Diabetic Arthropathy: Charcot Foot, Arthritis, and More - Verywell Health

People with diabetes are at increased risk of developing joint diseases, or arthropathies, and these conditions can potentially lead to permanent destructive changes in the joints, causing pain and limiting proper mobility needed to perform functional movements and everyday activities. 

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What Is Diabetic Arthropathy?

In patients with diabetes, decreased sensation in the joints as a result of diabetic peripheral neuropathy can cause chronic and progressive arthropathy. It occurs as a result of increased laxity of ligaments, increased range of motion of joints, instability, and repetitive microtraumas with poor healing that can damage joints over time. Increased blood sugar that occurs with diabetes also causes structural and molecular changes to the cartilage within joints.

Related Conditions

Charcot Foot

A Charcot foot can develop as a serious complication of diabetes, where progressive destruction of the bones and joints of the foot leads to deformity, increasing the risk of developing diabetic ulcers and making it very painful and difficult to walk.

Symptoms of a Charcot foot include:

• Increased redness
• Warmth
• Swelling at the foot and ankle
• Collapsing of the foot arch, causing the bones of the foot to shift out of place. This results in increased pressure on the bottom of the foot that can lead to pressure ulcers

During the initial stages, a Charcot foot can be mistakenly diagnosed as cellulitis.

Patients with diabetes often exhibit an increase in pro-inflammatory cytokines, molecules that increase inflammation, and increased growth of osteoclasts, cells that break down bones. Monocytes, specialized white blood cells, also exhibit a decreased ability to terminate an inflammatory response in patients with diabetes.

Advanced glycation end products (AGEs) are proteins that become altered by excess blood sugar molecules that are characteristic of diabetes and worsen the condition. AGEs break down collagen and cause hardening of tissues. The changes to these proteins combined with the increased inflammatory reactions and bone breakdown that occurs with diabetes can cause an altered structure of the foot, placing increased pressure at different areas with weight-bearing.

Treatment for a Charcot foot involves putting the affected foot in a cast and using crutches or a wheelchair to get around without weight-bearing on that foot for several months. Gradual progression to normal weight-bearing with prescription footwear will begin when redness, warmth, and swelling significantly decrease. 

Patients with chronic progression of a Charcot foot that does not respond to other treatments may undergo surgery to remove bone spurs, increase the length of the Achilles tendon to improve alignment of the foot and ankle, and fuse bones of the foot together for better stability, although surgery is best avoided to prevent complications with healing after the operation.

Without treatment, a Charcot foot can progress rapidly and result in irreversible damage in six months or less. The altered structure and decreased sensation of the foot increases the risk of foot ulcers, which can become infected. Without proper treatment, ulcers and infections can become severe enough that foot amputation may be necessary.

Osteoarthritis

Osteoarthritis is a chronic inflammatory condition of the joints that causes pain, inflammation, stiffness, and swelling as a result of cartilage degradation.

Symptoms of osteoarthritis include:

• Joint pain
• Muscle weakness
• Joint misalignment
• Decreased balance
• Decreased mobility of joints limiting everyday activities

Diabetes and osteoarthritis share similar risk factors, including age since pancreatic cell function declines with aging, increasing the risk of developing diabetes. Aging also increases the risk of developing osteoarthritis due to increased cumulative stress on joints and the resulting cartilage wear.

Obesity is another shared risk factor between diabetes and osteoarthritis. Obesity is a major risk factor for developing diabetes since a higher amount of excess fat cells stimulates an inflammatory response in the body and disrupts metabolism, leading to decreased insulin sensitivity and insulin resistance characteristic of diabetes.

Increased body weight also puts a greater amount of pressure on weight-bearing joints, causing faster degradation of the cartilage. In the presence of excess blood sugar, cartilage cells are more likely to secrete enzymes, specifically matrix metalloproteases, which cause cartilage cells to break down. Higher levels of reactive oxygen species are also released in the presence of excess blood sugar, and promote increased release of inflammatory proteins that cause degradation and death of cartilage cells.

The first-line treatment option for improving symptoms of osteoarthritis is exercise, including a combination of aerobic and resistance training. Exercising can help improve muscle weakness, joint stiffness and pain, and mobility. Physical activity can also improve metabolism and glucose tolerance, decrease body weight, and decrease inflammation to improve symptoms of diabetes.

Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory autoimmune condition in which the body produces an immune system response to attack its own joints, causing pain, inflammation, and swelling. Over time, the cartilage breaks down, narrowing the space between bones, and joints can become unstable or stiff. If left untreated, rheumatoid arthritis can cause permanent and irreversible joint damage. 

