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Journal of the association of physicians of india • vol 62 • published on 1st of every month 1st september, 2014
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Editorial
Rheumatic Musculoskeletal Complaints in
Diabetes—Adding Another Dimension to a
Multidimensional Disease!
Rohini Handa*
R
epetition, reiteration and reaffirmation
are similar sounding words. That
‘India is the epicentre of diabetes mellitus’
is repetition ad nauseam. ‘Nephropathy,
neuropathy and retinopathy are major
complications of diabetes’ is reiteration
ad infinitum. What is often overlooked
and needs highlighting, followed by
reaffirmation, is the fact that rheumatic
musculoskeletal complaints are
extremely common in diabetes. Despite
being ‘commonly’ present, they are
‘uncommonly’ addressed and tend to get
dwarfed by the micro and macrovascular
complications of the disease. These
‘mundane’ manifestations, however, have
the potential to exert a significant negative
influence on quality of life in diabetics.
Any clinician who has handled an elderly
diabetic with a frozen shoulder would
vouch for this clinical reality.
The study by Agrawal and colleagues
published in this issue of JAPI draws
attention to the inescapable fact that
rheumatic musculoskeletal manifestations
are seen in a whopping 57% of diabetics. 1
The prevalence was even higher in type
1 diabetes (62.7%). The authors studied
5736 diabetics and encountered various
complications like chieroarthropathy
(22.6%), frozen shoulder (20%), diffuse
idiopathic skeletal hyperostosis-DISH
(13%) , flexor tenosynovitis (8.1%),
Dupuytren’s contracture (7.2%), and
neuroarthropathy (2.9%). Osteoarthritis
was seen in a third of the patients.
Poor glycemic control was seen to be
associated with increased prevalence
of rheumatological manifestations. The
findings are in keeping with other studies
from India and elsewhere. 2,3 Whether
these complications are intrinsic to
diabetes or merely disorders exhibiting
*
Senior Consultant
Rheumatologist, Indraprastha
Apollo Hospitals, New Delhi
© JAPI • september 2014 • VOL. 62
increased prevalence in diabetics is a
matter of debate. The near ubiquitousness
in diabetes is unquestionable.
Apart from commonality, rheumatic
complaints in diabetes are associated
with pain, disability and impaired
quality of life. 4,5 International guidelines
like the Joslin Diabetes Center & Joslin
Clinic Clinical Guidelines for adults
with diabetes comprehensively cover
cardiovascular health, lipids, blood
pressure, kidneys, eyes, nerves, feet,
mental health, women’s and men’s health
and dental issues, but are silent about
musculoskeletal health. 6 Studies like
those by Agrawal and colleagues should
prompt us to move from ‘information’
to ‘action’. Physicians caring for patients
with diabetes should be encouraged
to routinely enquire about rheumatic
complaints in their patient history. The
acronym PASS can be adopted. This refers
to 4 simple screening questions that can
identify musculoskeletal problems- Pain,
limitation of Activities, Stiffness, and
Swelling in and around joints, muscles
and back. 7 A timely diagnosis facilitates
appropriate treatment. Exercise and
physiotherapy have the potential to
a m e l i o r a t e s e ve r a l m u s c u l o s k e l e t a l
symptoms in diabetes, especially when
instituted early.
One of the limitations of this field
h a s b e e n t h e k n o wl e d g e g a p a b o u t
p a t h o g e n e t i c p a t h wa y s , m o l e c u l a r
mechanisms and genetic linkages.
The information about rheumatic
complications and/or associations of
diabetes come mainly from observational
and epidemiologic studies. Recent
work focussing on PTPN22, a protein
tyrosine phosphatase nonreceptor,
 781
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Journal of the association of physicians of india • vol 62 • published on 1st of every month 1st september, 2014
expressed by the majority of cells belonging to the
innate and adaptive immune systems has shown
that polymorphisms in PTPN22 are associated with
several autoimmune diseases, such as systemic lupus
erythematosus, rheumatoid arthritis and type 1
diabetes. 8 The research implications of this finding
are as yet unclear. The link between endocrine and
rheumatic diseases needs to be explored further.
Diabetes is common. So also are rheumatic
musculoskeletal complaints in these patients.
However, these are neither routinely assessed nor
optimally attended. Minor they may be, unimportant
they are not. Physician awareness and attention
are the key steps to address this dimension in the
multidimensional disease that is diabetes!
References
1.
Agrawal RP, Gothwal S, Tantia P, Agrawal R, Rijhwani P, Sirohi
P, Meel JK. Prevalence of rheumatological manifestations in
diabetic population from North-West India. J Assoc Physicians India
2014;62:788-792.
782 
2.
Sarkar RN, Banerjee S, Basu AK, Bandyopadhyay R. Rheumatological
manifestations of diabetes mellitus. J Ind Rheumatol Assoc 2003; 11:
25–9.
3.
Mathew AJ, Nair JB, Pillai SS. Rheumatic-musculoskeletal
manifestations in type 2 diabetes mellitus patients in south India.
Int J Rheum Dis 2011;14:55-60.
4.
Silva MBG, Skare TL. Musculoskeletal disorders in diabetes mellitus.
Rev Bras Reumatol 2012;52:594-609.
5.
Serban AL, Udrea GF. Rheumatic manifestations in diabetic patients.
J Med Life 2012;5:252-7.
6.
Joslin Diabetes Center & Joslin Clinic Clinical Guidelines for adults.
Available at http://www.joslin.org/docs/Adult_guidelines_edits_05_16_2012-update_0213_(2).pdf. Accessed 20 July, 2014.
7.
Woolf AD, Walsh NE, Akesson K. Global core recommendations
for a musculoskeletal undergraduate curriculum. Ann Rheum Dis
2004;63:517–524.
8.
Liao KP, Gunnarsson M, Källberg H, Ding B, Plenge RM, Padyukov L,
et al. Specific association of type 1 diabetes mellitus with anti-cyclic
citrullinated peptide-positive rheumatoid arthritis. Arthritis Rheum
2009;60:653-60.
© JAPI • september 2014 • VOL. 62