European Journal of Internal Medicine 20 (2009) 718–721
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European Journal of Internal Medicine j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / e j i m
Original article
Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes Navdha Ramchurn a, Chiedza Mashamba b, Elizabeth Leitch a, Vijayaraman Arutchelvam b, Kilimangalam Narayanan b, Jola Weaver b, Jennifer Hamilton a, Carol Heycock a, Vadivelu Saravanan a, Clive Kelly a,⁎ a b
Department of Rheumatology, Gateshead health NHS foundation trust, Gateshead, United Kingdom Department of Endocrinology, Gateshead health NHS foundation trust, Gateshead, United Kingdom
a r t i c l e
i n f o
Article history: Received 28 May 2009 Received in revised form 2 July 2009 Accepted 10 August 2009 Available online 4 September 2009 Keywords: Diabetes mellitus Locomotor disease Glycaemic control GALS
a b s t r a c t Introduction: An increased prevalence of musculoskeletal disease is recognised in diabetes and is a common source of disability. It is known to predominantly affect the upper limbs especially the hand and shoulder. The relationship with other complications of diabetes and glycaemic control is uncertain. We designed this study to clarify these relationships, and to assess differences between types 1 and 2 diabetes. Methods: We identified a group of 96 people with established diabetes and examined them for the presence of locomotor disease focussing on the upper limbs. We recorded the mean HbA1c and the presence of diabetic complications, together with the health assessment questionnaire (HAQ) score. We explored correlations between locomotor disease and these variables using logistic regression. We compared data between type 1 and type 2 diabetics and contrasted the amalgamated data with that of a matched control population of medical out patients using Students t tests. Results: Locomotor disease was present in 75% of diabetics with the upper limb the commonest site for abnormalities. This prevalence was significantly higher than that seen in the controls (53%) [p = 0.02]. Shoulder capsulitis (25%), carpal tunnel syndrome (20%), tenosynovitis (29%), limited joint mobility (28%) and Dupuytrens contracture (13%) were the most frequent findings and were much commoner than in controls. Capsulitis usually coexisted with other upper limb abnormalities and best predicted the presence of retinopathy and/or neuropathy. The mean HbA1c was significantly higher in patients with combined shoulder and hand problems (9.1%) than in those with no upper limb problems (8.0%) [p = 0.018]. The pattern of results was similar in type 1 and type 2 diabetes, although the prevalence of abnormalities and mean HAQ were significantly greater in type 2 patients, which may be in part a function of their greater mean age. Conclusion: Upper limb locomotor abnormalities are very common in diabetes and are associated with worse glycaemic control and more diabetic complications. Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications. © 2009 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
1. Introduction It is recognised that certain types of musculoskeletal disease occur more frequently in persons with diabetes than in the general population [1–4]. Musculoskeletal disorders of the hand and shoulder appear to be particularly common [3,5,6]. One study reported that half of all people with diabetes surveyed demonstrated one or more locomotor problems in the hands alone, with carpal tunnel syndrome, Dupuytrens contracture, tenosynovitis and reduced joint mobility the commonest abnormalities [7]. Another report confirmed these findings against age matched controls and demonstrated an association with duration of diabetes and age [8], but did not show any clear distinction between type 1 and type 2 diabetes. The relationship
⁎ Corresponding author. E-mail address:
[email protected] (C. Kelly).
