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Dr Hossein Soleymani Assistant Prof of Rheumatology SSMU, May 2015, YAZD, IRAN

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Introduction MS complaint more frequent Metabolic change in CV tissue Glycosylation of proteins Micro-vascular abnormality Accumulation of extracellular matrix and soft tissue More seen in longstanding type I Some complications have direct association

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Pathogenesis: An increase in non-enzymatic glycosylation of collagen fiber Increase collagen crosslink Resistant to enzymatic digestion Increase in hydration mediated by aldolase reductase pathway Increased formation Advanced Glycosylation End product (AGEs)

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Pathogenesis: AGEs causes micro and macro vascular complications AGEs result from early glycosylation Accumulate in tissue Damage extra and intra cellular proteins There are receptors on cell surface for AGEs belong to IG receptors Signaling lead to cell dysfunction AGEs decrease vascular elasticity

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Condition limited to DM Diabetic Muscle Infarction

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Conditions more frequently in DM Diabetic cheiroarthrophaty (stiff hand synd) Trigger finger (flexor tenosynovitis) Dupuytrens contracture Carpal tunnel syndrome Adhesive shoulder capsulitis (frozen shoulder)Calcific shoulder tendonitis Reflex sympathetic dystrophy ( shoulder-hand syndrome) Diabetic osteoarthrophaty or charcota or neuropathic arthropathy

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Conditions Sharing Risk Factors of DM Diffuse Idiopathic Skeletal Hyperostosis Gout/ Pseudogout Osteoarthritis

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Case: 1 A 56-year-old man, Hs of 15 years uncontrolled DM complaint stiffness of hand, hand joint had limitation, no Raynaud phenomena

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Hand Diabetic cheiroathrophaty or diabetic stiff hand or limited mobility joint syndrome: 8% to 50% all type I DM,45%-70% type II Associated and predictor of other complication Thick, tight, waxy skin, begin in MCP&PIP 5 Like systemic sclerosis Limited joint mobility( finger flex and extend)

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Cheiroarthropathy Lack of following differentiated from Scledrema: Raynuads phenomena, dermal atrophy, telangiectasia and autoantibodies Nail fold capillaroscopic change may be seen Both type I and type II have higher prevalence retinopathy and nephropathy

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hand Flexion contracture of fingers cause Prayer sign

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Cheiroarthropathy

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Recommended treatment: 1- Glycemic control 2- Physical therapy 3- NSAIDs with caution

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Case: 2 A 44-year-old woman, Hx of 8 years DM, complaint of pain in 3,4 Rt fingers, catching or locking of fingers

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Hand: Trigger finger Catching sensation or locking phenomena Pain in affected finger Thumb, then third and forth 5%-36% type I, II (2% normal) Palpable nodule overlying MCP joint Thickening along the affected flexor tendon Prevalence related to duration of DM TF in 3 or more finger highly suggestive for DM

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Trigger Finger Treatments: 1-Change of activity 2- Splint 3- Use of NSAIDs with caution 4- CS injection 5- In severe case surgery

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Case: 3 A 65-year-old man, Hx of 14 years DM, retinopathy, complaints of nodules in palmar aspect of both hand, difficulties in finger extension

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Hand: Dupuytrens contracture Thickening, shortening, fibrosis of palmar facia Nodule along the facia causes flexion contractures of the finger Usually fourth but may be seen II to V fingers 16% to 42% of all DM more in elderly May be seen in early stage Prevalence more in longstanding DM

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Dupuytrens contracture More in third and fourth finger More in women Manifestations are more severe in men

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Dupuytrens contracture Treatments: 1- Intralesional injection of CS 2- Surgery 3- Physical therapy 4- Some studies show benefit from injection of collagenase Colstridium Histolyticum

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Case: 4 A 55-year-old woman HX of 6 years DM, complaint of Rt hand pain, numbness, radiate to arm, worse at night

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Hand: Carpal Tunnel syndrome 20% of diabetic patients more in women More in obese Median nerve entrapment Caused by diabetic-induced connective tissue alteration HX & PE Tinels sign, Phalens test In dubious case Electrophysiological studies helpful

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Carpal tunnel syndrome Treatments: 1- Splint, NSAIDs 2- Injection CS: response may be temporary and poorer in DM 3- Release surgery: post operative recovery is worse

