At Complete a significant proportion of our patients are diabetics. People with diabetes have a three-fold increased risk of developing a musculoskeletal condition. Musculoskeletal conditions refers to any muscle, joint, tendon, ligament  or nerve problem. Physiotherapy and ultrasound guided injections are a fundamental treatment strategy for many of the musculoskeletal conditions that diabetic patient’s experience. Diabetic patients are more treatment resistant compared to those without diabetes and recovery is often slower (Baskervile et al. 2018).

Diabetic patients often suffer with pain and loss of function due to the following conditions:

What is diabetes?

Diabetes is a very common condition in the UK and has a growing prevalence. It is where your blood glucose level is too high and your body is unable to produce enough insulin or the insulin produced is not effective. On some occasions the body cannot produce any insulin at all.

The successful management of diabetes is dependent on many lifestyle factors. It is essential to eat well, move a lot (exercise) and comply strictly with your medication regime. Exercise is an essential component of diabetic management.

Musculoskeletal pain and injury will often limit the amount of exercise that can be carried it and will negatively affect blood sugar control, causing complications and a decline in quality of life. Up to 50% of people who drop out of exercise interventions for type 2 diabetes do so due to musculoskeletal symptoms (Ranger et al, 2016).

Therefore, it is essential to diagnose and investigate pain in patients with diabetes as early as possible in order to provide effective treatment to allow them to successfully manage their diabetes.

Signs and Symptoms of Diabetes (Type 1 and 2):

  1. Increase in thirst
  2. Urinating more frequently, particularly at night
  3. Feeling very tired
  4. Weight loss and reduction of muscle bulk
  5. Blurred vision
  6. Cuts or wounds that heal slower than usual

What are the types of diabetes?

There are two main types of diabetes: type 1 and type 2.

Type 1 diabetes means you can make any insulin at all.

Type 2 diabetes means you can produce insulin but it does not work effectively, or you do not produce enough insulin.

Another type of diabetes is known as gestational diabetes, which some women develop during pregnancy.

Essentially in all types of diabetes, glucose build up in your blood as it unable to get into the cells . Too much glucose in your blood can cause many problems, including the symptoms of diabetes.

What musculoskeletal conditions do we see at Complete?

1. Tendinopathy, tendinitis or tendon pain

What are the symptoms of tendinopathy?

  1. Tenderness on palpation i.e. when you press it, at the site of pain
  2. Pain, often described as a dull ache, that often reduces as you start to gently move and exercise
  3. Pain with moving the effected region/joint and with muscle contraction
  4. Pain worse after activity and in the morning
  5. Occasional swelling at site of pain – this depend on which tendon

At Complete we see hundreds of tendon issues every year. A significant portion of these are diabetic patients. The main tendon complaints we see in the clinic are Achilles tendinopathy, rotator cuff (shoulder) pain and lateral epicondylitis (tennis elbow)It is unclear why diabetic patients (both type 1 and type 2) are at risk of developing tendon complaints (Lui et al, 2017).

Symptoms can last several months or even years and cause significant pain and loss of function. Approximately 5% of a GP diabetes caseload will develop tendon pain each year, compared with a prevalence of approximately 2% in non-diabetics (Ranger et al, 2016).

The term ‘tendinitis’ has been replaced with tendinopathy as it is more of a degenerative process (‘wear and tear’ process) which is thought to occus over many months or even years. In diabetic tendinopathy, the degeneration is due to advanced glycation end products accumulating in load-bearing collagen. A reduction in the vascularity (blood supply) and impaired healing are also involved. This means tendon complaints in diabetic patients take longer to heal and can be more difficult to treat.

Other factors that contribute to diabetics developing are tendon pain are:

  • Obesity
  • Hypertension (high BP)
  • Ageing
  • Alcohol
  • Smoking

2. Frozen shoulder

Frozen shoulder is characterised by severe pain, stiffness and increasing restriction and stiffness. Unfortunately, it can occur in both shoulders in diabetic patients. It is also experienced by non-diabetics but is often more severe and resistant to treatments. The exact cause for this is unknown.

The incidence of FS is 10%-20% and 7%-32% in type 21 diabetics and type 2 diabetics, respectively; the prevalence is 11%-19% and 2%-3% in diabetics versus normal controls of the same age (Huang et al, 2013).