The risk of developing diabetes and arthritis, including rheumatoid arthritis, goes hand in hand. It is estimated that 47% of adults with diabetes also have arthritis, and that people with arthritis have a 61% increased risk of developing diabetes compared to those without arthritis. 

Elevated inflammatory responses are associated with both rheumatoid arthritis and diabetes. Increased blood serum levels of interleukins and C-reactive protein, molecules that increase inflammation, are commonly seen across both conditions.

Medication used to treat rheumatoid arthritis can also increase the risk of developing diabetes due to its effect on increasing blood sugar. Corticosteroids are commonly used to treat rheumatoid arthritis to decrease inflammation, but also stimulate the liver to release more glucose, as a side effect, which increases blood sugar levels. 

Other treatment options to manage symptoms of rheumatoid arthritis besides medication include following an anti-inflammatory diet and exercising to decrease joint pain, stiffness, and weakness.

Diabetic Hand Syndrome (Diabetic Cheiroarthropathy)

Diabetic hand syndrome, also called diabetic cheiroarthropathy, is characterized by decreased range of motion of the finger joints and a waxy appearance on the back of the hands. Hand use becomes limited due to contractures and stiffness, causing difficulty with grip strength and fine motor movements. Diabetic hand syndrome can affect the proximal and distal interphalangeal joints and metacarpophalangeal joints and is often painless.

Diabetic hand syndrome is thought to develop from the accumulation of advanced glycation end products (AGEs), proteins that become altered by excess blood sugar molecules characteristic of diabetes. AGEs can break down collagen and deposit abnormal amounts of collagen in connective tissue around joints, resulting in stiffening and hardening of the joints and skin. These changes are potentially irreversible.

Physical and occupational therapy can be utilized to improve hand function by mobilizing the finger joints, stretching the muscles of the fingers and palms, and performing exercises and activities to improve hand strength and functional usage. In the presence of contractures, cortisone can be injected into the palmar tendon sheaths of the finger muscles to decrease inflammation.

Frozen Shoulder

Frozen shoulder, also called adhesive capsulitis, is a chronic inflammatory condition of the shoulder joint that causes stiffening of the joint and painful limitations with shoulder movements. The onset is often sudden without any specific incident underlying the pain, and the pathology of how frozen shoulder develops is not fully understood.

Frozen shoulder can be divided into three stages:

• Freezing stage, where pain and decreased range of motion start to affect daily functioning
• Frozen stage, where significant stiffness predominates and restricts movement
• Thawing stage, where symptoms gradually start to resolve

Frozen shoulder is more prevalent in people with diabetes, affecting as many as 30% with more severe symptoms and decreased responsiveness to treatment.

It is hypothesized that due to high blood sugar, increased levels of circulating glucose, or sugar molecules, in the blood of people with diabetes can stick to collagen within joints in a process called glycosylation. This causes the collagen that makes up the shoulder joint to become sticky, restricting movement and resulting in stiffening of the joint.

Biopsies of the synovial membrane that lines the shoulder joint capsule also exhibit reduced inflammatory growth factors, suggesting slowing of the inflammatory response. This increases the severity of frozen shoulder symptoms due to increased and prolonged inflammation.

Treatment options for frozen shoulder include oral anti-inflammatory medications, physical therapy to increase joint mobility and range of motion, and cortisone injections within the shoulder joint to decrease inflammation. Cortisone injections should be used with caution in patients with diabetes since they can increase blood sugar levels up to seven days after the procedure.

When these methods are ineffective, hydrodilation can be performed in which an injection of local anesthesia guided by ultrasound is injected into the shoulder joint, followed by an injection of saline solution to stretch the shoulder joint capsule. 

Surgery can also be performed with an arthroscopic capsular release where the shoulder joint capsule is surgically cut and loosened. A manipulation under anesthesia can also be performed where the shoulder is maximally stretched while being sedated under anesthesia to break up scar tissue that is restricting movement of the shoulder joint.

A Word From Verywell

Arthropathies that develop as a complication of diabetes can lead to destructive, painful, and potentially permanent changes to joints. If not treated properly, diabetic arthropathies can limit proper joint mobility needed to perform functional movements and everyday activities. If you have diabetes and are experiencing increased joint pain, stiffness, or swelling, it is important that you call your doctor to discuss your symptoms. Managing symptoms early is important to prevent irreversible progression of joint destruction.

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