between upper limb locomotor disability and other complications of diabetes is, at best, inconsistent [7–9] while the effect of improved metabolic control of diabetes on such disability has not been studied. The aims of this study were to confirm the increased prevalence of musculoskeletal disease in diabetes, to define the nature of locomotor abnormalities, to identify possible associations between musculoskeletal disorders and established complications of diabetes, and to assess whether they related to metabolic control. The degree of functional disability and differences between type 1 and type 2 diabetes were also investigated. 2. Methods Ethical approval was obtained for the study through the local regional ethical committee (LREC). Consecutive patients with diabetes attending the annual review clinics at the Gateshead Diabetes
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N. Ramchurn et al. / European Journal of Internal Medicine 20 (2009) 718–721
Centre were approached to take part in the survey during the period January to March 2007. They were offered an information sheet to read and, if consent was given, they were assessed following their appointment. This involved a GALS screening examination, which is a validated tool for eliciting musculoskeletal disease [10]; Regional examination of the musculoskeletal system (REMS) was performed when GALS indicated an abnormality. Assessments were performed without knowledge of which group patients were in. For the upper limb this included assessment for carpal tunnel syndrome, tenosynovitis, limited joint mobility and Dupuytrens contracture in the hand and for capsular restriction and/or tendonitis in the shoulder. The presence of carpal tunnel syndrome was assessed by looking for Tinel's sign, Phalen's sign, thenar muscle wasting with loss of power of abductor pollicis brevis and reduced sensation in the distribution of the median nerve. Each patient was also asked to shade in a diagram of the palms of the hands indicating any areas of numbness or tingling and to state whether or not the tingling or numbness was worse at night or during the day. Carpal tunnel syndrome was considered to be present if there was tingling/numbness in the distribution of the median nerve with either nocturnal wakening or a positive result to any functional test. We recorded patients' date of birth, type of diabetes, date of diagnosis, prior musculoskeletal disease and hypothyroidism. The presence of diabetic retinopathy and neuropathy were noted. HbA1c values were obtained, and the mean value for each patient was derived from all the measurements recorded over the past 5 years. Finally, the patient was asked to complete a health assessment questionnaire (HAQ) to assess the extent of any functional disability [11,12]. We recruited 100 patients with diabetes (50 with each of type 1 and type 2 disease) and used the same proforma in a control group of 100 medical out patients without diabetes, matched for gender and age (within 5 years). These were selected consecutively by the same clinicians, from a population with a wide variety of chronic diseases but excluding those attending rheumatological clinics. Statistical comparisons were made between the two groups using Students t test. The same test was applied to the comparisons between the cohorts with type 1 and type 2 diabetes. We used logistic regression to assess the relationship between the presence of musculoskeletal disease at the hand and/or shoulder and either neuropathy or retinopathy. Similarly logistic regression was used to assess the relationship between both HAQ and HbA1c and musculoskeletal disorders at each site. 3. Results We collected a complete set of data from 96 persons with diabetes with incomplete data leading to the exclusion of 4 individuals with type 1 diabetes. The groups' mean age was 55 and they were predominantly male (63%). Three quarters of all patients with diabetes had a positive GALS screening examination, with REMS showing positive hand findings in 63% and shoulder abnormalities in 25% (Table 1). The control group had a significantly lower prevalence of abnormalities on GALS (53%) [p = 0.02], in the hand (12%) [p = 0.01], and in the shoulder (2%) [p = 0.02]. Flexor tendon thickening and limited joint mobility were the commonest features, each occurring in 28% of diabetics. Carpal tunnel
Table 1 Baseline characteristics in the diabetic patients and medical controls. Diabetes n = 96 Male (%) Age (mean years) Positive GALS (%) Hand problem (%) Shoulder problem (%)
Control n = 100 63 55 75 63 25
63 60 53 12 2
ns ns p = 0.02 p = 0.01 p = 0.02
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syndrome was present in 20% of patients, and established Dupuytrens contracture was found in 13% overall. Shoulder capsulitis (20%) was found more frequently than tendonitis (5%) and appeared to be a later development, usually coexisting with hand problems. These results are summarised in Table 2, which also compares the prevalence of upper limb abnormalities between patients with type 1 and type 2 diabetes. Shoulder capsulitis was much commoner in type 2 disease, compared to type 1 (39% vs 11%) [p = 0.016] and hand problems were likewise found more frequently in type 2 diabetes (82% vs 44%) [p = 0.032]. Although patients with type 2 diabetes were older, type 1 patients had a much longer duration of diabetes. Mean HbA1c was identical at 8.6 in each group. The HAQ score was higher in type 2 diabetics, indicating significantly greater disability in this group (0.9 vs 0.2), [p = 0.032], although again type 2 diabetics were significantly older than those with type 1 disease. The graphs in Fig. 1 include data for the diabetic group as a whole and demonstrate the differences between those participants with no upper limb findings, hand abnormalities, shoulder problems and both hand and shoulder problems. Fig. 1a demonstrates that there is a link between increasing upper limb involvement and worse metabolic control of diabetes, with the mean HbA1c value rising from 8.0 for those with no upper limb disease to 9.1 for those with both hand and shoulder involvement [p = 0.018]. Fig. 1b shows the relationship of complications of diabetes to musculoskeletal disease. Either retinopathy or neuropathy was present in just 33% of patients with no upper limb disease, increasing to 41% with hand abnormalities, 67% with shoulder involvement and 76% in those with both hand and shoulder problems. Fig. 1c demonstrates that higher HAQ scores are commensurate with increasing musculoskeletal abnormalities. Patients with both hand and shoulder findings reported the greatest disability, while those patients with hand findings only or no upper limb findings reported the least disability.