Diagnosis is made by clinical assessment by your physiotherapist. A diagnostic ultrasound can be useful to rule out other causes of shoulder pain and confirm frozen shoulder. At Complete this is carried out as part of your assessment by one of our clinical specialists.

What are the symptoms of Frozen shoulder?

  1. Worsening pain and stiffness in the shoulder and arm
  2. Pain worse at night – difficulty sleeping
  3. Progressive stiffness in shoulder causing a significant reduction in shoulder
  4. Difficulty with dressing/undressing, putting on a coat and/or bra, lifting and carrying
  5. Unresponsive to physiotherapy and medication.

Frozen shoulder often resolves with time but complete resolution of symptoms can take a long period of time. Although the pain can resolve relatively quickly, full range of movement at the shoulder can take many years.

Conservative treatment depends on the stage of the condition.

During the first stage or painful phase treatment includes medication such as analgesia and NSAID’s and physiotherapy involving hands on manual therapy and gentle exercise such as pendular exercises. A corticosteroid injection carried out under ultrasound guidance can also provide rapid pain relief. A hydrodistention can also be considered in the painful stage. An injection is often recommended if the pain is not improving and/or interrupting sleep.

The second stage is characterised by stiffness, more than pain. Physiotherapy can play a significant role in this stage. The third stage is the ‘thawing’ phase where the shoulder becomes painfree and less stiff.

3. “Trigger finger” and “Trigger thumb” –  flexor tenosynovitis

Trigger finger is a painful condition in which a finger or thumb ‘clicks’ or ‘locks’ as it is bent towards the palm. “Trigger finger’ is characterised by inflammation of the flexor tendon sheaths of the finger. Inflammation of the tendon heath is known as ‘tenosynovitis’. People with insulin dependent diabetes are more prone to a trigger finger and/or thumb. But most trigger digits occur in people without diabetes.

We do not know exactly why some people get triggering and some do not. Certainly, those in manual jobs such as builders and carpenters are more prone to triggering. We also see it in musicians, gardeners, chefs and weight lifters. They can be very painful and inconvenient. They can occur after an injury such as a knocking your hand. It is also more prevalent in those with rheumatoid arthritis and other connective tissue disorders. These conditions can cause focal thickening of the tendon known as tendon nodules. It is not caused by osteoarthritis.

The tendon passes through a tunnel (called a pulley or a retinaculum) in the top of the palm of the hand, near the knuckle joint (see image). Due to the inflammation of the tendon it becomes thickened and roughening of the tendon surface cause the tendon to catch on the way in and out of the tunnel (pulley). It is often accompanied by the tunnel also getting tighter/smaller. This means it gets ‘stuck; when you bend the finger because the tendon cannot slide through the tunnel.

This can be very painful and is often worse in the mornings. Patients can awaken with the finger flexed toward the palm, and the locking and stiffness gradually reduces during the day. It becomes very uncomfortable and inconvenient when you use your hand. Sometimes the tendon gets a nodule (very focal swelling) which causes further thickening and can cause the finger to become locked.

On occasion the tendon or pulley can be so thick that the it is not possible to straighten the finger from a flexed position. This is referred to as ”locked fixed finger.”

What are the symptoms of trigger finger?

  1. Pain at the site of triggering in the palm of the hand or base of thumb
  2. Tenderness and thickening (nodule) if you press on the site of pain
  3. Clicking of the finger of thumb during movement, or locking in a bent position, often worse on waking in the morning. The digit may need to be straightened with pressure from the opposite hand.
  4. Stiffness, especially in trigger thumb where movement at the end joint is reduced.

The duration of this condition is long and the incidence is higher in poorly controlled type 1 diabetics (20%) than in well-controlled ones (3%) (12) and in type 2 diabetics (3.8%) than in controls (Ardic et al, 2003).

The diagnosis of trigger finger is quite straight forward as patients describe the ‘triggering/locking’ of the finger and there is tenderness and swelling of the flexor tendons. This tenderness is often located specifically over the A1 pulley. A diagnostic ultrasound scan will confirm the diagnosis but will also provide further information with the exact cause and severity of the issue. It will also rule out other potential causes for the pain and stiffness such as joint osteoarthritis.

