. [1]
References
  1. KIM R. P., EDELMAN S. V., KIM D. D.. Musculoskeletal Complications of Diabetes Mellitus. Clinical Diabetes [online] 2001 July, 19(3):132-135 [viewed 31 July 2014] Available from: doi:10.2337/diaclin.19.3.132
  2. ROGERS L. C., FRYKBERG R. G., ARMSTRONG D. G., BOULTON A. J. M., EDMONDS M., VAN G. H., HARTEMANN A., GAME F., JEFFCOATE W., JIRKOVSKA A., JUDE E., MORBACH S., MORRISON W. B., PINZUR M., PITOCCO D., SANDERS L., WUKICH D. K., UCCIOLI L.. The Charcot Foot in Diabetes. Diabetes Care [online] December, 34(9):2123-2129 [viewed 03 August 2014] Available from: doi:10.2337/dc11-0844
  3. BOTEK G., ANDERSON M. A., TAYLOR R.. Charcot neuroarthropathy: An often overlooked complication of diabetes. Cleveland Clinic Journal of Medicine [online] December, 77(9):593-599 [viewed 03 August 2014] Available from: doi:10.3949/ccjm.77a.09163
  4. NAGY MT, MACFARLANE RJ, KHAN Y, WASEEM M. The Frozen Shoulder: Myths and Realities Open Orthop J [online] :352-355 [viewed 03 August 2014] Available from: doi:10.2174/1874325001307010352