4. Discussion This study demonstrates a clear link between upper limb locomotor abnormalities in diabetes and evidence of poor glycaemic control with an increased risk of other diabetic complications. These findings occur on a background of data which confirms other published findings, including a higher prevalence of musculoskeletal disease in the upper limbs of people with diabetes compared to age and gender matched controls [1–9]. The study identified that hand problems are more frequent than shoulder disease, as noted previously [5–7]. The reported associations of locomotor disease with both age and duration of diabetes are also evident [3,4,8,9]. A properly designed RCT is required to confirm that poor glycaemic control is responsible for upper limb musculoskeletal abnormalities and that improvement in metabolic control ameliorates these. The commonest abnormalities in our study were in the hands, with flexor tendon thickening and limited joint mobility each affecting nearly 30% of our patients. This has been reported in up to Table 2 Detailed comparison of demographics, disease control, disability and upper limb findings in type 1 (T1) and in type 2 (T2) diabetes.
Mean age (years) Mean duration (years) Mean HbA1c Mean HAQ score Shoulder capsulitis (%) Hand abnormalities (%) - limited joint mobility - Dupuytrens contracture - flexor tenosynovitis - carpal tunnel syndrome
p value
T1
T2
0.031 0.022 NS 0.032 0.016 0.032 0.043 0.055 0.046 0.060
48 17 8.6 0.22 11 44 20 9 20 15
60 9 8.6 0.88 39 82 36 17 38 25
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lished in rather fewer patients than previously published [16,17] but was a major source of disability in those affected. Carpal tunnel syndrome was found in 20% of diabetics, consistent with other clinical studies [18–20]. Adhesive capsulitis of the shoulder has been reported in 25% of people with diabetes in previous studies, equating to a fivefold increase in prevalence compared to non-diabetic controls [21,22], and our work shows remarkably similar results. A recent report also describes an association between shoulder pain and poor glycaemic control [23]. Calcification of the peri-articular structures has also been reported as increased threefold in diabetes [24] and is likely to affect tendon function, producing the observed increase in tendonitis. Over a quarter of all patients treated for soft tissue shoulder problems had diabetes in one series [25], emphasizing the frequency with which this complication occurs. Relationships between shoulder and hand involvement have been recognised for over two decades [26,27], but a possible link with other complications of diabetes has only been examined more recently with one report of an increased prevalence of retinopathy in diabetic patients with shoulder and hand abnormalities [28]. Our study has demonstrated a firm association between locomotor manifestations of diabetes and the presence of other complications of diabetes, including neuropathy. Many type 2 diabetics are managed in the community. This is an important finding as it raises the possibility of using musculoskeletal abnormalities as an early indication of other less obvious complications. Shoulder involvement was particularly associated with a high prevalence of other diabetic complications, especially when it coexisted with musculoskeletal abnormalities of the hands. The value of these clinical observations is reinforced by the strong link with metabolic control shown in our study. Disability arising from upper limb involvement, as assessed by the HAQ score, was mainly linked to shoulder disease, while patients with both hand and shoulder abnormalities had mean HAQ scores nearly three times those with no locomotor disability. Interestingly, persons with type 1 diabetes had significantly less disability than type 2 disease overall, and this may reflect their much lower prevalence of shoulder abnormalities. However, given the fact that our work was hospital based and that many type 2 diabetics are managed in the community, it is possible that such patients may have less in the way of shoulder involvement than do hospital supervised subjects. Our work reinforces the overlap between musculoskeletal disability and endocrine disease recently highlighted in the Journal [29]. In conclusion, musculoskeletal disorders are common in people with diabetes and should be screened for on a regular basis to prevent undue disability and discomfort. In people with diabetes, locomotor disorders of the upper limb may now be considered a complication of the disease and an indicator of poor glycaemic control. This should trigger a search for other complications of diabetes and attempts to intensify measures to improve glycaemic control. 5. Learning points
Fig. 1. Degree of upper limb invovlement with: (a) mean HbA1c, (b) complications of diabetes, (c) mean HAQ score.
• Locomotor disease of the upper limb is common in diabetes • It is associated with poor metabolic control and an increased risk of other complications • Resulting disability is greater in type 2 diabetes than in type 1 disease.
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