The rheumatologic manifestations of diabetes mellitus

The painful diabetic shoulder

Different types of shoulder affection were studied in 62 diabetic patients with shoulder pain. Three groups of shoulder joint disorder were found: painful shoulder with restricted mobility (62%), tendinitis without mobility restriction (27%), and a small group with mixed diagnoses. Sixty per cent had hand symptoms and 38% had restricted mobility of their hip joints. High frequencies of retinopathy and neuropathy were found. Affection of the shoulder joint was seen with almost the same frequency in insulin-dependent as in non-insulin-dependent patients, but after a shorter duration of diabetes in the latter. A group of patients with the triad shoulder pain, hand symptoms and restricted mobility of the hip joints had a significantly higher frequency of proliferative retinopathy than patients with shoulder pain only. The long duration of diabetes, the high frequency of insulin treatment and classical late complications indicate that diabetic patients with painful shoulder and restricted mobility are suffering from clinically advanced diabetes mellitus.

Geometric influence of the sagittal and vertical apical base relationship on the ANB angle

OBJECTIVE

The objective of this study consisted in determining the variability of the ANB angle in relation to the position of the A- and B-points in the sagittal vertical plane.

MATERIALS AND METHODS

Using a theoretical model, we varied the position of the cephalometric points A and B in the sagittal vertical plane while its sagittal relationship was kept constant (Wits value = 0 mm). For this purpose, seven lines were erected perpendicular to the occlusal plane on a lateral cephalogram. The position of points A and B were determined on each of the vertical lines by calculating one anterior and one posterior angle in each case. In this way, the positions of all A- and B-points were clearly defined in the sagittal vertical plane.

RESULTS

The characteristic of the ANB angle in the sagittal vertical plane was graphically represented by determining both points A and B using two angles instead of one. This revealed that the ANB angle for the same sagittal base relationship was characterized by major variations depending on the position of the A- and B-points in relation to the anterior cranial base. The larger the SNA and SNB angles were, the larger the corresponding ANB angle. At the same time, the absolute value of ANB increased with the length of the vertical distance between the points A and B.

CONCLUSION

The ANB angle is strongly influenced by geometric factors. Accurate diagnosis of the sagittal base relationship should thus take the individual character of the ANB angle into account.

Musculoskeletal disorders in diabetes mellitus: an update

Diabetes mellitus (DM) is associated with several musculoskeletal disorders. The incidence of DM and the life expectancy of the diabetic patient have both increased, resulting in the increased prevalence and clinical importance of musculoskeletal alterations in diabetic subjects. The exact pathophysiology of most of these musculoskeletal disorders remains obscure. Connective tissue disorders, neuropathy, vasculopathy or combinations of these problems, may underlie the increased incidence of musculoskeletal disorders in DM. The development of musculoskeletal disorders is dependent on age and on the duration of DM; however, it has been difficult to show a direct correlation with the metabolic control of DM. Most of these disorders can be diagnosed clinically, but some radiological examination may help, especially in differential diagnosis. No specific treatment is available, and treatments used in the general population are also recommended for diabetic subjects. Infectious complications affecting the musculoskeletal system are common in DM subjects, and these, possibly life-threatening, complications should be systematically discussed.

Study of craniofacial morphology and skeletal maturation in juvenile diabetics (Type I)

The aims of this study were to examine the craniofacial morphology of patients with juvenile diabetes, to investigate the effects of juvenile diabetes on general growth and skeletal maturation, and to analyze the pattern of association between craniofacial morphology and skeletal maturation in these patients. The sample consisted of 20 male patients with juvenile diabetes whose ages ranged from 14 to 16 years and who were affected with the condition at least 5 years before the study. Twenty normal subjects, with the same age range, were chosen as a control group. Height, weight, lateral cephalometric and hand-wrist radiographs were taken for all subjects, corrected for magnification distortion, and analyzed. The diabetic patients showed decreased skeletal maturation and decreased cephalometric linear and angular measurements when compared with the control group. These results should be considered when diabetic patients require orthodontic or orthopedic treatment.

Connective tissue and joint disease in diabetes mellitus

Connective tissue is ubiquitous and subject to alterations that result in changes in the extracellular matrix of vessels and tissues leading to the long-term complications of diabetes. This article reviews only those abnormalities of interstitial connective tissue involving skeleton, joints, skin, and periarticular tissues. Abnormalities in the skin and periarticular tissues result in syndromes limiting joint movement, including limited joint mobility, Dupuytren disease, flexor tenosynovitis, carpal tunnel syndrome, stiff-hand syndrome, and shoulder-hand reflex dystrophy. Of these, only limited joint mobility and stiff-hand syndrome occur exclusively in patients with diabetes. In all of these conditions, advanced glycation end products are thought to form as a result of nonenzymatic reaction of glucose with proteins, causing stiffening.