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Case: 5 A 66-year-old man Hx of 15 years uncontrolled DM, complains of both shoulder pain, worse at night, problem daily working, joint mobility limited

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Shoulder: Frozen shoulder Frozen shoulder or adhesive capsulitis Most common shoulder involvement 10-29% diabetic patients, bilateral, elderly Stiffness Glenohumeral joint Reversible contraction joint capsule See in hyperthyroidism, Addison and Parkinson

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Adhesive capsulitis Progressive and painful manner Pain at night initially Three phase:(a) Pain (b) Stiffness (c) Recovery Diagnostic criteria by Pal: Shoulder pain at least one month, impossibility lying's one shoulder, limited active and passive movement Decreased range of motion in abduction and external rotation then internal rotation

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Adhesive capsulitis Treatments: 1- Analgesic 2- Physiotherapy 3- CS injection 4- Arthroscopy release

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Shoulder: Calcific shoulder tendonitis Three times more frequent in DM (type II) Coexist with adhesive capsulitis Deposit Ca hydroxy apatite Ca depostion in rotator cuff tendons 60% asymptomatic

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Sohulder:Reflex sympathetic dystrophy Shoulder-hand synd or complex regional pain synd Pain from shoulder to hand Swelling of affected limb Skin change: hair growth, shiny skin, color, temperature Increased sensitivity to pain and touch Vasomotor instability Transit patchy osteoporosis

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Case: 6 A 58-year-old woman, Hx of 20 years DM, Hx of neuropathy, complains of swellings in both feet, deformity, pain in walking and standing, no tenderness

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Feet: Charcots arthropathy Diabetic osteoarthropathy Rare: 0.1% to 0.4% Both type DM Average duration 15 years Advanced peripheral neuropathy

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Feet: Charcots arthropathy Loss of sensation in involved joint Inadvertent microtrauma to joint Consecutive degenerative change Severe destruction, lytic joint changes Most affect pedal bones

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Feet: Charcots arthropathy Erythema, swelling, hyperpimentation Purpura, soft tissue ulcer Joint loosening, instability, joint deformity Often no history of trauma

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Feet: Charcots arthropathy Diagnosis: based on radiographic findings Symptoms often milder than view of X-ray X-raysubluxation, bone fragment, osteolysis Periosteal reaction, deformity, ankylosis

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Feet: Charcots arthropathy CT sacn is insensitive MRI and bone scintigraphy adjuncts X-ray DD: Inflammatory, degenerative, infections, tumors, DVT

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Charcot arthropathy Treatments: 1- Prevent weight bearing on affected joint 2- Bisphosphanate 3- Calcitonin may be useful

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Muscle: Diabetic muscle infarction Rare condition Spontaneous infraction with no history of trauma Patients with long history of poorly controlled DM More in insulin requiring patients Most patients show microvascular complications like neuropathy, retinopathy, nephropathy

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Muscle: Diabetic muscle infarction Acute onset of pain and swelling on affected M Over days to weeks Usually thigh or calf Varying degree of tenderness CPK may be normal or increased

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Muscle: Diabetic muscle infarction D&D: Tumor, muscle infection/abscess, localized myositis, osteomyelitis, thrombosis CT Scan in insensitive MRI show high signals in muscle in T2 When incisional muscle biopsy? Only to rule out infection and malignancy (culture for atypical organisms) Treatments: rest, analgesic

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Case: 7 A 70-year-old man, Hx of 12 years controlled DM, complaint of mechanical thoracic pain, tenderness in thoracic spine, normal ESR, CRP, Hb

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Diffuse Skeletal Disease Diffuse idiopathic skeletal hyperostosis(DISH) Metaplastic calcification of spinal ligament Osteophyte formation Disc space, sacroiliac and facet joint: normal Thoracic spine most commonly affected May be accompanied by generalized calcification of other ligament

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Diffuse Idiopathic Skeletal Hyperostosis Unknown etiology IN DM patients more than normal Association with type II DM More in obese patients Pain is not prominent symptoms Complaint stiffness in neck and back Decreased range of motion

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Other disease with DM Osteoporosis: controversy, risk of Fx increased Osteoarthritis Hyperurecemia

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Thanks For Your Attention