The clinical assessment and diagnostic ultrasound scan carried out by your clinician will indicate the most optimal treatment for you. The goal of treatment is to reduce the ‘triggering’ of the finger by decreasing the swelling and inflammation of the flexor tendon sheath. This will allow friction free movement so the tendon can glide through the sheath.

Initial treatment can involve relative rest and immobilisation for 4-6 weeks. It is essential (if possible) to avoid the activities that cause the triggering and/or pain. Topical or oral anti-inflammatory medication may help to alleviate the pain. Using a small splint to hold the finger or thumb straight at night. A splint can be fitted by a hand therapist, but even a lollipop stick held on with tape can be used as a temporary splint. Holding the finger straight at night keeps the roughened segment of tendon in the tunnel and makes it smoother.

If the symptoms continue after 6 weeks then we would advise an ultrasound guided steroid injection into the sheath of the tendon. These normally stop the triggering within a week following the injection. A steroid injection stops the triggering in 70% of patients. Unfortunately, these outcomes are reduced in patients with diabetes. A second injection is sometimes helpful and can help to completely resolve the triggering.

To ensure the triggering does not return we will show you a set of stretching and strengthening exercises to carry out. If the injections fail to improve the triggering or it returns very quickly a surgical opinion should be considered. The surgery can be carried out under local anaesthetic (so you do not get put to sleep i.e. a general anaesthetic). However, it is entirely reasonable to try a few injections before considering surgical intervention.

4. Carpal tunnel syndrome (CTS)

Carpal tunnel syndrome is known as a neuropathy as it effects a nerve. More specifically the median nerve which sits in a tunnel (known as the carpal tunnel). There is a ligament on roof of the tunnel called the transverse ligament. Inside the tunnel we have our wrist and finger flexor tendons. These are the tendons that connect the flexor (forearm) muscles to the bone. They are responsible for bending the wrist and gripping.

Diabetes is the most common metabolic disease that causes carpal tunnel syndrome, with a prevalence of 14%-16%.

In one large study by Cagliero et al, carpal tunnel syndrome was found 11% in type 1 diabetics, 12% in type 2 diabetics, and 8% in control individuals (non-diabetics). It was more common in women, with an incidence of 8% in women vs 0.6% in men.

The disease manifests itself with paresthesia that worsens in the evenings in the thumb, index, and middle fingers of the hands, which wakes the patient up from sleep. Pain in the wrist and hand can cause clumsiness in hand movements.

The diagnosis of carpal tunnel syndrome is relatively straight forward. Clinical examination can often be normal, as generally patients have good wrist movement and there is not a lot to see! At Complete we will carry out an ultrasound scan to visualise the size of the median nerve. This will confirm the diagnosis of carpal tunnel syndrome. Nerve conduction studies are not required for the diagnosis of carpal tunnel syndrome.

What are the symptoms of Carpal tunnel Syndrome ?

  1. Numbness, tingling, burning and pain in the hand (palm more then back of hand) and particularly the thumb, index, middle, and half the ring fingers (see image below).
  2. Hand weakness and clumsiness – this may cause you to drop things or have a weak grip.
  3. Patients often “shake out” their hands to alleviate their symptoms. The numbness can become constant over time with more severe cases.
  4. Symptoms are often worse at night and in the mornings. A wrist brace worn at night may reduce the symptoms.

Carpal tunnel syndrome is also related to individuals whose job involves repetitive manual tasks such as builders, electricians and musicians and those who use vibrating tools such as hammer drills. It also common during pregnancy, due to the hormonal changes causing fluid retention and excessive pressure on the the median nerve. The good news is it normally resolves spontaneously following birth.
The treatment of carpal tunnel syndrome may involve:

  1. Avoiding the aggravating factors such as using vibration handtools and excessive computer use.
  2. Using a wrist splint at night to keep the wrist in a more neutral position and reduce the pressure on the nerve.
  3. Gentle wrist stretches  to improve bloodflow and nerve mobility. These should ideally by your physiotherapist.
  4.  If it is caused by excessive computer useable, than reducing your usage and improving your workstation (ergonomic set up) will also help.