Medical problems in a sports medicine setting

Becoming reliant on a diagnostic repertoire limited to common sports-related problems can result in delayed diagnoses and potential disservice to the athlete. Remaining aware of other conditions that can mimic the common disorders and maintaining an index of suspicion for their occurrence can aid both the primary care physician and the specialist when challenged with a refractory or atypical presentation in an athlete. Reliance on a thorough history and physical examination, with judicious use of ancillary testing, is the cornerstone for any medical evaluation and no less important in this scenario. When equipped with such knowledge and skills, the physician caring for athletes can provide the best possible service, insuring not only the individuals' overall health, but also their safe and complete return to their chosen sport.

Clinical and laboratory parameters in adult diabetics with and without calcific shoulder periarthritis

The clinical and laboratory parameters of calcific shoulder periarthritis (CSP) were examined in 900 patients with type II diabetes mellitus as well as in 350 age- and sex-matched control subjects. A threefold increased prevalence of CSP in diabetics compared with the control group was associated with the presence of longstanding and poorly controlled diabetes, hypercholesterolemia, and hypertriglyceridemia suggesting pronounced diabetic angiopathy, as well as with minor trauma and hypomagnesemia. Aging and serum calcium concentrations were not related to the presence of CSP. Thirty-two percent of diabetics with CSP were symptomatic; 15% of them presented with severe pain and restriction of shoulder movement. These findings confirm a close pathogenetic interrelation between CSP and diabetes mellitus.

Calcific shoulder periarthritis (tendinitis) in adult onset diabetes mellitus: a controlled study

Two groups, one of 824 adult diabetics and one of 320 age and sex matched non-diabetics, were examined for abnormal glucose metabolism and calcifications on anteroposterior shoulder x rays. Two hundred and sixty two (31.8%) of the diabetics had shoulder calcification compared with 33 (10.3%) of the control group, with a preponderant localisation in the right shoulder. Diabetes of long duration treated with insulin for a long time was associated with a larger percentage of shoulder calcifications. These data and previous laboratory findings suggest a possible pathogenetic correlation between the prevalence of calcific shoulder tendinitis and diabetes.

Muscle function of the lower extremities in rheumatoid arthritis and osteoarthrosis. A descriptive study of patients in a primary health care district

Thirty-six patients with rheumatoid arthritis (RA), 30 patients with cox- or gonarthrosis (OA), and a control group of 40 patients with diabetes mellitus (DM) were studied with the aim of analyzing and comparing patient experienced muscular problems of muscle-strength analyzing and comparing patient experienced muscular problems of muscle-strength, endurance and balance/coordination with muscle function as assessed by standardized tests. The results indicated that patient-experienced problems of muscle function of the lower extremities were frequent in both the RA and the OA groups (about 80%) compared to the DM group (10%). Multivariate analyses of variance (MANOVAs) on experienced and tested muscle strength, endurance and balance/coordination, revealed a significant RA-OA difference (p less than 0.05). Separate analyses of variance (ANOVAs) indicated OA patients to show decreased tested endurance compared with the RA group. There was no significant RA-OA difference as to pain. Results provide evidence for considering muscle function of the lower extremities in therapeutic programs for RA and OA within primary health care.

Skeletal and joint manifestations of childhood diabetes

The rheumatologic and skeletal manifestations of childhood diabetes have only recently been appreciated. This article reviews bone loss (osteopenia) in this population, and the differential diagnosis of the limited joint mobility commonly found in insulin-dependent diabetes in childhood.

Locomotor system disorders in diabetes mellitus. Increased prevalence of palmar flexortenosynovitis

Diabetes mellitus (DM) may be accompanied by a variety of locomotor system disorders including several hand syndromes. It has been suggested that palmar flexortenosynovitis (FTS) might be included among these hand syndromes, but no conclusive data have been available. Furthermore, recent studies have indicated that FTS may be a clue to previously undiagnosed impaired glucose tolerance. In the present study the prevalence of FTS among diabetics without inflammatory rheumatic disease was 11% compared with less than 1% (p less than 0.001) in a reference group. Thus, FTS could be included among the locomotor system disorders which are associated with DM.