Aswell as diabetes, obesity is also a known risk factor for carpal tunnel syndrome. Addressing these issues will help with the symptoms and can even resolve the issue.

If these failed to improve your symptoms and you have been diagnosed with carpal tunnel syndrome, than an ultrasound guided steroid injection can help to reduce the swelling of the nerve and decrease your symptoms. Steroid injections normally make a significant difference to your night symptoms. These  injections should always be carried out under ultrasound guidance to ensure that the nerve is avoided during the procedure.

NHS trusts and the NICE guidelines recommend that injections should be utilised before surgery is considered. Obviously if an injection or injections have not given you the required relief then there are surgical options which can give a more permanent solution.

Osteoarthritis

Around a half of all adults with diabetes have osteoarthritis and more than a quarter of these experience limitation in usual activities due to joint symptoms.

Osteoarthritis the most common condition we treat at Complete and we have a variety of treatment options from exercise prescription to injection therapy. The main symptom of osteoarthritis is pain, swelling  and stiffness in your joints. This can make it difficult to move the joint and effect your ability to carry our simple activities.

Osteoarthritis mainly affects the hip and knee joints in the lower limb and hands in the upper limb. It is not uncommon to suffer with more than one joint at a time and can cause significant disability.

Symptoms of osteoarthritis are:

  • joint tenderness
  • increased pain and stiffness when you have not moved your joints for a while for example in the morning or after sitting for a period of time.
  • joints appearing slightly larger or thicker than normal
  • a crackling or clicking sound or sensation in your joints
  • limitations in the range your joints can move
  • pain is worse in cold weather, better in warmer weather
  • weakness and muscle wasting

Osteoarthritis and type 2 diabetes mellitus (T2DM) often occur together, particularly in older adults. People with type 2 diabetes have been shown to have an increased susceptibility to developing osteoarthritis. In one study, osteoarthritis occurs in 52% of people with type 2 diabetes, compared to 27% without diabetes (Lawrence et al, 2008)

One of the main reasons for this link is the underlying risk factors shared by both osteoarthritis and diabetes; age and obesity (higher BMI). The exact reasons for this are still being debated but evidence does exist that alterations in lipid metabolism and hyperglycemia might have a direct impact on cartilage health and subchondral bone that contribute to the development and/or progression of osteoarthritis (Piva et al, 2015).

The most obvious link between osteoarthritis and diabetes is weight. We know increased bodyweight, increases your chance of developing type 2 diabetes but it is also strongly associated with lower limb osteoarthritis i.e. the knee and hip. Increased body weight imposes greater loads on the weight-bearing joints and can cause misalignment of the bones, which has shown to increase joint stress and affect cartilage degradation and wear, ultimately causing osteoarthritis.

Obesity has also been linked to muscle weakness, which will expose the joint to further strain and damage. However, obesity and excessive weight does not explain why diabetics have an increased prevalence to develop osteoarthritis of the hand (Stumer et al, 2001).

Osteoarthritis of non-weight bearing joints such as the hand suggest there is a systemic, non-mechanical influence i.e. it is not caused by weight gain (obesity).

This systemic link is not well understood, but it is thought that obesity causes chronic low-grade inflammation (Piva et al, 2015).

Hypertension (increased blood pressure) and dyslipidemia (increased cholesterol) are both risk factors for type 2 diabetes and have been proposed to also contribute to the development of osteoarthritis. It is suggested that high blood pressure and cholesterol might affect via narrowing of blood vessels and subchondral ischemia, which would initiate cartilage degradation (Piva et al, 2015). There is also literature suggesting that fatty acids are elevated in osteoarthritic bone and that excessive intake of poly-unsaturated fatty acids are associated with increased risk of bony and joint changes.

Interestingly, there is more evidence that osteoarthritis and diabetes may not just be linked to age and weight. A 20 year longitudinal cohort study of927 individuals by Schett et al (2015), suggest that in people with type 2 diabetics can predicts both joint failure and hip and knee arthroplasty surgery, independently of age, sex, and BMI. In support of these findings, another study reported that individuals with type 2 diabetics have increased risk for clinical diagnosis of knee and hand OA, after adjusting for age and BMI. Several authors have shown that altered glucose metabolism may have a direct link between osteoarthritis and diabetes.

The treatment of osteoarthritis is based on pain management. Medication, weight loss (particularly for knee osteoarthritis) and physiotherapy form the basis of the treatment. Optimisation of painkillers and anti-inflammatory medication is essential. Advise regarding weight loss and exercise prescription will help with pain and function. It is recommended at least 150 minutes a week of aerobic activities and 2 days a week of resistive exercises (Elsawy et al, 2010). Specific to aging and OA, regular flexibility and balance exercises should also be performed. It is important to note that the optimal exercise volume should be individually tailored by a trained professional such as one of our expert physiotherapists.

As an example, considerations should be given for resistive exercises (strength based exercises) in individuals with osteoarthritis of the knee. Exercises should begin with from minimal joint load and progressed to increase joint load when appropriate. They should performed at pain-free ranges and maximum resistance is not advised. For example, if a knee extensor muscles e.g. using the leg extension machine in the gym causes pain at 50-80 degrees knee flexion (bending) an alternative range of motion eg. 0-50 degrees should be utilised and progressed accordingly.

Injection therapy is a useful treatment adjunct if pain is poorly controlled. It can also be very effective at reducing swelling and provide a pin free window to engage in a course of physiotherapy. We have three injection options at Complete; steroid (also known as cortisone or corticosteroid), Hyaluronic Acid and PRP (known as platelet rich plasma). There is evidence to support their use in osteoarthritis as part of an overall treatment plan. Injection therapy as a stand alone treatment is not advised, however in conjunction with with a structured physiotherapy programme can provide short term and long term relief.

In conclusion, there is a clear link between diabetes and many common musculoskeletal issues that we see at Complete. Although diabetes is a long term condition with no obvious cure it can be well controlled with medication, a healthy lifestyle with regular exercise and a balanced diet. Well controlled diabetes will reduce your chances of developing many of the conditions discussed in this article.

If you would like to make an appointment or discuss if injection therapy may help you please call 020 7482 3875 or email info@complete-physio.co.uk

References

Ardic, F., Soyupek, F., Kahraman, Y. and Yorgancıoglu, R., 2003. The musculoskeletal complications seen in type II diabetics: predominance of hand involvement. Clinical rheumatology, 22(3), pp.229-233.

Elsawy, B. and Higgins, K.E., 2010. Physical activity guidelines for older adults. American family physician, 81(1), pp.55-59.

Huang, Y.P., Fann, C.Y., Chiu, Y.H., Yen, M.F., Chen, L.S., Chen, H.H. and Pan, S.L., 2013. Association of diabetes mellitus with the risk of developing adhesive capsulitis of the shoulder: a longitudinal population‐based followup study. Arthritis care &

Lawrence, R.C., Felson, D.T., Helmick, C.G., Arnold, L.M., Choi, H., Deyo, R.A., Gabriel, S., Hirsch, R., Hochberg, M.C., Hunder, G.G. and Jordan, J.M., 2008. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Pa

Piva, S.R., Susko, A.M., Khoja, S.S., Josbeno, D.A., Fitzgerald, G.K. and Toledo, F.G., 2015. Links between osteoarthritis and diabetes: implications for management from a physical activity perspective. Clinics in geriatric medicine, 31(1), pp.67-87.

Ranger, T.A., Wong, A.M., Cook, J.L. and Gaida, J.E., 2016. Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. British journal of sports medicine, 50(16), pp.982-989.

Schett, G., Kleyer, A., Perricone, C., Sahinbegovic, E., Iagnocco, A., Zwerina, J., Lorenzini, R., Aschenbrenner, F., Berenbaum, F., D’Agostino, M.A. and Willeit, J., 2013. Diabetes is an independent predictor for severe osteoarthritis: results from a longitudinal cohort study. Diabetes care, 36(2), pp.403-409.

Stürmer, T., Brenner, H., Brenner, R.E. and Günther, K.P., 2001. Non-insulin dependent diabetes mellitus (NIDDM) and patterns of osteoarthritis: the Ulm osteoarthritis study. Scandinavian journal of rheumatology, 30(3), pp.169-171.

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